Prescribing CRRT for Small Kids Modality Blood flow rate Hemofilter Solution(s) Ultrafiltration rate Anticoagulation Special considerations
CRRT Modality for Small Kids Am J Kid Dis, 18: , 2003
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
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 patients 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: , 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: , 2003
Survival by Modality ModalityNSurvivors CVVH2711 (41%) CVVHD123 (25%) CVVHDF124 (33%) CVVHD or CVVHDF247 (29%) p=NS Am J Kid Dis, 18: , 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: , 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 N=28
ppCRRT Data of Infants <10kg: Vascular Access Location N=28
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?