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Neonatal and Infant CRRT

Neonatal and Infant CRRT. Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org. Pediatric CRRT: Vicenza, 1984. CRRT Machines: Current Generation. Vascular Access for Pediatric CRRT.

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Neonatal and Infant CRRT

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  1. Neonatal and Infant CRRT Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org

  2. Pediatric CRRT: Vicenza, 1984

  3. CRRT Machines: Current Generation

  4. Vascular Access for Pediatric CRRT • Smaller patients require smaller catheters • Difficulty achieving access • Difficulty maintaining access • Limited access sites

  5. Choices for Vascular Access

  6. Access Sites for CRRT • Femoral veins • Jugular veins • Subclavian veins • Umbilical vessels • ECMO circuit

  7. Prescribing CRRT for Small Kids • Modality • Blood flow rate • Hemofilter • Solution(s) • Ultrafiltration rate • Anticoagulation • Special considerations

  8. CRRT Modality for Small Kids Am J Kid Dis, 18:833-837, 2003

  9. Hemofilters for Pediatric CRRT Am J Kid Dis, 18:833-837, 2003

  10. 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

  11. Anticoagulation for Infant CRRT • Heparin • Citrate • Nothing • ? Other things ?

  12. 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

  13. Potential Complications of Infant CRRT • Volume related problems • Biochemical and nutritional problems • Hemorrhage • Infection • Technical problems • Logistical problems • Bradykinin release syndrome

  14. 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

  15. 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

  16. 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

  17. Waste PRBC Bypass System to Prevent Bradykinin Release Syndrome Modified from Brophy, et al. AJKD, 2001.

  18. Normalize pH D Normalize K+ Waste Recirculation System to Prevent Bradykinin Release Syndrome Recirculation Plan: Qb 200ml/min Qd ~40ml/min Time 7.5 min Based on Pasko, et al. Ped Neph 18:1177-83, 2003

  19. 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

  20. 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

  21. Which Babies Require CRRT? N=85 Am J Kid Dis, 18:833-837, 2003

  22. Why do Babies Need CRRT? N=85 Am J Kid Dis, 18:833-837, 2003

  23. CRRT in Infants <10Kg: Outcome 38% Survival 41% Survival 25% Survival Patients <10kg Patients 3-10kg Patients <3kg Am J Kid Dis, 18:833-837, 2003

  24. 36% 71% 15% 42% 22% 0 50% 0 50% 50% 100% 0 60% Survival by Diagnosis Am J Kid Dis, 18:833-837, 2003 Totals: N=85; Survivors=32

  25. Survival by Modality Am J Kid Dis, 18:833-837, 2003 p=NS

  26. 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

  27. 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

  28. 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

  29. ppCRRT Data of Infants <10kg: Indications for CRRT N=28

  30. ppCRRT Data of Infants <10kg: Vascular Access Location N=28

  31. ppCRRT Infant Survival Data 50% Survival 64% Survival 41% Survival

  32. 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?

  33. Thanks!

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