1. case
20 kg child with sepsis and oliguria on norepinephrine with a BP of 95/45
Vent at 70% FIO2 and a PEEP of 8
FO at 15%
K of 6 meq/dl and a BUN of 100 mg/dl

2. What is your prescription
Access, size and location
BFR if applicable
What is your solution (bicarb, lactate, etc)
What is your dialysate/convection flow rate
Anticoagulation
Over what period of time do you remove fluid
How do you dose medications and nutrition

3. CRRT Case Prescription
Timothy E Bunchman MD
Professor & Director
Pediatric Nephrology

4. Access, size and location and BFR
Proper location
BFR
Access dependent with a beginning rate of ~ 5 mls/kg/min
BFR may increase unless risk of osmolar shift

5. Solutions components Historical solutions were lactate based
This will result in plasma lactate levels being detected making the question of sepsis or tissue damage a concern
All present commercially made solutions are bicarbonate based
Physiologic components of Na, K, Ca (if heparin based), HCO3 as well as phosphorous as needed

6. Convective Clearance
To increase clearance by convection, increase ultrafiltration rate (will require more replacement fluids)

7. Sieving Coefficients
Solute (MW) Convective Coefficient Diffusion Coefficient
Urea (60) 1.01 ± ± 0.07
Creatinine (113) 1.00 ± ± 0.06
Uric Acid (168) 1.01 ± ± 0.04*
Vancomycin (1448) 0.84 ± ± 0.04**
Calcium (protein bound)
Cytokines (large) adsorbed minimal clearance
*P< **P<0.01

8. ppCRRT [Cytokine] % Change: Convection vs. Diffusion
TNF-alpha
0.08
IL-1 beta
0.46
IL-6
0.21
IL-8
0.018
IL-10
0.007
IL-18
0.002
PELOD
0.26

9. How aggressive do you UF?
Net UF is often targeted to ~ mls/kg/hr but is dependent upon hemodynamics
Rule of thumb
Take off the fluid at about the same rate as it was required

10. pH correction upon Epi effect
(mic/kg/min)
MAP
Time

11. Comparison of Total Amino Acid losses: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 Apr;28(4): ) NS
Amino Acid Losses
(g/day/1.73 m2)

12. Medication dosing If possible make continuous
If possible use medications that can be measured (e.g Vancomycin)
Knowing Vanco in s~ 1500 Kda and ~ 75% protein bound will add it deciding dosing and frequency on other medications
Vaso pressor agents are often small molecular weight and non protein bound so the clearance will be immediate

13. So my prescription would be
IJ triple lumen 12 Fr catheter
BFR ~ 150 mls/min
Convection clearance at ~ liters/m2/hr or ~ 40 mls/kg/hr
Citrate anticoagulation
Net UF initially zero then once stable will target ~ 1-2 mls/kg/hr net UF
TPN/enteral nutrition ~ 3 gms/kg/day
Meds Vanc and a cephalosporin with vasopressors adjusted for MAP

14. Comparison of RRT modalities
Modality
CRRT
SLED
HD (standard or HF) PD
CFPD
BFR
3-5 mls/kg/min access dependent
10-20 mls/kg/pass
20-40 mls/kg/pass
Dialysis Flow Rate
0-4 liters/hr
6 liters /hr
30-50 liters/hr
0.5-2 liters/hr
Convective Flow Rate
Systemic Anticoagulation
Heparin or citrate
Heparin or none
none
Thermic control
Yes
yes
partial
Ultrafiltration control
Solutions
Industry made
On Line production
Drug clearance
Continuous
Intermittent
Nutritional clearance
Hemodynamic stability
(1 best; 4 least) 1 4 5 3 2
Solute clearance