1 / 34

Neonatal and Infant CRRT

Neonatal and Infant CRRT. Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org. Pediatric CRRT: Vicenza, 1984. CRRT Machines: Current Generation. Vascular Access for Pediatric CRRT.

alton
Download Presentation

Neonatal and Infant CRRT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org

  2. Pediatric CRRT: Vicenza, 1984

  3. CRRT Machines: Current Generation

  4. Vascular Access for Pediatric CRRT • Smaller patients require smaller catheters • Difficulty achieving access • Difficulty maintaining access • Limited access sites

  5. Choices for Vascular Access

  6. Access Sites for CRRT • Femoral veins • Jugular veins • Subclavian veins • Umbilical vessels • ECMO circuit

  7. Prescribing CRRT for Small Kids • Modality • Blood flow rate • Hemofilter • Solution(s) • Ultrafiltration rate • Anticoagulation • Special considerations

  8. CRRT Modality for Small Kids Am J Kid Dis, 18:833-837, 2003

  9. Hemofilters for Pediatric CRRT Am J Kid Dis, 18:833-837, 2003

  10. Ultrafiltration Rate for Infant CRRT • As tolerated by the patient • Potentially limited by hemofilter, blood flow rates • Small errors have a larger effect in a tiny patient

  11. Anticoagulation for Infant CRRT • Heparin • Citrate • Nothing • ? Other things ?

  12. Other Special Considerations for CRRT in Infants • Large extracorporeal volume compared to small patient • Blood prime (1:1 PRBC:Albumin 5%) at initiation frequently required • Risk of thermic loss often requires heating system

  13. Potential Complications of Infant CRRT • Volume related problems • Biochemical and nutritional problems • Hemorrhage • Infection • Technical problems • Logistical problems • Bradykinin release syndrome

  14. Logistical Issues for Infant CRRT • Infrequently performed procedure in neonatal units • Vascular access can be difficult to organize and obtain • Neonatology staff may be unfamiliar with equipment, procedure, risks • Written procedures may improve coordination and results of therapy

  15. 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

  16. Technique Modifications to Prevent Bradykinin Release Syndrome • Buffered system: add THAM, CaCl, NaBicarb to PRBCs • Bypass system: prime circuit with saline, run PRBCs into patient on venous return line • Recirculation system: recirculate blood prime against dialysate

  17. Waste PRBC Bypass System to Prevent Bradykinin Release Syndrome Modified from Brophy, et al. AJKD, 2001.

  18. Normalize pH D Normalize K+ Waste Recirculation System to Prevent Bradykinin Release Syndrome Recirculation Plan: Qb 200ml/min Qd ~40ml/min Time 7.5 min Based on Pasko, et al. Ped Neph 18:1177-83, 2003

  19. Outcomes for Pediatric CRRT • Data are scant • Most studies are single-center, retrospective • No randomized controlled trials • Small numbers limit power • Extension from adult studies may not be appropriate

  20. CRRT in Pediatric Patients <10Kg • Multi-center, retrospective study • 5 pediatric centers • 85 patients • Demographic data • Technique description • Outcome Am J Kid Dis, 18:833-837, 2003

  21. Which Babies Require CRRT? N=85 Am J Kid Dis, 18:833-837, 2003

  22. Why do Babies Need CRRT? N=85 Am J Kid Dis, 18:833-837, 2003

  23. CRRT in Infants <10Kg: Outcome 38% Survival 41% Survival 25% Survival Patients <10kg Patients 3-10kg Patients <3kg Am J Kid Dis, 18:833-837, 2003

  24. 36% 71% 15% 42% 22% 0 50% 0 50% 50% 100% 0 60% Survival by Diagnosis Am J Kid Dis, 18:833-837, 2003 Totals: N=85; Survivors=32

  25. Survival by Modality Am J Kid Dis, 18:833-837, 2003 p=NS

  26. Retrospective Study of Infant CRRT: Summary • Overall outcome acceptable • 3 – 10kg: outcome similar to that for older patients • Metabolic disorders: good outcome • <3kg, selected diagnoses: poor outcome • No clear advantage between modalities Am J Kid Dis, 18:833-837, 2003

  27. Prospective Pediatric CRRT Registry (ppCRRT) • Multi-center registry of pediatric CRRT • Currently eleven US centers participating • Collecting demographic, technical and outcome data on all pediatric patients receiving CRRT • Sub-analysis of infants <10kg presented at ASN and PAS/ASPN

  28. ppCRRT Data of Infants <10kg: Demographic Information • 28 children <10 kg • 14 boys, 14 girls • Median age 40 days old • Range 3 days to 2.9 years • Median weight 4.1 kg • Range 1.3 to 9.5 kg

  29. ppCRRT Data of Infants <10kg: Indications for CRRT N=28

  30. ppCRRT Data of Infants <10kg: Vascular Access Location N=28

  31. ppCRRT Infant Survival Data 50% Survival 64% Survival 41% Survival

  32. Infant CRRT: Continuing Questions • How does CRRT compare to other modalities for small patients? • What is optimal nutrition for infants on CRRT? • What further equipment refinements are necessary? • What is the long-term effect of CRRT?

  33. Thanks!

More Related