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0 CRRT Prescription Akash Deep Director - PICU King’s College Hospital London Chair Renal/CRRT Section European Society of Pediatric and Neonatal Intensive.

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Presentation on theme: "0 CRRT Prescription Akash Deep Director - PICU King’s College Hospital London Chair Renal/CRRT Section European Society of Pediatric and Neonatal Intensive."— Presentation transcript:

1 0 CRRT Prescription Akash Deep Director - PICU King’s College Hospital London Chair Renal/CRRT Section European Society of Pediatric and Neonatal Intensive Care (ESPNIC)

2 Vascath – Size, location Rates & Dose Blood flow Dialysis fluid Replacement fluid Ultrafiltration rate Anticoagulation Drug Dose Suggested Not necessarily a recipe Overview

3 CRRT for AKI or Sepsis or Liver failure –does the dose matter ? Modality : Do you do convective or diffusive or both, does it matter? Blood Flow rate: based upon the size of the child or what the vascular access can give you? Anticoagulation – Which, when, dose, mode of delivery Drug dosing – a perennial debate!!!! Is there a “typical” prescription?

4 Decide the Indication to start CRRT PRESCRIBE: VASCULAR ACCESS – Size Location Haemofilter and appropriate Sized Blood line set Priming Solution Blood Flow Modality /Dose – Replacement Fluid/Dialysis Fluid Prescribe Fluid loss rate Prescription of electrolyte corrections Anticoagulation – Dose,Modality, Monitoring Drug Dosing Essential steps in CRRT Prescription

5  Qb  Age & weight – based  Promote circuit lifespan + patient stability: clots vs alarms  Highly access-dependent  Aim return access pressures ~ < 200 mmHg, no alarms  Start lower and increase by about 10 minutes (?) – 50% of target and then go up 10% every 10 minutes till desired flow reached Blood flow rate

6  No set “perfect rates”  From 3 to ~10 ml/kg/min, depending on age though we use minimum of 50 mls/min for newborns  Examples: 0-10 kg: 25-50ml/min 11-20kg: ml/min 21-50kg: ml/min >50kg: ml/min  Neonates 8 to 12 ml/kg/min  Children 4 to 8 ml/kg/min  Older 2 to 4 ml/kg/min.  Most not > 200 ml/min: not dangerous just not necessary Based on previously most commonly used machine Blood flow rate

7 May need to modify:  - Patient hemodynamics – initial and subsequent  which might change with CRRT  - Be aware of access and return pressure  - Visually inspect filter for clots  - Trans-membrane pressure – may need to increase blood flow Blood flow rate

8 Treatment Dose

9  Clearance mostly a function of:  Dialysis fluid flow rate (Qd)  Replacement fluid flow rate (Qr)  Molecular weight and sieving coefficient  Higher rates = higher clearance for IEM, drug removal, severe high K = more middle molecule clearance (CVVH/CVVHDF) = more hypophosphatemia, kalaemia, magnesaemia = more amino acid losses = more drug clearance = more work to change bags, give electrolyte infusions Qd + Qr (CVVHDF) Dialysis and Replacement Fluid Rates: Clearance & Dose

10  No well-defined right “dose” of clearance.  For CRRT: mostly expressed in terms of effluent (ml/kg) per hour “Standard” suggestion: Qd or Qr or Qd+Qr ~ ml/kg/hour OR 2 to 2.5 liters/hr/1.73msq. Some do much higher: some machines as high as 8L/hourREALIZE: What you prescribe is not necessarily what the patient gets!! Time off circuit, microclots in filter over time, predilution Urea clearance ~ ml/min/1.73msq Dialysis and Replacement Fluid Rates: Clearance & Dose

11 Prescribed and Delivered therapy dose Typically, therapy dose would be prescribed at 35 ml/kg/hr, in practice the delivered therapy dose was on average 8ml/kg/hr less. Prescription should exceed that calculated to be adequate because of the known gap. Why might we ‘lose’ significant amounts of therapy dose? –Recirculation in vascular access –High filtration fractions –Filter clogging and clotting –Troubleshooting skills –Changing of circuits –Filter down time Vesconi et al Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury Crit care (2);r57

12 CVVH Qr = 300 ml/hour CVVHD Qd = 300 ml/hour CVVHDF Qd = 150ml/hour Qr = 150 ml/hour 10 kg child: 30 ml/kg/hr “clearance” OR ~ 0.26 msq: 2L/1.73msq/hour = 300 ml/hour

13 Dialysis Dose and Outcome Ronco et al. Lancet 2000; 351: Conclusions: Minimum UF rates should be ~ 35 ml/kg/hr Survivors had lower BUNs than non-survivors prior to commencement of hemofiltration 425 patients Endpoint = survival 15 days after D/C HF 146 UF rate 20ml/kg/hr survival significantly lower in this group compared to the others 139 UF rate 35ml/kg/hr p= UF rate 45ml/kg/hr p=0.0013

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15 ATN Study

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17 Randomised Evaluation of Normal vs Augmented Level Replacement (RENAL) Therapy ) 1500 critically ill adults CVVHDF 25 ml/kg/hour 40 ml/kg/hour Mortality at 28 days was similar in the higher- intensity and lower-intensity treatment groups (38.5% and 36.9%, respectively), and mortality at 90 days was the same (44.7%) in both groups.

