david askenazi md, msph associate professor of pediatrics 2smaller circuits for smaller patients...
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David Askenazi MD, MSPHAssociate Professor of Pediatrics
2Smaller Circuits for Smaller PatientsImproving Renal Support with Aquadex™
Machine
Potential conflict of interest
Speaker for AKI foundation
Small children are dialyzed differently!
< 5kg
N = 170
> 5kg
N = 251Anticoagulation Protocol
<0.001
Citrate 76 (45%) 155 (62%)Heparin 94 (55%) 96 (38%)
Prime <0.001
Blood 164 (96.5%) 202 (80%)Saline 5 (3%) 29 (12%)Albumin 1 (0.5%) 20 (8%)
Blood Flow *(ml/kg/min) 12 (7.9-15.6) 6.6 (4.8-8.8) <0.001
Daily Effluent Volume*(ml/hr/1.73m2) 3328 (2325-4745)
2321 (1614-2895)
<0.001
Circuit LIfe 28 (11-67) 37 (16-67) 0.15
Askenazi et al. Journal of Pediatrics 2013;162:587-92.
<10 kg >10 kg0%
10%
20%
30%
40%
50%
60%
70%P< 0.001
Survival in ppCRRT Reg-istry
Neonatal CRRT Circuit Priming
Smaller patients require blood priming to prevent hypotension/hemodilution Circuit volume > 10-15% patient blood
volume Example
4 kg infant : Blood Volume = 320 cc (80/kg) Circuit (extracorporeal volume = 165 ml) Therefore ≈ 50% extracorporeal volume
Added Risk for PRBC prime Packed RBCs
HYPOCALCEMIC Citrate
HYPERKALEMIC LYSIS OF CELLS
ACIDICThere are no Plts in packed pRBC’s
Every prime you start CRRT you should expect for your plts count to drop
There are no coagulation factors in pRBC’s Every prime you start CRRT you should expect
for your coagulation factor to drop.
What if you did that to me?
4 kg 70 kg
Blood Volume 320 ml 5000 ml
Extracorporeal volume
165 ml (50% of ECV)
2.5 L
Blood Flow 12 ml/kg/min 840 ml/min
Clearance 100 ml /kg/hr 7000 ml/hr
Filter 5 times BSA 8.6 m2
We must then acknowledge Its amazing we do CRRT in babies…. Even with the best practices….this
approach exposes the smallest children to added risk
BenefitRISK≠
We must then acknowledge Its amazing we do CRRT in babies…. Even with the best practices….this
approach exposes the smallest children to added risk
You have reason to be nervous… What about the 1-2 kg baby?
Do we just ignore him/her….? If we believe that critically ill patients do
better with renal support…we must strive to do better?
Lets adapt a machine
• Aquadex – • FDA approved for
ultrafiltration in 2007
• 33 cc circuit volume
• 4 kg = 10 % ECV
In 2012, received a Impact Grant from Children’s of Alabama
Lets adapt a machine
Rx• Blood flow = 40
ml/min• Prismasol with
additives at 30 ml/kg/hr
• Heparin anti-coagulation
12 children received CVVH on Aquadex™ 5 in CICU and 7 in NICU 9 for AKI and 3 for severe congenital CKD median age at initiation = 30 days (IQR = 13, 38 days) median weight at initiation was 3.4 kg (IQR = 3.0 – 4.3 kg)
The median duration = 14.5 days (IQR = 10, 22.8 days).
Access double lumen vascular access (n=9) (4 = 8F; 4 = 7F; 1 =
6F) 2 x single lumen catheters in 3 with congenital heart
disease had 2 single lumen catheters.
Children’s of Alabama (Dec 2013 – April 2015)
Can we use umbilical lines?
101 circuits – 261 days 12 new starts 89 restarts
59 (61%) circuits lasted 72 hours
Prime 80% Blood Prime
ECV > 10% (<4 kg) pRBC + NaHC03 + CaCl 80% for Saline prime in 20% Cross prime circuit for routine change out
20% Saline Prime
Children’s of Alabama (Dec 2013 – April 2015)
Clearance
1 2 30
1
2
3
4
5
6
Changes in SCr over the first 3 days of CRRT
Days of CRRT
Seru
m C
reati
nine
(mg/
dl)
7/12 survived to come off CVVH 6/12 survived to hospital discharge
1 died before hospital discharge for non-renal complications 5 died due to progressive cardiac/pulmonary disease
Complications from CVVH 4/101 (4%) initiation associated with need for increased BP
support All very mild and transient
3 hypothermia 4 bleeding 1 had a right atrial thrombus
Children’s of Alabama (Dec 2013 – April 2015)
Summary Aquadex – CRRT experience
Nephrologist Like it! Renal Support Goals Achieved Steady reduction in BUN / Cr Excellent control of electrolytes balance. Fluid goals achievable No crashes on initiation!
Critical Care Docs Like it! Dialysis Nurses Like it! Bedside Nurses Like it! Babies hardly know they are on it!
Limitations
Small retrospective case series IV infusion system does not
communicate to machine We probably can, but haven’t tried
citrate anti-coagulation No counter-current dialysis A circuit <24 ml would mean all
saline primes in our case series!
Smaller circuits will revolutionize how neonatal ICU care!
Acknowledgements
• Pediatric Nephrologist Colleagues• Dan Feig MD• Sahar Fathallah MD• Monica Cramer MD• Frank Tenney MD
• Critical Care Faculty• Dialysis Nurses
• Lynn Dill RN• Daryl Ingram RN
• Bedside Nurses