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AcuteRenalReplacementTherapyfortheInfantDr.FahadGadi,MDPediatricsDemonstratorKingAbdulazizUniversityRabighMedicalSchoolAcuteRenalReplacementTherapObjectivesIndicationsandgoalsforacuterenalreplacementtherapyModalitiesforrenalreplacementtherapyPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)SpecialissuesrelatedtotheinfantObjectivesIndicationsandgoalIndicationsforRenalReplacementVolumeoverloadMetabolicimbalanceToxins(endogenousorexogenous)InabilitytoprovideneededdailyfluidsduetoinsufficienturinaryexcretionIndicationsforRenalReplacemGoalsofRenalReplacementRestorefluid,electrolyteandmetabolicbalanceRemoveendogenousorexogenoustoxinsasrapidlyaspossiblePermitneededtherapyandnutritionLimitcomplicationsGoalsofRenalReplacementRestRenalReplacementfortheInfant:

ASetofSpecialChallengesSmallsizeofthepatientEquipmentdesignedforlargerpeopleSmallbloodvolumewillmagnifyeffectsofanyerrorsAchievingaccessmaybedifficultStaffmayhaveinfrequentexperienceRenalReplacementfortheInfaModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemePD:ConsiderationsforInfantsADVANTAGESExperienceinthechronicsettingNovascularaccessNoextracorporealperfusionSimplicity?Preferredmodalityforcardiacpatients?DISADVANTAGESInfectiousriskLeak?Respiratorycompromise?SodiumsievingDeadspaceintubingPD:ConsiderationsforInfantsModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeIHD:ConsiderationsforInfantsADVANTAGESRapidparticleandfluidremoval;mostefficientmodalityDoesnotrequireanticoagulation24h/dDISADVANTAGESVascularaccessComplicatedLargeextracorporealvolumeAdaptedequipment?PoorlytoleratedIHD:ConsiderationsforInfantModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeCRRTforInfants:

ASeriesofChallengesSmallpatientwithsmallbloodvolumeEquipmentdesignedforbiggerpeopleNospecificprotocolsComplicationsmaybemagnifiedNoclearguidelinesLimitedoutcomedataCRRTforInfants:

