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Putting it all together: When resources are scarce

Putting it all together: When resources are scarce. Mignon McCulloch Associate Professor Department of Paediatric Critical Care Red Cross Children’s Hospital (RXH) University of Cape Town. Acknowledgements. Thanks to Stuart and Tim Including all forms of CRRT Disclosures

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Putting it all together: When resources are scarce

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  1. Putting it all together:When resources are scarce Mignon McCulloch Associate Professor Department of Paediatric Critical Care Red Cross Children’s Hospital (RXH) University of Cape Town

  2. Acknowledgements • Thanks to Stuart and Tim • Including all forms of CRRT • Disclosures • Passionate about PD • Access for children with AKI in poorly resourced areas

  3. 2.5kg boy Complex Congenital Heart Post-op surgical No urine output x 8hrs What next? 12year old boy Meningococcal Sepsis Shocked needing inotropic support Poor urine output x 12hrs What next? Clinical Patients

  4. Less than 1km down the road…

  5. Role of Fluid • FO >20% @ time of CRRT initiation %FO = (Fluid In – Fluid Out) x 100% (PICU Admission weight) Goldstein et al(2005). KI 67:653-658 • But what happens before?

  6. Goal directed therapy Study of Emergency Department Management

  7. Rivers et al, N Engl J Med, 2001

  8. de Oliveira CF et al, Intensive Care Med, 2008

  9. de Oliveira CF et al, Intensive Care Med, 2008

  10. Severe sepsis and septic shock guidelines 2008

  11. FEAST Trial ?

  12. FEAST Study(Fluid Expansion as Supportive Therapy)NEJM June 30, 2011 Maitland et al • Severe febrile illness & impaired perfusion randomised to: • Bolus 5% Albumin 20-40ml • Bolus 0,9% Saline • No bolus • Halt recruitment 3141/3600 • 48hour mortality • 10.6% bolus vs 7.3% non-bolus(p=0.003)

  13. Maitland et al, N Engl J Med, 2011

  14. Maitland et al, N Engl J Med, 2011

  15. Criticisms- NEJM Oct 6, 2011 • Severely anaemic children - 32% Hb<5mg/dl • Acute haemodilution in pre-existing anaemia • Impaired oxygen delivery leading to organ failure • Malaria – 57% thus have sequestration of red cells in microcirculation • Shock – not all forms are the same – related to high CO or diminished O2 • Compromised oxygen delivery – 77% thus worsening cellular dysoxia • Malnutrition

  16. Plans • Rapid triage and treatment • Monitoring in a low resource setting • What is possible? CVP • What is physiologic fluid best for bolusing • Blood vs fluid boluses • Choice of fluids BMJ 2010;341 Maitland, • Colloids vs Crystalloids for fluid resuscitation Cochrane 2012 – Perel P • Low-volume fluid resuscitation insufficient for patients in shock – Inotropes?

  17. Needed:Observational Trial in Septic Shock • Fluid challenge – 10-20ml/kg…then • Observe response: • Heart rate and BP, Resp rate, Oxygen sats • Cardiac output in response to fluid • Portable Uscom/Echocardiography validation • Pulmonary oedema – Lung impedance • High flow Oxygen/CPAP/Ventilation • Inotropes – peripheral/central • AKI???

  18. Renal Replacement Therapy What we have done in Cape Town?

  19. Initial Management • Urine output: Aim for > 1ml/kg/hr • Fluid challenge • 10ml/kg 0.9% Saline over 30 minutes and reassess urine output • If no improvement & no signs of fluid overload, repeat bolus • Clinical assessment regarding intravascular volume status +/- invasive assessment

  20. “Encouraging Agents” • Fluid and Perfusion • Furosemide ivi • Boluses 1 - 5mg/kg or • Infusion 0.1 – 1mg/kg • Mannitol/Metolazone • Aminophylline 1 - 5mg/kg ivi if stable • **Dopamine 2 – 5mcg/kg/min infusion

  21. Kenya Nigeria IPNA/ISN Training for Africa Benin Ghana Uganda Nigeria

  23. Challenges on Return • Poor Staffing 100% • Lack of Facilities & Equipment 86% • Radiology – Ultrasound only 86% • Support from Home Institutions 71% • Histology support 57%

  24. Paradise ?

  25. ISN Sister Program PD Workshop Accra, Ghana 04.12.2011

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

  27. Devices for Peritoneal Dialysis

  28. New Generation Cook Catheters

  29. Kimal ‘Peel-away’ Tenchkoff

  30. Tips for Success • Size matters…keep skin nick at minimum or nil at all • Else will leak!!! • Avoid metal needle that comes with pack • Rather Jelco/Venous access catheter • Withdraw needle 0.5mm as go thru peritoneum and advance plastic sheath • Run fluid in freely to fill abdomen before wire and catheter • If not free-flowing  pull needle back slightly • May be in bowel?....role of ultrasound • Don’t forget to empty bladder

  31. Automated Dialysis Home choice machine

  32. Manual Dialysis with Fluid Warmer

  33. Post Abdominal Surgery 8Fr Cook Pigtail multi-purpose drainage device 8Fr Cook PD Catheter

  34. Improvised equipment and solution used in the procedure 8/10/2014 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 41

  35. 5-yr old with HUSPD duration - 8 days 8/10/2014 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 42

  36. PD progress in 1st 24 hrs 8/10/2014 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 43

  37. PD in session 8/10/2014 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 44

  38. CONCLUSION • Peritoneal dialysis as a form of acute renal replacement therapy is: • Practical • Appropriate for developing countries • Results reflected suggest that due to ease of use, it may also be appropriate for centers where access to CVVH/D may not be available • due to lack of equipment or • trained staff

  39. Practical Skills WorkshopIPNA/ISN/SKCF/Saving Young Lives…..and all other supporters12-16 Nov 2012

  40. Thank you to all my colleagues @ RXH Thank you for your time and attention !

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