Acute Renal Replacement Therapy for the Infant by c0z1Mq7

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									Acute Renal Replacement Therapy
          for the Infant




                Jordan M. Symons, MD
     University of Washington School of Medicine
    Children’s Hospital & Regional Medical Center
                     Seattle, WA
           jordan.symons@seattlechildrens.org
              Objectives
• Indications and goals for acute renal
  replacement therapy
• Modalities for renal replacement therapy
  – Peritoneal dialysis
  – Intermittent hemodialysis
  – Continuous renal replacement therapy
    (CRRT)
• Special issues related to the infant
Indications for Renal Replacement

 •   Volume overload
 •   Metabolic imbalance
 •   Toxins (endogenous or exogenous)
 •   Inability to provide needed daily fluids
     due to insufficient urinary excretion
 Goals of Renal Replacement
• Restore fluid, electrolyte and metabolic
  balance
• Remove endogenous or exogenous
  toxins as rapidly as possible
• Permit needed therapy and nutrition
• Limit complications
Renal Replacement for the Infant:
  A Set of Special Challenges
• Small size of the patient
• Equipment designed for larger people
• Small blood volume will magnify effects
  of any errors
• Achieving access may be difficult
• Staff may have infrequent experience
    Modalities for Renal
      Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
  therapy (CRRT)
    Modalities for Renal
      Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
  therapy (CRRT)
PD: Considerations for Infants
      ADVANTAGES                 DISADVANTAGES
•   Experience in the       •   Infectious risk
    chronic setting         •   Leak
•   No vascular access      •   ? Respiratory
•   No extracorporeal           compromise?
    perfusion               •   Sodium sieving
•   Simplicity              •   Dead space in tubing
•   ? Preferred modality
    for cardiac patients?
Sodium Sieving: A Problem of Short Dwell PD



                         H2O                  H2O    Na+
                   H2O
       Na+                                                 H2O

 H2O                                                           Na+


                    Result: Hypernatremia
 Na+
                                                              H2O
        H2O
                                                    H2O Na+
                     H2O
             Na+           Na+   H2O   H2O
                                             Na+
Dead Space: A Problem
 with Low Volume PD
    Modalities for Renal
      Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
  therapy (CRRT)
  IHD: Considerations for Infants
     ADVANTAGES                   DISADVANTAGES
• Rapid particle and fluid   •   Vascular access
  removal; most efficient    •   Complicated
  modality                   •   Large extracorporeal
• Does not require               volume
  anticoagulation 24h/d      •   Adapted equipment
                             •   ? Poorly tolerated
    Modalities for Renal
      Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
  therapy (CRRT)
Pediatric CRRT: Vicenza, 1984
         CRRT for Infants:
       A Series of Challenges
•   Small patient with small blood volume
•   Equipment designed for bigger people
•   No specific protocols
•   Complications may be magnified
•   No clear guidelines
•   Limited outcome data
     Potential Complications of
           Infant CRRT
•   Volume related problems
•   Biochemical and nutritional problems
•   Hemorrhage, infection
•   Thermic loss
•   Technical problems
•   Logistical problems
CRRT in Infants <10Kg: Outcome

                                                    N
                                                    Survivors


        85   38%
             Survival                 41%
                                 69
                                      Survival

              32                      28
                                                        25%
                                                   16   Survival
                                                         4


   Patients <10kg         Patients 3-10kg        Patients <3kg

Am J Kid Dis, 18:833-837, 2003
ppCRRT Data of Infants <10Kg:
  Demographic Information
Number of Subjects 84
                     (51 boys (61%))
                     (33 girls (39%))
Age                Median 69 days
                     (1 d - 2.9 y)
ICU Admit weight   Median 4.4 kg
                     (1.3 - 10 kg)
 ppCRRT Data of Infants <10Kg:
     Primary Diagnoses
          10%                     35%
15%




19%
                             21%
  Sepsis        GI/Hepatic
  Cardiac       Inborn Error of Metabolism
  Pulmonary
 ppCRRT Data of Infants <10Kg:
     Indications for CRRT

Fluid Overload and Electrolyte Imbalance    84%
Other (Endogenous Toxin Removal)            16%


                                           N=84
  ppCRRT Data of Infants <10Kg:
         Clinical Data
Parameter                      Median Range
Days in ICU prior to CRRT         2   0 - 135
PRISM score — ICU admit         17.5  0 - 48
PRISM score — CRRT start         20   0 - 48
Inotrope number — CRRT start      1    0-4
Urine output — CRRT start       0.7   0 - 12
(ml/kg/hr over prior 24hrs)
% Fluid overload from ICU       13.7   -28 - 220
  admission to CRRT start
 ppCRRT Data of Infants <10Kg:
Technical Characteristics of CRRT
       Catheter Site   Femoral            60%
                       Internal Jugular   28%
                       Subclavian         12%
       Modality        CVVHD              59%
                       CVVH               18%
                       CVVHDF             23%
       Anticoagulation Citrate            55%
                       Heparin            45%
       Prime           Blood              87%
                       Saline             8%
N=84
                       Albumin            5%
  ppCRRT Data of Infants <10Kg:
     CRRT Treatment Data
Parameter                                  Median    Range
Blood Flow (ml/kg/min)                       8       1.7-46
Fluid Flow (ml/kg/hour)                     67        7-571
Average CRRT Clearance (ml/hr/1.73M 2)      2582    135-19319
Aggregate CRRT Clearance (ml/hr/1.73M 2)    3540    135-12713
CRRT duration (days)                         5        0-83




