Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Childrens...
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Transcript of Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Childrens...
Neonatal and Infant CRRT
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, [email protected]
Pediatric CRRT: Vicenza, 1984
CRRT Machines: Current Generation
Vascular Access for Pediatric CRRT
• Smaller patients require smaller catheters
• Difficulty achieving access
• Difficulty maintaining access
• Limited access sites
Choices for Vascular Access
Catheter Type Manufacturers Potential Pts.
Single-lumen 5Fr CookSmall Neonates
Double-lumen 7FrCook
Medcomp3 – 6 Kg
Triple-lumen 7Fr Medcomp 3 – 6 Kg
Double-lumen 8FrKendall
Arrow6 – 30 Kg
Access Sites for CRRT
• Femoral veins
• Jugular veins
• Subclavian veins
• Umbilical vessels
• ECMO circuit
Prescribing CRRT for Small Kids
• Modality
• Blood flow rate
• Hemofilter
• Solution(s)
• Ultrafiltration rate
• Anticoagulation
• Special considerations
CRRT Modality for Small Kids
2%
18%16%
21%43%
CVVH CVVHD CVVHDF SCUF >1 Modality
Am J Kid Dis, 18:833-837, 2003
Hemofilters for Pediatric CRRT
Filter N MaterialSurface
area (m2)Prime
vol (ml)
Renaflo® II HF-400 41 (48%) Polysulfone 0.3 28
Multiflow 60 20 (24%) AN-69 0.6 48
Fresenius F3 19 (22%) Polysulfone 0.4 30
Amicon® Minifilter® 5 (6%) Polysulfone 0.08 15
Am J Kid Dis, 18:833-837, 2003
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
Anticoagulation for Infant CRRT
• Heparin
• Citrate
• Nothing
• ? Other things ?
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
Potential Complications of Infant CRRT
• Volume related problems
• Biochemical and nutritional problems
• Hemorrhage
• Infection
• Technical problems
• Logistical problems
• Bradykinin release syndrome
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
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
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
Bypass System to Prevent Bradykinin Release Syndrome
PRBC Waste
Modified from Brophy, et al. AJKD, 2001.
Recirculation System to Prevent Bradykinin Release Syndrome
D
Waste
Recirculation Plan:
Qb 200ml/min
Qd ~40ml/min
Time 7.5 min
Based on Pasko, et al. Ped Neph 18:1177-83, 2003
Normalize pH
Normalize K+
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
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
Which Babies Require CRRT?Congenital heart disease
Metabolic disorder
Multiorgan dysfunction
Sepsis syndrome
Liver failure
Malignancy
Congenital nephrotic syndrome
Congenital diaphragmatic hernia
Congenital renal/urological disease
Hemolytic uremic syndrome
Heart failure
Other
16.5%
16.5%
15.3%
14.1%
10.6%
5.9%
4.7%
3.5%
2.4%
2.3%
2.3%
5.9%
N=85
Am J Kid Dis, 18:833-837, 2003
Why do Babies Need CRRT?
Combined volume overload and biochemical abnormalities of renal failure
54%
Volume overload 18%
Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia)
14%
Biochemical abnormalities of renal failure 9%
Other (e.g., medication overdose) 4%
Volume overload and hyperammonemia 1% N=85
Am J Kid Dis, 18:833-837, 2003
CRRT in Infants <10Kg: Outcome
85
69
16
32 28
4
N
Survivors
Patients <10kg Patients 3-10kg Patients <3kg
38% Survival 41%
Survival
25% Survival
Am J Kid Dis, 18:833-837, 2003
Survival by Diagnosis14
14
13
12
9
5
4
3
2
2
1
1
5
5
10
2
5
2
0
2
0
1
1
1
0
3
Congen Ht Dz
Metabolic
Multiorg Dysfxn
Sepsis
Liver failure
Malignancy
Congen Neph Synd
Congen Diaph Hernia
HUS
Ht Failure
Obstr Urop
Renal Dyspl
Other
N
Survivors
Totals: N=85; Survivors=32
0
36%
71%
15%
42%
22%
0
50%
50%
50%
100%
0
60%
Am J Kid Dis, 18:833-837, 2003
Survival by Modality
Modality N Survivors
CVVH 27 11 (41%)
CVVHD 12 3 (25%)
CVVHDF 12 4 (33%)
CVVHD or CVVHDF 24 7 (29%)
p=NSAm J Kid Dis, 18:833-837, 2003
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
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
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
ppCRRT Data of Infants <10kg: Indications for CRRT
75%
25%Fluid and Electrolyte Imbalance
Metabolic Anomaly or Toxin
N=28
ppCRRT Data of Infants <10kg: Vascular Access Location
18%
67% 15%
Femoral Internal Jugular Subclavian
N=28
ppCRRT Infant Survival Data
1711
28
7 714
<5 kg 5 - 10 kg <10 kg
N
Survivors
41% Survival
64% Survival
50% Survival
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?
Thanks!