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Complications of Pediatric CRRT

Complications of Pediatric CRRT. Theresa A. Mottes RN Pediatric Dialysis/Research Nurse C.S. Mott Children’s Hospital University of Michigan . Complications of Pediatric CRRT. Temperature instability Hemodynamic instability Anticoagulation Risk Circuit/Access Complications.

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Complications of Pediatric CRRT

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  1. Complications of Pediatric CRRT Theresa A. Mottes RN Pediatric Dialysis/Research Nurse C.S. Mott Children’s Hospital University of Michigan

  2. Complications of Pediatric CRRT • Temperature instability • Hemodynamic instability • Anticoagulation Risk • Circuit/Access Complications

  3. Factors effecting hemodynamics • Patient Volume Status • Ultrafiltration Rate • patients hemodynamic • typically vasopressor dependent • patients intravascular volume • Ultrafiltration Rate • 1-2ml/kg/hour net ultrafiltration • absolute necessity to control ultrafiltration • error of accurate ultrafiltration monitoring

  4. RESULTS(Smoyer et al, CRRT 1997) Trilogy Pump: Accuracy over Range of Flow Rates % Error IV Pump Flow Rate (ml/hr)

  5. Ultrafiltration accuracy2.8 kg infant on PRISMA Prescription BFR 30 mls/min Dx FR 300 mls/hr Ccs/hr Hour of Therapy

  6. Factors effecting hemodynamics • What now? • Hourly assessment of Intake and Output • Hourly Ultrafiltration calculations • adjusting for pump error • Accurate measuring of Ultrafiltration • Close monitoring of hemodynamics • Accurate daily weight

  7. Factors effecting hemodynamics • Calculation for Pump Error

  8. Factors effecting hemodynamics • Vasopressor clearance • Vasopressor agents all have in common a small molecular weight and minimal protein binding • Epinephrine • Norepinephrine • Dopamine • Dobutamine

  9. Factors effecting hemodynamics • Vasopressors • Due to proximity of infusion • be aware of infusing vasopressor agents in immediate proximity to the “arterial” port of the hemofiltration machine • potential for recirculation • effects delivery and clearance

  10. Intravascular Blood Volume • < 10 kg 80 ml/kg • e.g. 8 kg infant = 640 ml intravascular volume • > 10 kg 70 ml/kg • e.g. 20 kg child has 1.4 liter intravascular volumeBlood • Priming Hemofiltration Circuit • Recommended when circuit volume > 10 % of patients intravascular blood volume

  11. Anticoagulation • Heparin • Citrate • None

  12. Circuit Complications • Circuit Clotting • Inability to ultrafiltrate desired amount • Increasing Access/Return Pressure • Inadequate clearances • Observe clotting in filter/ tubing

  13. Clotting with CVVH vs CVVHD(Mottes et al, CRRT 1999)

  14. Flow Rates • Blood • 5-10 ml/kg/min keeping venous pressure under 200 mm Hg • Dialysate/Replacement fluid • 2 liters/1.73 m2/hr • (extrapolation of adult data)

  15. Access Complications • What is the correct access? • One that works

  16. In Flow Difficulties • Obstruction or clot on the return line • high intrathoracic pressure with HIFI • up against the vessel wall • Clamp on inflow • Access kinked at skin site • Consider reversing or changing access

  17. Out Flow Difficulties • Clamp on access/”arterial” line • Inflow port up against vessel wall • Patient “dry” eg with femoral site • High of blood flow requirements based upon flow ability of access • Consider • reverse flow, change access, decrease blood flow rates

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