18 These adult studies have failed to note a dose response curve of survival These studies are flawed for IHD vs CRRT was compared and CRRT was both convective and diffusive Does the dose of solution exposure per unit of time matter

19 If you start with a standard prescription Eg –BFR 5-10 mls/kg/min (access dependent) –Membrane surface area proportional to patient body surface area –Decision of convective or diffusive at approx /mls/hr/1.73m2 So

20 If the marker of your clearance is not achieved –E.g. inadequate clearance of Urea, Ammonia, intoxicant, lactate Then increase your solution exposure per unit of time Maximize convective clearance before adding diffusive clearance Consider increasing the BFR and increasing surface area of the membrane Filter downtimes to be minimised and

21  CVVHD – dialysis fluid for diffusive clearance  CVVH – replacement fluid:  replacing fluid you are removing to achieve solute clearance by convection  CVVHDF – both  Priming solutions – Saline /blood prime  Anticoagulant solutions Using these to correct metabolic abnormalities (remove) and prevent treatment-related metabolic abnormalities (replace). Solutions

22  Personal suggestion: use the same solution  If needed (e.g. alkalosis) can modify the replacement solution  Regulatory issues may hinder:  Replacement solution – saline, with additives Dialysis fluid? Replacement fluid?

23 Barletta et al, Pediatr Nephrol, 2006 Survey: ICU, Nephrology, CRRT  16/31 programs reported solution compounding errors with manually dispensed solutions  2 deaths  1 non lethal cardiac arrest  6 seizures (hypo/hypernatremia)  7 without complications Solutions: watch for errors!

24  No Study has identified effective, safe UF rates in Children.  General acceptance that 1-2ml/kg/hr is often safe (stable patient)  Choose UF rate to: - balance input (e.g. boluses, citrate, calcium, etc) - remove excess fluid over time - “make room” for IV fluids and nutrition - Also provides solute clearance by convection Ultrafiltration/fluid removal Rates

25  Fluid removal should be safe AND effective – no need to sacrifice one for other: –Frequent communication –Frequent reassessment (MD), Hourly reassessment (RN)  Know what the “usual hourly input is”: »IV fluids »Citrate & calcium »Nutrition (give!!) »Meds/infusions »Provide “rules” for removing “intermittent fluids” Be aware of the “outs” (tubes, urine, diarrhea) Decide desired DAILY fluid removal based on: Haemodynamics TOTAL severity of Fluid Overload Ultrafiltration/fluid removal Rates

26  Removes protein bound small substances:  e.g. copper/Wilson's, drugs, toxins of liver failure  Albumin live a scavenger Dialysis:  albumin-containing solution across highly permeable membrane  20% albumin NOT “added” to dialysis fluid bag- it sinks however it is mixed with normal dialysate via 3 way tap -it's “single pass” - bags are changed  Shouldn't affect sodium – may affect (reduce) other electrolytes Collins et al, Pediatr Nephrol, 2008 Askenazi et al, Pediatrics, 2004 Ringe, Pediatr Crit Care Med, 2011 SINGLE PASS Albumin dialysis -SPAD

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28 ANTICOAGULATION

29 Choice of anticoagulant Dose Route of delivery – systemic, into the circuit ANTICOAGULATION-Points to consider

30 Heparin Citrate Prostacyclin Anticoagulation

31 Heparin – U/kg/hour Prostacyclin – 2-8 ng/kg/min Citrate – separate protocol All anticoagulants to be used pre-filter with post filter monitoring ( ACT in heparin, ionised Ca in citrate) Dosing and Route

32 Drug Dose Alteration Drug dosing- important ( antibiotics, anticonvulsants, sedation, inotropes) Hepatic failure + CRRT – Bigger issues Based on: –Protein Binding Information –Volume of Distribution –Molecular Weight

33 Drug Prescribing in Renal Failure edited by George Aronoff et al Commonly carried text by pharmacists baptist.louisville.edu/renalbo ok/http://www.kdp- baptist.louisville.edu/renalbo ok/ New edition to come out soon Recommendations for new drugs IHD and CRRT recommendations Pediatric recommendations (T bunchman)

34  Blood flow: balance access/circuit life with tolerability  Solutions: Many choices »Know their content, regional rules, CRRT type used »Decide on desired flexibility »Decide what's best for your institution (volume, expertise) »Bicarbonate and calcium are most substantial differences »Be aware of errors – can be life threatening  Dialysis/replacement fluid rates: ie clearance dose »Balance desired clearance with undesired losses »2-2.5 L/hour/1.73msq – suggested only  Ultrafiltration rate: »Frequent reassessment, team + targeted fluid removal decisions »Safety AND efficacy are feasible Summary

35 T Bunchman pCRRT Foundation CRRT team at King’s Acknowledgements

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