3This is a schematic of one of our old CRRT set-ups This is a schematic of one of our old CRRT set-ups. Here is a simple blood pump with an attached hemofilter. There are separate IV pumps for replacement fluids, for dialysate, and to generate the negative pressure to remove the ultrafiltrate. Because this system has dialysate and replacement fluids, it would most accurately be called CVVHDF.These glued-together systems were not terribly user friendly and could be inaccurate as well.
4CRRT Machines: Current Generation Now, we have fancy new machines, dedicated to CRRT, able to perform numerous modalities accurately on a single platform.This one over here on the right, the Baxter BM-25, happens to be the machine we use here at Children’s.These new machines, and the other new technologies and techniques that have become available in only the last few years, have made CRRT a tremendously effective tool in the care of critically ill patients.I would add that despite all of this advancing technology, what really makes CRRT work for our patients is the incredible care and commitment of our nursing staff. Without our remarkable dialysis and ICU nurses, all of this would be useless.
8Prescribing CRRT for Small Kids ModalityBlood flow rateHemofilterSolution(s)Ultrafiltration rateAnticoagulationSpecial considerations
9CRRT Modality for Small Kids Am J Kid Dis, 18: , 2003
10Hemofilters for Pediatric CRRT NMaterialSurface area (m2)Prime vol (ml)Renaflo® II HF-40041 (48%)Polysulfone0.328Multiflow 6020 (24%)AN-690.648Fresenius F319 (22%)0.430Amicon® Minifilter®5 (6%)0.0815Am J Kid Dis, 18: , 2003
11Ultrafiltration Rate for Infant CRRT As tolerated by the patientPotentially limited by hemofilter, blood flow ratesSmall errors have a larger effect in a tiny patient
12Anticoagulation for Infant CRRT HeparinCitrateNothing? Other things ?
13Other Special Considerations for CRRT in Infants Large extracorporeal volume compared to small patientBlood prime (1:1 PRBC:Albumin 5%) at initiation frequently requiredRisk of thermic loss often requires heating system
14Potential Complications of Infant CRRT Volume related problemsBiochemical and nutritional problemsHemorrhageInfectionTechnical problemsLogistical problemsBradykinin release syndrome
15Logistical Issues for Infant CRRT Infrequently performed procedure in neonatal unitsVascular access can be difficult to organize and obtainNeonatology staff may be unfamiliar with equipment, procedure, risksWritten procedures may improve coordination and results of therapy
16Bradykinin Release Syndrome Mucosal congestion, bronchospasm, hypotension at start of CRRTResolves with discontinuation of CRRTThought to be related to bradykinin release when patient’s blood contacts hemofilterExquisitely pH sensitive
17Technique Modifications to Prevent Bradykinin Release Syndrome Buffered system: add THAM, CaCl, NaBicarb to PRBCsBypass system: prime circuit with saline, run PRBCs into patient on venous return lineRecirculation system: recirculate blood prime against dialysate
18Bypass System to Prevent Bradykinin Release Syndrome PRBCWasteModified from Brophy, et al. AJKD, 2001.
19Recirculation System to Prevent Bradykinin Release Syndrome Normalize pHNormalize K+Recirculation Plan:Qb 200ml/minQd ~40ml/minTime 7.5 minWasteBased on Pasko, et al. Ped Neph 18: , 2003
20Outcomes for Pediatric CRRT Data are scantMost studies are single-center, retrospectiveNo randomized controlled trialsSmall numbers limit powerExtension from adult studies may not be appropriate
25Survival by Diagnosis Totals: N=85; Survivors=32 Am J Kid Dis, 18: , 200336%71%15%42%22%50%100%60%Percentages instead of numbersTotals: N=85; Survivors=32
26Survival by Modality Modality N Survivors CVVH 27 11 (41%) CVVHD 12 3 (25%)CVVHDF4 (33%)CVVHD or CVVHDF247 (29%)Am J Kid Dis, 18: , 2003p=NS
27Retrospective Study of Infant CRRT: Summary Overall outcome acceptable3 – 10kg: outcome similar to that for older patientsMetabolic disorders: good outcome<3kg, selected diagnoses: poor outcomeNo clear advantage between modalitiesAm J Kid Dis, 18: , 2003
28Prospective Pediatric CRRT Registry (ppCRRT) Multi-center registry of pediatric CRRTCurrently eleven US centers participatingCollecting demographic, technical and outcome data on all pediatric patients receiving CRRTSub-analysis of infants <10kg presented at ASN and PAS/ASPN
29ppCRRT Data of Infants <10kg: Demographic Information 28 children <10 kg14 boys, 14 girlsMedian age 40 days oldRange 3 days to 2.9 yearsMedian weight 4.1 kgRange 1.3 to 9.5 kg
30ppCRRT Data of Infants <10kg: Indications for CRRT
31ppCRRT Data of Infants <10kg: Vascular Access Location
33Infant 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?