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Acute Renal Replacement Therapy for the Infant

Acute Renal Replacement Therapy for the Infant. Dr.Fahad Gadi, MD Pediatrics Demonstrator King Abdulaziz University Rabigh Medical School. Objectives. Indications and goals for acute renal replacement therapy Modalities for renal replacement therapy Peritoneal dialysis

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Acute Renal Replacement Therapy for the Infant

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  1. Acute Renal Replacement Therapy for the Infant Dr.Fahad Gadi, MD Pediatrics Demonstrator King Abdulaziz University Rabigh Medical School

  2. 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

  3. Indications for Renal Replacement • Volume overload • Metabolic imbalance • Toxins (endogenous or exogenous) • Inability to provide needed daily fluids due to insufficient urinary excretion

  4. 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

  5. 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

  6. Modalities for Renal Replacement • Peritoneal dialysis • Intermittent hemodialysis • Continuous renal replacement therapy (CRRT)

  7. Modalities for Renal Replacement • Peritoneal dialysis • Intermittent hemodialysis • Continuous renal replacement therapy (CRRT)

  8. ADVANTAGES Experience in the chronic setting No vascular access No extracorporeal perfusion Simplicity ? Preferred modality for cardiac patients? DISADVANTAGES Infectious risk Leak ? Respiratory compromise? Sodium sieving Dead space in tubing PD: Considerations for Infants

  9. 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+

  10. Dead Space: A Problem with Low Volume PD

  11. Modalities for Renal Replacement • Peritoneal dialysis • Intermittent hemodialysis • Continuous renal replacement therapy (CRRT)

  12. ADVANTAGES Rapid particle and fluid removal; most efficient modality Does not require anticoagulation 24h/d DISADVANTAGES Vascular access Complicated Large extracorporeal volume Adapted equipment ? Poorly tolerated IHD: Considerations for Infants

  13. Modalities for Renal Replacement • Peritoneal dialysis • Intermittent hemodialysis • Continuous renal replacement therapy (CRRT)

  14. Pediatric CRRT: Vicenza, 1984

  15. 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

  16. Potential Complications of Infant CRRT • Volume related problems • Biochemical and nutritional problems • Hemorrhage, infection • Thermic loss • Technical problems • Logistical problems

  17. 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

  18. ppCRRT Data of Infants <10Kg: Demographic Information

  19. ppCRRT Data of Infants <10Kg: Primary Diagnoses

  20. ppCRRT Data of Infants <10Kg: Indications for CRRT N=84

  21. ppCRRT Data of Infants <10Kg: Clinical Data

  22. ppCRRT Data of Infants <10Kg: Technical Characteristics of CRRT N=84

  23. ppCRRT Data of Infants <10Kg: CRRT Treatment Data N=84

  24. ppCRRT Data of Infants <10Kg: Survival by Weight p=0.001 p=1.0 44% 42% 43% 64%

  25. ppCRRT Data of Infants <10Kg: Factors Effecting Survival

  26. ppCRRT Data of Infants <10Kg: Survival by Return to Dry Weight 78% 65% 35% 22%

  27. PRISMA • Dedicated CRRT device • Highly automated • Designed for ease of use at the bedside

  28. 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

  29. Waste PRBC Bypass System to Prevent Bradykinin Release Syndrome

  30. 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

  31. Infant ICU Nurse Time Zero: Move pt to room with dialysis water Get orders from resident for IV fluids to keep access open 20 – 40 min: Meet MD; discuss RRT plan 60 – 120 min: Meet ICU team Dialysis Nurse 10 – 60 min: Arrive and begin setup 20 – 40 min: Meet MD; discuss RRT plan 60 – 120 min: Complete prime; ready for access Begin RRT Meet ICU team Acute Initiation Checklist: Example

  32. Nephrology MD Time Zero: Contact dialysis nurse to start RRT urgently 10 – 20 min: Bring catheters to ICU Enter orders for RRT 20 – 40 min: Meet ICU MDs & RNs, discuss plan 60 – 120 min: Present in ICU for initiation Meet ICU team IV Access MD 10 – 30 min: Arrive and begin insertion of dialysis access 60 min (or when circuit is ready for Rx) Complete insertion of access Connect ports to heparin IV solutions Acute Initiation Checklist: Example

  33. 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

  34. Thanks!

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