PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart...
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![Page 1: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/1.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Multi-Center Pediatric CRRT Registry
Stuart L. Goldstein, MDAssistant Professor of Pediatrics
Baylor College of Medicine
![Page 2: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/2.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Overview
• Registry study phases– Study design– Study aims
• Current participating centers– Institutional practice protocol variation
• Current data analysis
![Page 3: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/3.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry: Phase 1 Design
• Collect prospective data from 5 to 10 pediatric centers treating 15 to 20 patients annually (200-300 patients over 3 years)
• Each center follows own institutional practice– Patient selection– Initiation and termination– Anti-coagulation protocols– Convection versus diffusion versus hemodiafiltration– Fluid composition
• Cytokine clearance study
![Page 4: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/4.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry: Phase 1 Aims
• Assess for potential associations between various practices and pediatric patient outcomes
• Assess for potential associations between varying practices and CRRT machine functioning
• Determine CRRT clearance rates of various SIRS and CARS cytokines in children with sepsis
![Page 5: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/5.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Current Registry Centers and PI
• Texas Children’s Hospital (January 2001)• Boston Children’s Hospital (March 2001)• Seattle Children’s Hospital (July 2001)• Univ of Alabama Children’s (July 2001)• Univ of Michigan (December 2002)
• Stuart Goldstein, MD• Michael Somers, MD• Jordan Symons, MD• Timothy Bunchman, MD• Patrick Brophy, MD Melissa
Gregory, MD
![Page 6: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/6.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Pre-CRRT Registry Data
• Demographics– Primary disease, co-morbid illness, age, gender, days in PICU
• CRRT specifics– Treatment or prevention of fluid overload and/or electrolyte
imbalance– Access size and site
• Renal failure indices– GFR (Schwartz)– Percent fluid overload (%FO)– Urine output in previous 24 hours
![Page 7: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/7.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Registry PICU Data
• PRISM 2 at ICU admission and CRRT initiation• CRRT initiation
– CVP– MAP– Pressor number and specific drugs– Diuretic use
• CRRT course– Maximum pressor number– MAP change– Pressors weaned?
![Page 8: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/8.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Circuit Data
• Separate data page for each circuit• Machine brand• Extracorporeal volume• Priming fluid
– NS– albumin– blood mixed with
• FFP, albumin, or bicarbonate
• Dialysis or replacement fluid composition– Normocarb™ (Dialysis Solutions, Inc)– Baxter hemofiltration fluid™– Saline, Ringer’s lactate, peritoneal dialysis fluid
![Page 9: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/9.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Circuit Data• Anticoagulation
– Citrate– Heparin rate
• ACT measured per hour• Mean ACT• # ACT < 180 seconds
• Clearance prescription– CVVH versus CVVHD versus CVVHDF– ml/1.73m2/hour
• Nutrition prescription– Kcal/kg/day– Grams protein/kg/day
![Page 10: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/10.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Patient Data: Outcome
• Survival versus death (discharge from PICU)• Attainment of target dry weight• Reason to discontinue CRRT
– Death– Regained renal function– Underlying illness resolved– Tolerates intermittent hemodialysis
![Page 11: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/11.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Circuit Data: Outcome
• Filter life-span (hours)• Reason for circuit change
– clotting– access malfunction– machine malfunction– unrelated patient indication (e.g., needs CT scan)– CRRT discontinued
![Page 12: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/12.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry: Results (4/1/2002)
• 42 patients entered into study• 36 with complete data• 128 circuits• 4905 cumulative treatment hours
– Mean 41.2 + 28.9 hours– Range 1 to 118 hours
![Page 13: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/13.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Baseline Demographics
Age 8.2 + 7.3 years
Weight 33.8 + 28.4 kg
GFR 35.3 + 25.3 ml/min/1.73m2
![Page 14: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/14.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Registry Center Census
Center
Pat
ient
s
0
2
4
6
8
10
12
14
16
18
20
Houston Boston UAB Seattle
![Page 15: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/15.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Primary Disease
Primary Disease
Pat
ient
s
0
1
2
3
4
5
6
7
8
9
10
Sep
sis
Car
diom
yopa
thy
RV
T
BM
T
ATN
CV
Sho
ck
Tum
or L
ysis
AM
L
Bow
el P
erf
Met
abx
FO
MO
SF
Nep
hrtx
Met
abol
ic
AR
F
HU
S
![Page 16: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/16.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Modality
MODALITY
Pat
ient
s
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
CVVH CVVHDF CVVHD SCUF
![Page 17: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/17.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Reason to Start CRRT
Reason to Start CRRT
Pat
ient
Num
ber
35.9% 35.9%
12.8%
7.7% 7.7%
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
FO Only FO and EI EI Only Other Prevention of FO
![Page 18: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/18.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Outcome
OUTCOME
Pat
ient
s
38.9%
61.1%
0
2
4
6
8
10
12
14
16
18
20
22
24
Death Survival
![Page 19: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/19.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Clinical Variables and Outcome• Survival not associated with
– GFR– Pressor number– MAP– PRISM at ICU admission– Age– Weight
• Survival associated with– PRISM at CRRT initiation– % Fluid overload at CRRT initiation
![Page 20: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/20.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
PRISM at CRRT Initiation and Outcome
±Std. Dev.±Std. Err.Mean
OUTCOME
PR
ISM
AT
CR
RT
Initi
atio
n
2
6
10
14
18
22
26
30
Death Survival
P < 0.0005
![Page 21: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/21.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Fluid Overload and Outcome
±Std. Dev.±Std. Err.Mean
OUTCOME
Per
cent
Flu
id O
verlo
ad a
t CR
RT
Initi
atio
n
-5
0
5
10
15
20
25
30
35
40
Death Survival
P < 0.05
![Page 22: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/22.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Fluid Overload and Outcome:Renal Failure Only
±Std. Dev.±Std. Err.Mean
OUTCOME
Per
cent
Flu
id O
verlo
ad a
t CR
RT
Initi
atio
n
-5
0
5
10
15
20
25
30
35
40
Death Survival
P < 0.05
![Page 23: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/23.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Fluid Overload, Severity of Illness and Outcome
• Greater degrees of fluid overload associated with death, even when controlled for severity of illness by PRISM score (multiple regression analysis; p<0.03)
![Page 24: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/24.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Circuit Change Reason
Reason to Change Circuit
Circ
uit N
umbe
r
0
3
6
9
12
15
18
21
24
27
30
33
36
Scheduled ChangeClotted
OtherAccess Malfunction
Patient Test
![Page 25: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/25.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
Anticoagulation Method and Circuit Life
±Std. Dev.±Std. Err.Mean
Anticoagulation
Circ
uit L
ife (H
ours
)
-10
10
30
50
70
90
Heparin Citrate
P < 0.003
N=69
N=38
![Page 26: PCRRT Multi-Center Registry Data Effective April 1, 2002 Multi-Center Pediatric CRRT Registry Stuart L. Goldstein, MD Assistant Professor of Pediatrics.](https://reader035.fdocuments.us/reader035/viewer/2022062503/5a4d1b0f7f8b9ab05998e279/html5/thumbnails/26.jpg)
pCRRT Multi-Center Registry Data Effective April 1, 2002
pCRRT Registry Future Phases• Assess association between nutrition and outcome• Assess cytokine levels and clearance• Test new products devices safely and efficiently• Prospective randomized trials
– Dose– Fluid options– Selective cytokine removal– Time to intervention– Disease-specific protocol and outcome
• Web-based for easy access and query