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CRRT for Neonates

CRRT for Neonates. David Askenazi MD MSPH pCRRT meeting September 28, 2012. Transparency…. I am on the speaker’s bureau for Gambro Will not be discussing specific differences of CRRT machines I will be talking about non-FDA indications for Devices

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CRRT for Neonates

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  1. CRRTfor Neonates David Askenazi MD MSPH pCRRT meeting September 28, 2012

  2. Transparency…. • I am on the speaker’s bureau for Gambro • Will not be discussing specific differences of CRRT machines • I will be talking about non-FDA indications for Devices • No CRRT devices are approved for < 20 kg.

  3. Educational Objectives • Acute kidney injury and CRRT epidemiology • Indications for RRT in children • Type of RRT – PD vs. HD vs. CRRT • Prescription of CRRT for pediatric patients • Vascular access • Priming the machine • Anticoagulation • Blood flow rates • Clearance • Net ultrafiltration goals

  4. Children are not small adults • Different Sizes, and Shapes • 0 days to 21+ years • 1.3 kg to 200 kg • Not present • Diabetes • Older age • Atherosclerotic disease • Hypertension • Volume of patients • Present • Size/Access variation • Less frequent than adults/less experience • Machinery is adapted (not made) for pediatrics

  5. Small Children are not Big Children • Blood Primes • Access • Machines are Really not designed for small children • Need high blood flow /kg • Need high clearances for citrate clearance • Thermic Control is critical • Not FDA approved for small children

  6. “Just pull off the sticker” “Explain it to the family”

  7. Indications for RRT in the ICU A -- Alkalosis or Acidosis ( metabolic) E -- Electrolyte disturbances -- Hyperkalemia -- hypocalcemia -- Hypernatremia -- hypercalcemia -- Hyperphosphatemia -- hyperuricemia I -- Intoxication with a drug that can be dialyzed I – Inborn Error of Metabolism O -- Overload of Fluids ( H20 retention) -- Pulmonary edema or hypertension U -- Uremia- Not azotemia which can be secondary to steroids, bleeding -- CNS encephalopathy, vomiting, pericarditis NOT AMNEABLE TO MEDICAL THERAPY

  8. Neonatal AKI Definition

  9. Challenges to SCr Based Definitions • SCr is a surrogate of FUNCTION not INJURY • 25-50% functional loss is needed to for SCr changes to occur • SCr is affected by medications, billirubin and muscle mass • SCr rises in Pre-Renal Azotemia – Is that AKI?

  10. Challenges to SCr based definitions in neonates Normal Creatinine levels x gestational age Gallini F: Pediatric Nephrology 2000 (15); 119-124

  11. Epidemiology NeonatalAKI and CRRT

  12. What are the outcomes in those with AKI? • How often does it happen? • What are the outcomes in those with CRRT

  13. Neonatal AKI in VLBW Infants • Prospective 18 month study at UAB • Neonates with BW ≤ 1500 grams • Categorical SCr based AKI definiton • clinically-indicated measurements and • remnant samples – 10 mcl of serum using Mass Spec • No UOP criteria used Koralkar, Askenazi et al…Pediatric Research 2010

  14. Neonatal AKI in VLBW Infants 18% incidence of AKI Koralkar et al…Pediatric Research 2010

  15. Difference in Survival between infants with AKI and without AKI Koralkar et al…Pediatric Research 2010

  16. AKI in ELBW infants • 472 ELBW Neonates at Case Western University • AKI Definition • SCr ≥ 1.5 mg/dl or UOP < 1 ml/kg/hr\ • 12.5 % Incidence of AKI Viswanathan et al. Ped Nephrology 2012

  17. AKI in ELBW infants • 472 ELBW Neonates at Case Western University • AKI Definition • SCr ≥ 1.5 mg/dl or UOP < 1 ml/kg/hr • 12.5 % Incidence of AKI • Infants with AKI had increased mortality • 33/46 (70%) vs. 10/46 (22%); p < 0.0001) • oliguric patients higher mortality • 31/38 (81%) vs. 2/8 (25%), p = 0.003. Viswanathan et al. Ped Nephrology 2012

  18. Neonatal AKI in sick near-term/term infants admitted to level 2 and 3 NICU • 58 Neonates admitted to Level 2 or 3 NICU • No congenital anomalies of the kidney • Birth weight > 2000 grams • 5 minute Apgar ≤ 7 • SCr criteria only • 16% Incidence of AKI Askenazi et. al. Abstract at ASN 2011 - Philadelphia

  19. Neonatal AKI in infants w/ perinatal asphyxia treated w/ hypothermia • 96 consecutive infants at U. of Michigan • AKIN • 38% AKI Selewski , et al… abstract presented at CRRT 2012

  20. Neonatal AKI in infants w/ perinatal asphyxia treated w/ hypothermia Selewski , Askenazi et al… abstract presented at CRRT 2012

  21. Neonatal AKI in infants with CDH on ECMO • Infants with congenital diaphragmatic hernia on ECMO (retrospective study) Gadepalli SK, Selewski DT et. al. J Pediatr Surg. Apr 2011

  22. Neonatal AKI in infants with CDH on ECMO • Patients with stage RIFLE “failure” • Increased time on ECMO • Decreased ventilator free days • Survival (p< 0.001) AKI = 27% No AKI = 80% Gadepalli SK, Selewski DT et. al. J Pediatr Surg. Apr 2011

  23. Neonatal AKI after Cardio-pulmonary Bypass Surgery • Retrospective chart review of 430 infants • <90 days, (median age 7 days) with CHD. • AKI was defined using a modified AKIN definition • urine output criteria included Blinder JJ, et al.. J ThoracCardiovasc Surg. 2011 Jul 26.

