1、Acute Renal Replacement Therapy for the InfantDr.Fahad Gadi,MDPediatrics DemonstratorKing Abdulaziz UniversityRabigh Medical SchoolObjectives Indications and goals for acute renal replacement therapy Modalities for renal replacement therapy Peritoneal dialysis Intermittent hemodialysis Continuous re
2、nal replacement therapy(CRRT)Special issues related to the infantIndications for Renal Replacement Volume overload Metabolic imbalance Toxins(endogenous or exogenous)Inability to provide needed daily fluids due to insufficient urinary excretionGoals of Renal Replacement Restore fluid,electrolyte and
3、 metabolic balance Remove endogenous or exogenous toxins as rapidly as possible Permit needed therapy and nutrition Limit complicationsRenal Replacement for the Infant:A Set of Special Challenges Small size of the patient Equipment designed for larger people Small blood volume will magnify effects o
4、f any errors Achieving access may be difficult Staff may have infrequent experienceModalities for Renal Replacement Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy(CRRT)Modalities for Renal Replacement Peritoneal dialysis Intermittent hemodialysis Continuous renal
5、replacement therapy(CRRT)PD:Considerations for InfantsADVANTAGES Experience in the chronic setting No vascular access No extracorporeal perfusion Simplicity?Preferred modality for cardiac patients?DISADVANTAGES Infectious risk Leak?Respiratory compromise?Sodium sieving Dead space in tubingModalities
6、 for Renal Replacement Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy(CRRT)IHD:Considerations for InfantsADVANTAGES Rapid particle and fluid removal;most efficient modality Does not require anticoagulation 24h/dDISADVANTAGES Vascular access Complicated Large extra
7、corporeal volume Adapted equipment?Poorly toleratedModalities for Renal Replacement Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy(CRRT)CRRT for Infants:A Series of Challenges Small patient with small blood volume Equipment designed for bigger people No specific p
8、rotocols Complications may be magnified No clear guidelines Limited outcome dataPotential Complications of Infant CRRT Volume related problems Biochemical and nutritional problems Hemorrhage,infection Thermic loss Technical problems Logistical problemsCRRT in Infants 10Kg:Outcome85691632284NSurvivor
9、sPatients 10kgPatients 3-10kgPatients 3kg38%Survival41%Survival25%SurvivalAm J Kid Dis,18:833-837,2003ppCRRT Data of Infants 10Kg:Demographic InformationNumber of Subjects84(51 boys(61%)(33 girls(39%)AgeMedian 69 days(1 d-2.9 y)ICU Admit weightMedian 4.4 kg(1.3-10 kg)ppCRRT Data of Infants 10Kg:Prim
10、ary DiagnosesppCRRT Data of Infants 10Kg:Indications for CRRTFluid Overload and Electrolyte Imbalance84%Other(Endogenous Toxin Removal)16%N=84ppCRRT Data of Infants 10Kg:Clinical DataParameterMedianRangeDays in ICU prior to CRRT20-135PRISM score ICU admit17.50-48PRISM score CRRT start200-48Inotrope
11、number CRRT start10-4Urine output CRRT start(ml/kg/hr over prior 24hrs)0.70-12%Fluid overload from ICU admission to CRRT start13.7-28-220ppCRRT Data of Infants 10Kg:Technical Characteristics of CRRTCatheter SiteFemoral60%Internal Jugular28%Subclavian12%ModalityCVVHD59%CVVH18%CVVHDF23%Anticoagulation
12、 Citrate55%Heparin45%PrimeBlood87%Saline8%Albumin5%N=84ppCRRT Data of Infants 10Kg:CRRT Treatment DataN=84ParameterMedianRangeBlood Flow(ml/kg/min)81.7-46Fluid Flow(ml/kg/hour)67 7-571Average CRRT Clearance(ml/hr/1.73M2)2582135-19319Aggregate CRRT Clearance(ml/hr/1.73M2)3540135-12713CRRT duration(da
13、ys)50-83ppCRRT Data of Infants 10Kg:Survival by Weight0%10%20%30%40%50%60%70%5 kg5-10 kg10 kg44%42%43%64%p=0.001p=1.0ppCRRT Data of Infants 10Kg:Factors Effecting SurvivalClinical VariableSurvivors Non-SurvivorsPAdmission PRISM score 16210.05GI/Hepatic disease8%31%0.01Multiorgan dysfunction68%91%0.0
14、4Pressor Dependency36%69%0.01Mean Airway Pressure112010%Overload at Start43%71%0.02PRISMA Dedicated CRRT device Highly automated Designed for ease of use at the bedsideBradykinin Release Syndrome Mucosal congestion,bronchospasm,hypotension at start of CRRT Resolves with discontinuation of CRRT Thoug
15、ht to be related to bradykinin release when patients blood contacts hemofilter Exquisitely pH sensitiveBypass System to Prevent Bradykinin Release SyndromePRBCWasteRecirculation System to Prevent Bradykinin Release SyndromeDWasteRecirculation Plan:Qb 200ml/minQd 40ml/minTime 7.5 minNormalize pHNorma
16、lize K+Acute Initiation Checklist:ExampleInfant ICU Nurse Time Zero:Move pt to room with dialysis water Get orders from resident for IV fluids to keep access open 20 40 min:Meet MD;discuss RRT plan 60 120 min:Meet ICU teamDialysis Nurse 10 60 min:Arrive and begin setup 20 40 min:Meet MD;discuss RRT
17、plan 60 120 min:Complete prime;ready for access Begin RRT Meet ICU teamAcute Initiation Checklist:ExampleNephrology MD Time Zero:Contact dialysis nurse to start RRT urgently 10 20 min:Bring catheters to ICU Enter orders for RRT 20 40 min:Meet ICU MDs&RNs,discuss plan 60 120 min:Present in ICU for in
18、itiation Meet ICU teamIV Access MD 10 30 min:Arrive and begin insertion of dialysis access 60 min(or when circuit is ready for Rx)Complete insertion of access Connect ports to heparin IV solutionsInfant RRT:Summary All modalities of RRT possible for infants No modality is perfect Technical challenges can be met Careful planning with institution,program,and individuals improves care Cooperation,communication,and collaboration will increase our successThanks!
