Presentation on theme: "Putting it all together: When resources are scarce Mignon McCulloch Associate Professor Department of Paediatric Critical Care Red Cross Children’s Hospital."— Presentation transcript:
Putting it all together: When resources are scarce Mignon McCulloch Associate Professor Department of Paediatric Critical Care Red Cross Children’s Hospital (RXH) University of Cape Town
Acknowledgements Thanks to Stuart and Tim Including all forms of CRRT Disclosures Passionate about PD Access for children with AKI in poorly resourced areas
Clinical Patients 2.5kg boy Complex Congenital Heart Post-op surgical No urine output x 8hrs What next? 12year old boy Meningococcal Sepsis Shocked needing inotropic support Poor urine output x 12hrs What next?
Less than 1km down the road…
Role of Fluid FO time of CRRT initiation %FO = (Fluid In – Fluid Out) x 100% (PICU Admission weight) Goldstein et al(2005). KI 67: But what happens before?
Goal directed therapy Study of Emergency Department Management
Rivers et al, N Engl J Med, 2001
de Oliveira CF et al, Intensive Care Med, 2008
Severe sepsis and septic shock guidelines 2008
FEAST Trial ?
FEAST Study (Fluid Expansion as Supportive Therapy) NEJM June 30, 2011 Maitland et al Severe febrile illness & impaired perfusion randomised to: Bolus 5% Albumin 20-40ml Bolus 0,9% Saline No bolus Halt recruitment 3141/ hour mortality 10.6% bolus vs 7.3% non-bolus(p=0.003)
Maitland et al, N Engl J Med, 2011
Criticisms - NEJM Oct 6, 2011 Severely anaemic children - 32% Hb<5mg/dl Acute haemodilution in pre-existing anaemia Impaired oxygen delivery leading to organ failure Malaria – 57% thus have sequestration of red cells in microcirculation Shock – not all forms are the same – related to high CO or diminished O2 Compromised oxygen delivery – 77% thus worsening cellular dysoxia Malnutrition
Plans Rapid triage and treatment Monitoring in a low resource setting What is possible? CVP What is physiologic fluid best for bolusing Blood vs fluid boluses Choice of fluids BMJ 2010;341 Maitland, Colloids vs Crystalloids for fluid resuscitation Cochrane 2012 – Perel P Low-volume fluid resuscitation insufficient for patients in shock – Inotropes?
Needed: Observational Trial in Septic Shock Fluid challenge – 10-20ml/kg…then Observe response: Heart rate and BP, Resp rate, Oxygen sats Cardiac output in response to fluid Portable Uscom/Echocardiography validation Pulmonary oedema – Lung impedance High flow Oxygen/CPAP/Ventilation Inotropes – peripheral/central AKI???
Renal Replacement Therapy What we have done in Cape Town?
Initial Management Urine output: Aim for > 1ml/kg/hr Fluid challenge 10ml/kg 0.9% Saline over 30 minutes and reassess urine output If no improvement & no signs of fluid overload, repeat bolus Clinical assessment regarding intravascular volume status +/- invasive assessment
“Encouraging Agents” Fluid and Perfusion Furosemide ivi Boluses 1 - 5mg/kg or Infusion 0.1 – 1mg/kg Mannitol/Metolazone Aminophylline 1 - 5mg/kg ivi if stable **Dopamine 2 – 5mcg/kg/min infusion
IPNA/ISN Training for Africa Nigeria BeninUganda Kenya Ghana
Challenges on Return Poor Staffing100% Lack of Facilities & Equipment86% Radiology – Ultrasound only86% Support from Home Institutions71% Histology support57%
ISN Sister Program PD Workshop Accra, Ghana
PD Catheters Art of Medicine? Innovative and Creative Cannulas Naso-gastric tubes/Chest Drains Venous Central lines Rigid ‘Stick’ catheters ‘Peel away’ Tenchkoff Flexible Multi-purpose drainage catheters Auron A et al Am J Kidney Dis 2007
Devices for Peritoneal Dialysis
New Generation Cook Catheters
Kimal ‘Peel-away’ Tenchkoff
Tips for Success Size matters…keep skin nick at minimum or nil at all Else will leak!!! Avoid metal needle that comes with pack Rather Jelco/Venous access catheter Withdraw needle 0.5mm as go thru peritoneum and advance plastic sheath Run fluid in freely to fill abdomen before wire and catheter If not free-flowing pull needle back slightly May be in bowel?....role of ultrasound Don’t forget to empty bladder
Automated Dialysis Home choice machine
Manual Dialysis with Fluid Warmer
Post Abdominal Surgery 8Fr Cook PD Catheter 8Fr Cook Pigtail multi-purpose drainage device
Improvised equipment and solution used in the procedure 5/9/2015Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH 41
5-yr old with HUS PD duration - 8 days 5/9/2015 Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH 42
PD progress in 1 st 24 hrs 5/9/ Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH
PD in session 5/9/ Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH
CONCLUSION Peritoneal dialysis as a form of acute renal replacement therapy is: Practical Appropriate for developing countries Results reflected suggest that due to ease of use, it may also be appropriate for centers where access to CVVH/D may not be available due to lack of equipment or trained staff
PRACTICAL SKILLS WORKSHOP IPNA/ISN/SKCF/Saving Young Lives …..and all other supporters Nov 2012
Thank you to all my RXH Thank you for your time and attention !