  24. Neonatal AKI after Cardio-pulmonary Bypass Surgery Blinder JJ, et al.. J ThoracCardiovasc Surg. July 2011

  25. Neonatal AKI after Cardio-pulmonary Bypass Surgery • AKI (all stages) - Longer ICU stay • AKI stages 2 and 3 • Increased mechanical ventilation • Increased post-operative inotropic therapy. • AKI was associated with higher mortality • 27/225 (12%) vs. 6/205 (3%) P <0.001 • Stage 2 OR for death = 5.1 • (95% CI =1.7 – 15.2; p= 0.004) • Stage 3 OR for death = 9.5 • (95% CI = 2.9 – 30.7; p= .0002. Blinder JJ, et al.. J ThoracCardiovasc Surg.

  26. Outcomes Children < 10 kg receiving CRRT

  27. 36% 14 Congen Ht Dz 5 71% 14 Metabolic 10 15% 13 Multiorg Dysfxn 2 42% 12 Sepsis 5 22% 9 Liver failure 2 0 5 Malignancy 0 50% 4 Congen Neph Synd 2 0 3 Congen Diaph Hernia 0 50% 2 HUS 1 50% 2 Ht Failure 1 100% 1 Obstr Urop 1 0 1 Renal Dyspl 0 60% 5 Other 3 Survival by Diagnosis N Survivors Am J Kid Dis, 18:833-837, 2003

  28. Children < 10 kg in the ppCRRT Registry Askenazi et.al. Journal of Pediatrics 2012 – in press

  29. ppCRRT Data of Infants < 10 kg: Askenazi et.al. Journal of Pediatrics 2012 – in press

  30. Smaller infants in ppCRRT have lower survival Askenazi et.al. Journal of Pediatrics 2012 – in press

  31. Children < 10 kg in the ppCRRT Registry

  32. ppCRRT Data of Infants < 10 kg Askenazi et.al. Journal of Pediatrics 2012 – in press

  33. Survival Differences by Fluid Overload in Infants < 10 kg enrolled in ppCRRT Askenazi et.al. Journal of Pediatrics 2012 – in press

  34. Fluid overload is bad for neonates Askenazi et.al. Journal of Pediatrics 2012 – in press

  35. Small children are dialyzed differently! Askenazi et.al. Journal of Pediatrics 2012 – in press

  36. Prescribing Pediatric CRRT

  37. Which is better PD, HD or CRRT?

  38. PD vs. HD vs. CRRT • Each has advantages & disadvantages • Choice is guided by • Patient Characteristics • Disease/Symptoms • Hemodynamic stability • Goals of therapy • Fluid removal • Electrolyte correction • Both • Availability, expertise and cost VS Pediatr Nephrol (2009) 24:37–48

  39. Peritoneal dialysis • Advantages • No blood prime needed • Low volume PD initiation soon after catheter insertion • PD prescription • 10 cc /kg dwell • 10 minute fill / 40 minute / 10 minute drain • Relatively low effort • Disadvantages • Risk of peritonitis • Abdominal disease is contraindication • Low clearances

  40. Hemodialysis • Advantages • Highest efficiency • Disadvantages • High Effort and Cost • High Acuity • Accomplish Goals in 3 – 4 hours difficult • Daily blood prime – implications on transplant

  41. CRRT • Advantages • Slow and Steady • Less Hemodynamic Instability • ? More physiologic • Disadvantages • Cost • Education of multiple bedside staff

  42. Vascular Access for CRRT • Put in the largest and shortest catheter when possible • The IJ site is preferable (over femoral) when clinical situation allows • A 7 or 8 F catheter may not fit in the femoral vein

  43. Blood Prime for CRRT

  44. Priming the Circuit for Pediatric CRRT • Blood • Small patient, large extracorporeal volume • Albumin • Hemodynamic instability • Saline • Common default approach • Self • Volume loaded renal failure patient

  45. Pediatric CRRT Circuit Priming Smaller patients require blood priming to prevent hypotension/hemodilution Circuit volume > 10-15% patient blood volume Example 5 kg infant : Blood Volume = 400 cc (80/kg) Prismalex circuit – M60 extracorporeal volume ≈ 100 ml Therefore 25% extracorporeal volume

  46. Added Risk for PRBC prime Packed RBCs HYPOCALCEMIC (I Ca++ = 0.2 Citrate HYPERKALEMIC (K+ = 5-12 meq/dl) LYSIS OF CELLS ACIDIC High HCT (70%) Protocols for initiation of CRRT use NaHCO3 and Calcium infusions around the time of initiation

  47. Blood Primes • Prime directly to the machine then hook up the patient • Baby Buffer technique • Give blood to baby and while you pull baby’s blood to prime circuit • Dual Prisma Setup for restarts.

  48. Blood Prime PRBC NaHCO3 Calcium Gluconate GO 10 ml / min 10 ml / min Waste NS Bag Brophy et al. AJKD 2001 Blood Flow = 20 ml / min

  49. Blood Prime PRBC NaHCO3 Waste NS Bag Brophy et al. AJKD 2001

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