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Acute Renal Replacement Therapy for the Infant

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

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Acute Renal Replacement Therapy for the Infant

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  1. 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

  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. Infant CRRT at Children’s Hospital & Regional Medical Center, Seattle

  28. 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

  29. 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

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

  31. CRRT Filter Sets for Prisma * Not available in US

  32. 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

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

  34. 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

  35. Simple Systems to Limit Likelihood of Bradykinin Release Syndrome • Don’t prime on with blood • Don’t use the AN-69 membrane

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. Thanks!

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