 N=84
ppCRRT Data of Infants <10Kg:
    Survival by Weight
 70%
                               p=0.001
 60%

 50%
                p=1.0

 40%

 30%
       44%              42%         43%      64%
 20%

 10%

 0%
       <5 k g       5-10 k g       <10 k g   >10 k g
   ppCRRT Data of Infants <10Kg:
     Factors Effecting Survival
Clinical Variable                 Survivors Non-Survivors     P
Admission PRISM score                16          21         <0.05
GI/Hepatic disease                   8%         31%          0.01
Multiorgan dysfunction              68%         91%          0.04
Pressor Dependency                  36%         69%         <0.01
Mean Airway Pressure                 11          20         <0.001
Initial urine output (ml/kg/hr)      2.4         1.0         0.02
%Fluid Overload at Start            15%         34%          0.02
>10% Overload at Start              43%         71%          0.02
ppCRRT Data of Infants <10Kg:
Survival by Return to Dry Weight
90%

80%
      78%
70%
                          65%
60%

50%
                                   Dry Weight Achieved
40%         35%                    Dry Weight Not Achieved


30%
                   22%
20%

10%

0%
       Survivors   Non-survivors
Infant CRRT at Children’s Hospital &
  Regional Medical Center, Seattle
Infant CRRT in Seattle: Overview
 • Coordinated by nephrology
 • Performed in infant/pediatric ICU
 • Set up by dialysis nurses
 • Run at the bedside by neonatology or
   critical care nurses
 • Dedicated CRRT device
     – BM-25: 1999 – 2005
     – Prisma: 2005 - present
CRRT Access in the Neonate:
      What Works?
• Hemodialysis Line: 7 Fr double lumen
• Two single lumen lines:
  – 5 Fr catheters or introducers
• Umbilical lines:
  – 5 Fr UAC; 7 Fr UVC
• Leg position - be creative
• Tape on the skin - may need to get
  creative
      PRISMA
• Dedicated CRRT device
• Highly automated
• Designed for ease of use
  at the bedside
   CRRT Filter Sets for Prisma
            Surface Priming
                                    Membrane
             Area   Volume
M-10*       0.042m2     50ml          AN-69

M-60          0.6m2     90ml          AN-69

M-100         0.9m2     107ml         AN-69
                                Polyarylethersulfone
HF-1000      1.15m2     128ml
                                      (PAES)
* Not available in US
 Bradykinin Release Syndrome
• Mucosal congestion, bronchospasm,
  hypotension at start of CRRT
• Resolves with discontinuation of CRRT
• Thought to be related to bradykinin release
  when patient’s blood contacts hemofilter
• Exquisitely pH sensitive
   Bypass System to Prevent
 Bradykinin Release Syndrome



                    PRBC        Waste




Modified from Brophy, et al. AJKD, 2001.
Recirculation System to Prevent
 Bradykinin Release Syndrome
                 Normalize pH
                                                      D
                Recirculation
                Plan:
                Qb 200ml/min
                Qd ~40ml/min
                Time 7.5 min
                 Normalize K+
                                                   Waste
Based on Pasko, et al. Ped Neph 18:1177-83, 2003
Simple Systems to Limit Likelihood
 of Bradykinin Release Syndrome

     • Don’t prime on with blood
     • Don’t use the AN-69 membrane
         Thermal Regulation
•   Hotline® blood warming tubing
•   Place at venous return to patient
•   Leave on at set temperature of 39 C
•   Treat temp elevations if they occur
    Infant CRRT in Seattle:
           CRRT Staffing
• Dialysis RN sets-up & initiates therapy
• PICU/IICU RN manages patient
• Nephrology/Dialysis RN on call 24/7
• Acuity assigned to pump as if a
  separate patient
• Staffing determined by acuity
Infant CRRT in Seattle: How to
   Handle a Rare Procedure
• Developed an Acute Initiation Checklist
  defining specific roles/actions for:
  – Infant ICU MD
  – Nephrology MD
  – Infant ICU RN
  – Dialysis RN
  – IV access MD
Acute Initiation Checklist: Example
     Infant ICU Nurse                       Dialysis Nurse
• Time Zero:                         • 10 – 60 min:
   – Move pt to room with dialysis      – Arrive and begin setup
     water                           • 20 – 40 min:
   – Get orders from resident for
                                        – Meet MD; discuss RRT plan
     IV fluids to keep access open
                                     • 60 – 120 min:
• 20 – 40 min:
                                        – Complete prime; ready for
   – Meet MD; discuss RRT plan
                                          access
• 60 – 120 min:                         – Begin RRT
   – Meet ICU team                      – Meet ICU team
Acute Initiation Checklist: Example
      Nephrology MD                           IV Access MD
• Time Zero:                           • 10 – 30 min:
   – Contact dialysis nurse to start      – Arrive and begin insertion of
     RRT urgently                           dialysis access
• 10 – 20 min:                         • 60 min (or when circuit is
   – Bring catheters to ICU              ready for Rx)
   – Enter orders for RRT                 – Complete insertion of access
• 20 – 40 min:                            – Connect ports to heparin IV
                                            solutions
   – Meet ICU MDs & RNs,
     discuss plan
• 60 – 120 min:
   – Present in ICU for initiation
   – Meet ICU team
      Infant RRT: Summary
• All modalities of RRT possible for infants
• No modality is perfect
• Technical challenges can be met
• Careful planning with institution, program,
  and individuals improves care
• Cooperation, communication, and
  collaboration will increase our success
Thanks!

								
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