1 CRRT Therapy in the Pediatric Critical Care Patient An overview of common complications and solutions for Pediatric Critical Care Patients undergoing CRRT Therapy By Tom MacCrae RN, BSN

2 Speaker Information 2 1/2 Years experience as EMT in Santa Clara County Graduated with BSN from Azusa Pacific University 2004 PICU RN at Lucile Packard Children’s Hospital since 2004 CRRT Clinical Coordinator in PICU since 2006

3 Hungry for Knowledge? Lets Get Ready to Learn!!!!

4 Objectives Explanation of common catheter, filter, and pump complications with CRRT in the Pediatric Patient Examine specific patient related complications for pediatric patients undergoing CRRT therapy. Discuss the recommended solutions to common CRRT complications in the Pediatric Patient Review select case scenarios from the PICU at LPCH and discuss how specific CRRT complications were addressed

5 CRRT with Prisma Machine

6 Catheter complications Sluggish blood flow through the catheter Catheter entry site complications Patient position problems Blood clotting complications Blood Products / Drugs affecting catheter function Left Femoral Catheter

7 Solutions To Catheter Complications Re-positioning the patient TPA for clotted catheters Infuse blood products and drugs as far away from the CRRT catheter as possible Reversing the catheter access if necessary

8 Example of Catheter Location Tunneled Catheters Non-tunneled Catheter

9 CRRT Catheter with Pig-Tail Lumen

10 Double Lumen Catheter with Dilator and Wire

11 Filter / Pump Complications Sluggish blood flow in the filter and tubing Failing or clotting filter Cracked filter or ruptured tubing Filter saturation, and short filter life Frequent air and blood leak alarms

12 Filter Saturation

13 Solutions To Filter / Pump Complications Adjust blood flow rate to accommodate for rising or falling access and return pressures Anticipate more frequent filter changes for PT in DIC Special attention to calcium and citrate infusions can help to minimize filter and pump complications

14 Solutions To Filter / Pump Complications Careful observation for clots in the filter may warn of impending failure Keeping machine clean will also eliminate potential alarms and reduce pump complications Trouble shooting alarms instead of silencing them will decrease associated complications.

15 Pediatric Patient Complications Blood Pressure instability Electrolyte imbalance Risk of Bleeding Decreased HCT / HGB Kids Don’t Hold Still Smaller kids = smaller catheters = restricted blood flow

16 Solutions To Pediatric Patient Complications Blood Prime Used for Small babies and Patients with low HCT **special considerations** Albumin Prime Used for Patients with B/P instability Saline Prime Decreases exposure to blood products in stable patients Pre-Medication Administration CACL, Albumin, isotonic volume Frequent Lab and VS monitoring Chem 10, CBC, Coags

17 Case Scenarios (1) Pt J.J., a morbidly obese teenager in renal failure, fighting sepsis who is undergoing CRRT. (2) Pt C.P., an active teenage patient undergoing CRRT and plasmapheresis simultaneously using the same catheter (3) Pt A.M., a small infant with multi-system organ failure waiting for a liver transplant

18 Case Scenario #1 (Pt. J.J.) In addition to his underlying metabolic disorder J.J. experienced multi-system organ failure, severe respiratory distress, and sepsis. Making things even more complicated was the fact the J.J. was morbidly obese. J.J. experienced catheter and filter complications while on CRRT. J.J. was also very unstable and frequently dealt with B/P instability. He required multiple blood transfusions while on CRRT.

19 Case Scenario #1 (Pt. J.J.) An Overview of Complications Larger patients require much faster blood flow rates when undergoing CRRT therapy. The faster rates increase the strain on the HD catheter and generally lead to more complications with CRRT therapy Patients with large amounts of subcutaneous tissue generally have more frequent complications with their HD Catheter Patients who are unstable on CRRT may require multiple blood transfusions and pharmacological interventions while undergoing therapy. These additional therapies are problematic as they often lead to clotted filters.

20 Case Scenario #1 (Pt. J.J.) An Overview of Solutions If possible, using the largest size HD catheter in the obese patients will allow for optimum blood flow rates which will enable the CRRT therapy to be most effective By adjusting the blood flow rates as soon as catheter blood flow becomes a problem, the associated catheter complications may be avoided Infusing the necessary blood transfusions and drug products as far away from the CRRT catheter can minimize complications with the catheter and the filter. (opposite side of body and diaphragm) TPA and heparin are useful tools to maintain a patent catheter. When used to lock the catheter during circuit changes TPA or heparin can un-clot an occluded catheter

21 Case Scenario #2 (Pt. C.P.) C.P. was a very unique patient in the PICU because of her mobility. C.P. was one of the very few patients to undergo CRRT and was stable enough to sit up in bed and interact as a relatively normal teenage girl. During the course of her CRRT it was determined that C.P. would benefit from plasma pheresis. The decision was made to run plasma pheresis and CRRT on the same catheter, thereby increasing the amount of strain on the CRRT catheter

22 Case Scenario #2 (Pt. C.P.) An Overview of Complications Active children and teenagers can often complicate CRRT therapy with frequent and unpredictable movement which can clamp off the HD catheter both internally and externally Children with medical conditions which require additional intravenous therapies may increase the likelihood of complications with their CRRT therapy

23 Case Scenario #2 (Pt. C.P.) An Overview of Solutions Encourage the medical / surgical team to place the HD catheter in a location which will be minimally kinked with patient movement Proper dressing and arm board placement to extremities with HD catheters in place can minimize complications Adjusting the blood flow rate of the CRRT during any additional intravenous therapies will help minimize any potential complications

24 Case Scenario #3 (Pt. A.M.) A.M. was one of the smallest patients that we have placed on CRRT in the PICU While waiting for a liver transplant this patient developed renal failure Without a functioning liver or kidney the patients body began retaining fluid and toxins The benefit of CRRT for this patient outweighed the risks associated with using CRRT on such a small patient

25 Case Scenario #3 (Pt. A.M.) An Overview of Complications Babies often encounter unique complications with CRRT therapy because of their small size Complications can include blood pressure instability, electrolyte imbalances, and catheter complications Small patients require extra special attention to fluid and electrolyte removal when receiving CRRT therapy

26 Case Scenario #3 (Pt. A.M.) An Overview of Solutions The smaller the patient the smaller the amount of fluid that can be safely removed at a given time (smaller patients = slower pump speed) Special attention must be taken not to drop the blood pressure or blood volume of the small CRRT patients When changing the CRRT machine every 3 days a “circuit to circuit prime” can lower the risk of blood pressure instability and lower the amount of exposure to additional blood products. By administering certain medications such as CACL or albumin prior to initiating CRRT therapy, specific complications can be minimized

27 Circuit to Circuit Prime This priming process takes advantage of the circulating blood volume in the existing CRRT circuit The dialysis RN can connect the new filter and tubing to the old filter and tubing and by running the circuits together, can use the blood from the existing circuit to prime the new one This process benefits the patient by not requiring any exposure to new blood products. In addition the patient is benefited by lowering the potential for a drop in circulating blood volume (blood pressure)

28 Conclusion Knowing what complications to expect when running CRRT and anticipating their solutions has many benefits. These benefits include: ● Decreasing the stresses associated with maintaining CRRT ● Providing the most efficient and effective treatment for patients undergoing CRRT ● Decreasing the amount of circuit changes due to circuit failure ● Minimizing the need for blood and electrolyte replacement during CRRT therapy