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ACUTE PERITONEAL DIALYSIS ALTERNATIVE FORM OF CRRT

ACUTE PERITONEAL DIALYSIS ALTERNATIVE FORM OF CRRT. Mignon McCulloch Departments of Paediatric Nephrology & PICU Red Cross Children ’ s Hospital & University of Cape Town. Paediatric Modified RIFLE (pRIFLE) Criteria. * eCCL = 40 x height (cm) / s-creatinine ( μ mol/L)

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ACUTE PERITONEAL DIALYSIS ALTERNATIVE FORM OF CRRT

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  1. ACUTE PERITONEAL DIALYSISALTERNATIVE FORM OF CRRT Mignon McCulloch Departments of Paediatric Nephrology & PICURed Cross Children’s Hospital & University of Cape Town

  2. Paediatric Modified RIFLE (pRIFLE) Criteria *eCCL = 40 x height (cm) / s-creatinine (μmol/L) Akcan-Arikan A et al Kidney Int 2007; 71: 1028-1035

  3. AKI: Treatment Modality Selection Ashita Tolwani, M.D., M.Sc. University of Alabama at Birmingham Critical Care Nephrology – Vicenza June 2015

  4. Use of Peritoneal Dialysis in AKI: A Systematic Review AshitaTolwani • 24 studies identified • 19/24 from Asia, Africa, and South America • 13 studies with PD only • 11 studies with PD and EBP • 7 observational • 4 randomized Chionh CY et al. Clin J Am Soc Nephrol 8: 1649–1660, 2013

  5. Clinical Problems Produced By AKI

  6. PD as CRRT • Alternative to Extracorporeal systems • Difficult Venous access • Small infants • “Challenged” resources • No equipment • No surgical back-up appropriate • Not about Chronic PD

  7. Peritoneal Dialysis in PICU RRT in PICU Dr Mignon McCulloch Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Trust London

  8. PICU 8818 Admissions 413 deaths Mortality 4.7% 20 Beds Staffing: 7 Consultants 20 Fellows 150 Nurses Training in nurses: CVVH 30% trained PD in 100% nurses Evelina Children’s HospitalAndrew DurwardPersonal Communication

  9. Evelina Children’s Hospital PICU2002 – 2009

  10. Red Cross Children’s Hospital(RXH)University of Cape Town Experience • Increasing incidence in association with multi-organ failure in paediatric ICU’s • 1 200 – 1 400 admissions per year • Acute medical cases 600/yr • Cardiac cases 250/yr • Burns 50/yr • Head injuries 50/yr • Other Rest • Mortality 6% predicted 10-12% • Dialysis 3.5%

  11. Causes of Acute Kidney Injury

  12. Causes of Acute Kidney Failure

  13. Practicalities of PD • Quick – really quick – 20 mins K+ 9! • Bed-side insertion by Paeds Nephrologist/Intensivist/Surgeons • (Surgeons as backup) • Cook/Peel Away Tenckhoff/Formal Tenckhoff • Empty Bladder • Sedation + Local Anaesthetic

  14. Practicalities of PD • Prescription • 10-20ml/kg increase as tolerated to 50ml/kg • Dialysis fluid • 1.5%/2.5%/4.25% • Dianeal(Lactate buffered) or Bicarb based • Cycles: Fill/Dwell/Drain • 10/30-90/20mins • Manual or Cycling Home choice > 3kg • Adapted to ventilatory requirements

  15. PD Catheters • Art of Medicine?Innovative and Creative • Cannulaes • Naso-gastric tubes/Chest Drains • Venous Central lines • Rigid ‘Stick’ catheters • ‘Peel away’ Tenckhoff • Flexible Multi-purpose drainage catheters • Auron A et al Am J Kidney Dis 2007

  16. New Generation Cook Catheters

  17. Kimal ‘Peel-away’ Tenckhoff

  18. Complications of PD • Dysequilibration Syndrome (rare in acute) • Hypotension • Infection • Blocked / Displaced catheter • Respiratory difficulties • Diaphragmatic leak • Hyperglycaemia

  19. Equipment – Audit at RXH

  20. Automated Dialysis Home choice machine

  21. Manual Dialysis with Fluid Warmer

  22. Acute Peritoneal DialysisJanuary 1999 to January 2004

  23. Acute PDLong term outcome

  24. Acute PD in PICU 1999-2009 Presented IPNA Aug 2010 New York Red Cross Children’s Hospital, Cape Town SA • Total 406 cases/10years • Wt range 900g – 70kg • Age 1 day – 16yrs • Diphtheria – Liver Transplant

  25. PD IN PICU • Total Nos 406 • Neonates(<1mth) 85(21%) • Infants(<1yr) 221(54%) • Cardiac 95(23%)

  26. Overall Mortality Rate Rate %

  27. Peritoneal Dialysis in NICU Vesna Stojanović, MD, PhD Institute for Child and Youth Health Care of Vojvodina, Intensive Care Unit Novi Sad, Serbia

  28. Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country

  29. Specific Paeds Management IssuesVery Low Birth Weight InfantsKoralkar R et al. Ped Research 2011;69:4:354-8 • AKI reduces survival in infants <1500g • Independent risk factor • Very low glomerular filtration rate • Mild exposure – high degree of injury • High rates of infection • Nephrotoxic drugs • Premature infants <1000g • Increase SCr of 1.0mg/dL(88.5umol/l) • Doubles the odds of death

  30. Duration Of Dialysis

  31. OUTCOME • 15/25(60%) Infants survived to come off dialysis • No bleeding complications • 2/15 catheters blocked - day 3 & 4 on dialysis • Nil required long term dialysis

  32. Manual Dialysis with Fluid Warmer

  33. PD Paed system

  34. Quick and Easy

  35. Post Cardiac Surgery Nitric Oxide, Oscillator & PD

  36. Contra-indication?Post Abdominal Surgery 8Fr Cook Pigtail multi-purpose drainage device 8Fr Cook PD Catheter

  37. Improvised equipment and solution used in the procedure 1/2/2020 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 44

  38. CFPD • Performed with two bedside placed catheters: • the first conventionally placed in the midline below the umbilicus • the second one placed midway between the superior iliac crest and the umbilicus

  39. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8 • CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007 • Especially in children • Especially if small haemodynamically infant • Developing and Developed countries • Future • Larger studies in Paeds • Higher flow volumes • Improved catheter technology

  40. Venous bubble traptransducer toBM 11 BM 14 Blue pump BM 14 Fluid Heater PD Solution Air detector Patient Yellow pump BM 14 Pressure transducer to BM 11 Schematic drawing of CFPD Waste Bag

  41. Overall recommendations: Critically ill patient with AKI • Early fluid resuscitation in acute hypovolaemia + septic shock states • Early consultation and assessment of %FO • Early initiation of CRRT + Inotropes over fluid administration to maintain BP • Appropriate expertise in management of RRT • DO what you are good at! • Do not delay • Call a friend

  42. Take Home Message • PD is available in resource poor environment • PD is appropriate in acute setting in PICU • Not dependant on large nos and well trained staff members • Certain patient groups more suitable for PD • Practical for small infants – access + stability • Even in ‘resource rich’ hospital settings, there is a role for acute PD

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