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Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Childrens Hospital & Regional Medical Center Seattle, WA

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Presentation on theme: "Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Childrens Hospital & Regional Medical Center Seattle, WA"— Presentation transcript:

1 Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Childrens Hospital & Regional Medical Center Seattle, WA

2 Pediatric CRRT: Vicenza, 1984

3

4 CRRT Machines: Current Generation

5 Vascular Access for Pediatric CRRT Smaller patients require smaller catheters Difficulty achieving access Difficulty maintaining access Limited access sites

6 Choices for Vascular Access Catheter TypeManufacturersPotential Pts. Single-lumen 5FrCook Small Neonates Double-lumen 7Fr Cook Medcomp 3 – 6 Kg Triple-lumen 7FrMedcomp3 – 6 Kg Double-lumen 8Fr Kendall Arrow 6 – 30 Kg

7 Access Sites for CRRT Femoral veins Jugular veins Subclavian veins Umbilical vessels ECMO circuit

8 Prescribing CRRT for Small Kids Modality Blood flow rate Hemofilter Solution(s) Ultrafiltration rate Anticoagulation Special considerations

9 CRRT Modality for Small Kids Am J Kid Dis, 18: , 2003

10 Hemofilters for Pediatric CRRT FilterNMaterial Surface area (m 2 ) Prime vol (ml) Renaflo ® II HF (48%)Polysulfone0.328 Multiflow 6020 (24%)AN Fresenius F319 (22%)Polysulfone0.430 Amicon ® Minifilter ® 5 (6%)Polysulfone Am J Kid Dis, 18: , 2003

11 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

12 Anticoagulation for Infant CRRT Heparin Citrate Nothing ? Other things ?

13 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

14 Potential Complications of Infant CRRT Volume related problems Biochemical and nutritional problems Hemorrhage Infection Technical problems Logistical problems Bradykinin release syndrome

15 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

16 Bradykinin Release Syndrome Mucosal congestion, bronchospasm, hypotension at start of CRRT Resolves with discontinuation of CRRT Thought to be related to bradykinin release when patients blood contacts hemofilter Exquisitely pH sensitive

17 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

18 Bypass System to Prevent Bradykinin Release Syndrome PRBC Waste Modified from Brophy, et al. AJKD, 2001.

19 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: , 2003 Normalize pH Normalize K +

20 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

21 CRRT in Pediatric Patients <10Kg Multi-center, retrospective study –5 pediatric centers –85 patients Demographic data Technique description Outcome Am J Kid Dis, 18: , 2003

22 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% 15.3% 14.1% 10.6% 5.9% 4.7% 3.5% 2.4% 2.3% 5.9% N=85 Am J Kid Dis, 18: , 2003

23 Why do Babies Need CRRT? Combined volume overload and biochemical abnormalities of renal failure 54% Volume overload18% Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia) 14% Biochemical abnormalities of renal failure9% Other (e.g., medication overdose)4% Volume overload and hyperammonemia1% N=85 Am J Kid Dis, 18: , 2003

24 CRRT in Infants <10Kg: Outcome Patients <10kgPatients 3-10kgPatients <3kg 38% Survival 41% Survival 25% Survival Am J Kid Dis, 18: , 2003

25 Survival by Diagnosis Totals:N=85; Survivors= % 71% 15% 42% 22% 0 50% 100% 0 60% Am J Kid Dis, 18: , 2003

26 Survival by Modality ModalityNSurvivors CVVH2711 (41%) CVVHD123 (25%) CVVHDF124 (33%) CVVHD or CVVHDF247 (29%) p=NS Am J Kid Dis, 18: , 2003

27 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: , 2003

28 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

29 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

30 ppCRRT Data of Infants <10kg: Indications for CRRT N=28

31 ppCRRT Data of Infants <10kg: Vascular Access Location N=28

32 ppCRRT Infant Survival Data 41% Survival 64% Survival 50% Survival

33 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?

34 Thanks!


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