ASeriesofPotentialComplicationsofInfantCRRTVolumerelatedproblemsBiochemicalandnutritionalproblemsHemorrhage,infectionThermiclossTechnicalproblemsLogisticalproblemsPotentialComplicationsofInfCRRTinInfants<10Kg:OutcomePatients<10kgPatients3-10kgPatients<3kg38%Survival41%Survival25%SurvivalAmJKidDis,18:833-837,2003CRRTinInfants<10Kg:OutcomeppCRRTDataofInfants<10Kg:DemographicInformationNumberofSubjects84 (51boys(61%)) (33girls(39%))AgeMedian69days (1d-2.9y)ICUAdmitweightMedian4.4kg (1.3-10kg)ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:PrimaryDiagnosesppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:IndicationsforCRRTFluidOverloadandElectrolyteImbalance84%Other(EndogenousToxinRemoval)16%N=84ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:ClinicalDataParameterMedianRangeDaysinICUpriortoCRRT20-135PRISMscore—ICUadmit17.50-48PRISMscore—CRRTstart200-48Inotropenumber—CRRTstart10-4Urineoutput—CRRTstart(ml/kg/hroverprior24hrs)0.70-12%FluidoverloadfromICUadmissiontoCRRTstart13.7-28-220ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:TechnicalCharacteristicsofCRRTCatheterSiteFemoral60%InternalJugular28%Subclavian12%ModalityCVVHD59%CVVH18%CVVHDF23%AnticoagulationCitrate55%Heparin45%PrimeBlood87%Saline8%Albumin5%N=84ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:CRRTTreatmentDataN=84ParameterMedianRangeBloodFlow(ml/kg/min)81.7-46FluidFlow(ml/kg/hour)677-571AverageCRRTClearance(ml/hr/1.73M2)2582135-19319AggregateCRRTClearance(ml/hr/1.73M2)3540135-12713CRRTduration(days)50-83ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:SurvivalbyWeight44%42%43%64%p=0.001p=1.0ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:FactorsEffectingSurvivalClinicalVariableSurvivorsNon-SurvivorsPAdmissionPRISMscore1621<0.05GI/Hepaticdisease8%31%0.01Multiorgandysfunction68%91%0.04PressorDependency36%69%<0.01MeanAirwayPressure1120<0.001Initialurineoutput(ml/kg/hr)2.41.00.02%FluidOverloadatStart15%34%0.02>10%OverloadatStart43%71%0.02ppCRRTDataofInfants<10Kg:PRISMADedicatedCRRTdeviceHighlyautomatedDesignedforeaseofuseatthebedsidePRISMADedicatedCRRTdeviceBradykininReleaseSyndromeMucosalcongestion,bronchospasm,hypotensionatstartofCRRTResolveswithdiscontinuationofCRRTThoughttoberelatedtobradykininreleasewhenpatient’sbloodcontactshemofilterExquisitelypHsensitiveBradykininReleaseSyndromeMucBypassSystemtoPreventBradykininReleaseSyndromePRBCWasteBypassSystemtoPreventBradyRecirculationSystemtoPreventBradykininReleaseSyndromeDWasteRecirculationPlan:Qb200ml/minQd~40ml/minTime7.5minNormalizepHNormalizeK+RecirculationSystemtoPrevenAcuteInitiationChecklist:ExampleInfantICUNurseTimeZero:MovepttoroomwithdialysiswaterGetordersfromresidentforIVfluidstokeepaccessopen20–40min:MeetMD;discussRRTplan60–120min:MeetICUteamDialysisNurse10–60min:Arriveandbeginsetup20–40min:MeetMD;discussRRTplan60–120min:Completeprime;readyforaccessBeginRRTMeetICUteamAcuteInitiationChecklist:ExAcuteInitiationChecklist:ExampleNephrologyMDTimeZero:ContactdialysisnursetostartRRTurgently10–20min:BringcatheterstoICUEnterordersforRRT20–40min:MeetICUMDs&RNs,discussplan60–120min:PresentinICUforinitiationMeetICUteamIVAccessMD10–30min:Arriveandbegininsertionofdialysisaccess60min(orwhencircuitisreadyforRx)CompleteinsertionofaccessConnectportstoheparinIVsolutionsAcuteInitiationChecklist:ExInfantRRT:SummaryAllmodalitiesofRRTpossibleforinfantsNomodalityisperfectTechnicalchallengescanbemetCarefulplanningwithinstitution,program,andindividualsimprovescareCooperation,communication,andcollaborationwillincreaseoursuccessInfantRRT:SummaryAllmodalitThanks!Thanks!AcuteRenalReplacementTherapyfortheInfantDr.FahadGadi,MDPediatricsDemonstratorKingAbdulazizUniversityRabighMedicalSchoolAcuteRenalReplacementTherapObjectivesIndicationsandgoalsforacuterenalreplacementtherapyModalitiesforrenalreplacementtherapyPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)SpecialissuesrelatedtotheinfantObjectivesIndicationsandgoalIndicationsforRenalReplacementVolumeoverloadMetabolicimbalanceToxins(endogenousorexogenous)InabilitytoprovideneededdailyfluidsduetoinsufficienturinaryexcretionIndicationsforRenalReplacemGoalsofRenalReplacementRestorefluid,electrolyteandmetabolicbalanceRemoveendogenousorexogenoustoxinsasrapidlyaspossiblePermitneededtherapyandnutritionLimitcomplicationsGoalsofRenalReplacementRestRenalReplacementfortheInfant:

