Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA [email protected]
Jan 19, 2016
Neonatal and Infant CRRT
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, [email protected]
Pediatric CRRT: Vicenza, 1984
CRRT Machines: Current Generation
Vascular Access for Pediatric CRRT
• Smaller patients require smaller catheters
• Difficulty achieving access
• Difficulty maintaining access
• Limited access sites
Choices for Vascular Access
Catheter Type Manufacturers Potential Pts.
Single-lumen 5Fr CookSmall Neonates
Double-lumen 7FrCook
Medcomp3 – 6 Kg
Triple-lumen 7Fr Medcomp 3 – 6 Kg
Double-lumen 8FrKendall
Arrow6 – 30 Kg
Access Sites for CRRT
• Femoral veins
• Jugular veins
• Subclavian veins
• Umbilical vessels
• ECMO circuit
Prescribing CRRT for Small Kids
• Modality
• Blood flow rate
• Hemofilter
• Solution(s)
• Ultrafiltration rate
• Anticoagulation
• Special considerations
CRRT Modality for Small Kids
2%
18%16%
21%43%
CVVH CVVHD CVVHDF SCUF >1 Modality
Am J Kid Dis, 18:833-837, 2003
Hemofilters for Pediatric CRRT
Filter N MaterialSurface
area (m2)Prime
vol (ml)
Renaflo® II HF-400 41 (48%) Polysulfone 0.3 28
Multiflow 60 20 (24%) AN-69 0.6 48
Fresenius F3 19 (22%) Polysulfone 0.4 30
Amicon® Minifilter® 5 (6%) Polysulfone 0.08 15
Am J Kid Dis, 18:833-837, 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 patient’s 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 18:1177-83, 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, 18:833-837, 2003
Which Babies Require CRRT?Congenital heart disease
Metabolic disorder
Multiorgan dysfunction
Sepsis syndrome
Liver failure
Malignancy
Congenital nephrotic syndrome
Congenital diaphragmatic hernia
Congenital renal/urological disease
Hemolytic uremic syndrome
Heart failure
Other
16.5%
16.5%
15.3%
14.1%
10.6%
5.9%
4.7%
3.5%
2.4%
2.3%
2.3%
5.9%
N=85
Am J Kid Dis, 18:833-837, 2003
Why do Babies Need CRRT?
Combined volume overload and biochemical abnormalities of renal failure
54%
Volume overload 18%
Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia)
14%
Biochemical abnormalities of renal failure 9%
Other (e.g., medication overdose) 4%
Volume overload and hyperammonemia 1% N=85
Am J Kid Dis, 18:833-837, 2003
CRRT in Infants <10Kg: Outcome
85
69
16
32 28
4
N
Survivors
Patients <10kg Patients 3-10kg Patients <3kg
38% Survival 41%
Survival
25% Survival
Am J Kid Dis, 18:833-837, 2003
Survival by Diagnosis14
14
13
12
9
5
4
3
2
2
1
1
5
5
10
2
5
2
0
2
0
1
1
1
0
3
Congen Ht Dz
Metabolic
Multiorg Dysfxn
Sepsis
Liver failure
Malignancy
Congen Neph Synd
Congen Diaph Hernia
HUS
Ht Failure
Obstr Urop
Renal Dyspl
Other
N
Survivors
Totals: N=85; Survivors=32
0
36%
71%
15%
42%
22%
0
50%
50%
50%
100%
0
60%
Am J Kid Dis, 18:833-837, 2003
Survival by Modality
Modality N Survivors
CVVH 27 11 (41%)
CVVHD 12 3 (25%)
CVVHDF 12 4 (33%)
CVVHD or CVVHDF 24 7 (29%)
p=NSAm J Kid Dis, 18:833-837, 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, 18:833-837, 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
75%
25%Fluid and Electrolyte Imbalance
Metabolic Anomaly or Toxin
N=28
ppCRRT Data of Infants <10kg: Vascular Access Location
18%
67% 15%
Femoral Internal Jugular Subclavian
N=28
ppCRRT Infant Survival Data
1711
28
7 714
<5 kg 5 - 10 kg <10 kg
N
Survivors
41% Survival
64% Survival
50% Survival
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?
Thanks!