ASetofSpecialChallengesSmallsizeofthepatientEquipmentdesignedforlargerpeopleSmallbloodvolumewillmagnifyeffectsofanyerrorsAchievingaccessmaybedifficultStaffmayhaveinfrequentexperienceRenalReplacementfortheInfaModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemePD:ConsiderationsforInfantsADVANTAGESExperienceinthechronicsettingNovascularaccessNoextracorporealperfusionSimplicity?Preferredmodalityforcardiacpatients?DISADVANTAGESInfectiousriskLeak?Respiratorycompromise?SodiumsievingDeadspaceintubingPD:ConsiderationsforInfantsModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeIHD:ConsiderationsforInfantsADVANTAGESRapidparticleandfluidremoval;mostefficientmodalityDoesnotrequireanticoagulation24h/dDISADVANTAGESVascularaccessComplicatedLargeextracorporealvolumeAdaptedequipment?PoorlytoleratedIHD:ConsiderationsforInfantModalitiesforRenalReplacementPeritonealdialysisIntermittenthemodialysisContinuousrenalreplacementtherapy(CRRT)ModalitiesforRenalReplacemeCRRTforInfants:

ASeriesofChallengesSmallpatientwithsmallbloodvolumeEquipmentdesignedforbiggerpeopleNospecificprotocolsComplicationsmaybemagnifiedNoclearguidelinesLimitedoutcomedataCRRTforInfants:

ASeriesofPotentialComplicationsofInfantCRRTVolumerelatedproblemsBiochemicalandnutritionalproblemsHemorrhage,infectionThermiclossTechnicalproblemsLogisticalproblemsPotentialComplicationsofInfCRRTinInfants<10Kg:OutcomePatients<10kgPatients3-10kgPatients<3kg38%Survival41%Survival25%SurvivalAmJKidDis,18:833-837,2003CRRTinInfants<10Kg:OutcomeppCRRTDataofInfants<10Kg:DemographicInformationNumberofSubjects84 (51boys(61%)) (33girls(39%))AgeMedian69days (1d-2.9y)ICUAdmitweightMedian4.4kg (1.3-10kg)ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:PrimaryDiagnosesppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:IndicationsforCRRTFluidOverloadandElectrolyteImbalance84%Other(EndogenousToxinRemoval)16%N=84ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:ClinicalDataParameterMedianRangeDaysinICUpriortoCRRT20-135PRISMscore—ICUadmit17.50-48PRISMscore—CRRTstart200-48Inotropenumber—CRRTstart10-4Urineoutput—CRRTstart(ml/kg/hroverprior24hrs)0.70-12%FluidoverloadfromICUadmissiontoCRRTstart13.7-28-220ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:TechnicalCharacteristicsofCRRTCatheterSiteFemoral60%InternalJugular28%Subclavian12%ModalityCVVHD59%CVVH18%CVVHDF23%AnticoagulationCitrate55%Heparin45%PrimeBlood87%Saline8%Albumin5%N=84ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:CRRTTreatmentDataN=84ParameterMedianRangeBloodFlow(ml/kg/min)81.7-46FluidFlow(ml/kg/hour)677-571AverageCRRTClearance(ml/hr/1.73M2)2582135-19319AggregateCRRTClearance(ml/hr/1.73M2)3540135-12713CRRTduration(days)50-83ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:SurvivalbyWeight44%42%43%64%p=0.001p=1.0ppCRRTDataofInfants<10Kg:ppCRRTDataofInfants<10Kg:FactorsEffectingSurvivalClinicalVariableSurvivorsNon-SurvivorsPAdmissionPRISMscore1621<0.05GI/Hepaticdisease8%31%0.01Multiorgandysfunction68%91%0.04PressorDependency36%69%<0.01MeanAirwayPressure1120<0.001Initialurineoutput(ml/kg/hr)2.41.00.02%FluidOverloadatStart15%34%0.02>10%OverloadatStart43%71%0.02ppCRRTDataofInfants<10Kg:PRISMADedicatedCRRTdeviceHighlyautomatedDesignedforeaseofuseatthebedsidePRISMADedicatedCRRTdeviceBradykininReleaseSyndromeMucosalcongestion,bronchospasm,hypotensionatstartofCRRTResolveswithdiscontinuationofCRRTThoughttoberelatedtobradykininreleasewhenpatient’sbloodcontactshemofilterExquisitelypHsensitiveBradykininReleaseSyndromeMucBypassSystemtoPreventBradykininReleaseSyndromePRBCWasteBypassSystemtoPreventBradyRecirculationSystemtoPrev

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