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PCRRT PRESCRIPTIONS in ARF

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Title: PCRRT PRESCRIPTIONS in ARF


1
PCRRT PRESCRIPTIONSin ARF
  • Patrick D. Brophy MD University of Michigan
    Pediatric Nephrology

2
Objectives
  • Define ARF
  • Prescriptions Based on What?
  • Case Format
  • Modality
  • BFR
  • UF rate
  • Dialysate/FRF rates
  • Other issues anticoagulation, access

3
Acute Renal failure
  • Definition A life threatening abrupt
    cessation/reduction of urinary output to less
    than 300ml/m2 caused by prolonged renal ischemia
    in most cases (may occasionally present as high
    output renal failure- high urinary output with
    increasing BUN and Creatinine)
  • Can lead to severe hypertension (fluid overload)
    metabolic abnormalities (acidosis, hyperkalemia)
    requiring emergent therapy

4
ARF-- Etiology
  • Developing Countries
  • Hemolytic-Uremic Syndrome (31)
  • Glomerulonephritis (23)
  • Post-Op Sepsis/Prerenal ischemia
  • Chan et.al. PIR, 232002
  • Industrialized Countries
  • Intrinsic Renal Disease (44)
  • Post-Op Septic Shock (34)
  • Organ/Bone Marrow Transplant (13)

5
ARFTreatment Options
  • Conservative- fluid management and nutrition
  • Renal Replacement Options
  • Hemodialysis- Hemodynamic Instability
  • Peritoneal Dialysis- efficiency
  • CVVH(D)/(DF)- Hemodynamically less volatile than
    HD, Can provide optimal fluid and nutritional
    management Clearance

6
PEDIATRIC PRESCRIPTION for CRRT
  • Classic Case
  • 10kg infant (75 cm) BSA0.45m2, high vent
    settings-lungs wet, ? sepsis
  • up 2 kg from dry weight, no urine for 12 hr
  • HR 160, BP 80/40 on pressors, pH 7.2
  • Creatinine 1.0 mg/dl BUN 40, lactate 4.0,
    iCa1.0, K5.8

7
Approach
  • This patient clearly is in need of Hemofiltration
  • ISSUES Determining the prescription
  • CAVH(D)/(DF) vs CVVH(D)/(DF)
  • Blood Flow Rate
  • Ultrafiltrate (dialysate/FRF rate)
  • Access Machinery
  • Fluids for dialysate/Filter Replacement
  • Anticoagulation

8
CAVH(D) vs CVVH(D)
  • CAVH(D)
  • Initial form of therapy, Dependent on BP of
    patient (difficult to control UF),
    Technologically easier (require 2 catheters)
  • CVVH(D)
  • Newer machines, 1 catheter, improved solute
    clearance, increased extracorporeal volume,
    standard of care

9
Werner et al.,1994, Critical Care Medicine, 22,
320-325
  • Goals Evaluation of CVVH using 4 week old lambs
    (pediatric size 12.2 kg)
  • Compared 3 systems postdilution, predilution and
    hemofiltration (post-filter replacement) with
    counter-current dialysis (standardized UF, BFR
    and hemofilter)

10
Werner et al.,1994, Critical Care Medicine, 22,
320-325
11
Werner et al.,1994, Critical Care Medicine, 22,
320-325
  • Conclusions
  • 1) CVVH(D) feasible in this size group
  • 2) Stable blood flow rates from 5-10 ml/kg/min
  • 3) BFR in this range with UF rates of 1ml/kg/ min
    can produce urea clearance of 1 ml/kg/min
    (without causing to large a negative intrafilter
    pressure)
  • 4) dialysis didnt increase urea clearance
    (animals not uremic though)

12
Bunchman et al 1995, AJKD, 25,17-21
13
Bunchman et al 1995, AJKD, 25,17-21
14
Bunchman et al 1995, AJKD, 25,17-21
15
Bunchman et al 1995, AJKD, 25,17-21
16
Zobel et al,1991 in Contiuous Hemofiltration.
Contrib Nephrol. V93 pp257-260
17
Dialysate/ Ultrafiltration Rates
  • No Study has identified effective, safe UF or
    dialysate flow rates in Children.
  • For HEMODIALYSIS NET UF rate of 0.2ml/kg/min is
    tolerated (Donckerwolke Ped Neph
    8103-106,1994)-This extrapolates out to 1 ml/kg/
    hr (NET UF) over 48 hr of continuous
    hemofiltration.

18
Dialysate/ Ultrafiltration Rates
  • The UF rate/plasma flow rate BFRx(1-HCT) ratio
    should lt 0.35-0.4 in order to avoid filter
    clotting (Golper AJKD 6 373-386,1985)
  • Dialysate flow rates ranging from 10-20 ml/min/m2
    (2000ml/1.72m2/hr) are usually adequate
    (experiential but consistent with adult data)

19
Ronco et al. Lancet 2000 351 26-30
20
Ronco et al. Lancet 2000 351 26-30
  • Conclusions
  • Minimum UF rates should reach at least 35
    ml/kg/hr
  • Survivors in all their groups had lower BUNs than
    non-survivors prior to commencement of
    hemofiltration

21
Access Machinery
  • Machinery
  • PRISMA, DIAPACT, BAXTER, EDWARDS, FRESENIUS
  • Access
  • If poor blood flow- no point in continuing!
  • Generally want to keep Venous pressure no gt 200
    mm Hg
  • IJ placement preferable (triple lumen ideal!)
  • Size based on Patients size

22
Bicarbonate Vs Lactate Fluid
  • Commercial vs Custom Solutions For FRF or
    Dialysate
  • Generally Bicarbonate based solutions preferable
    (no definitive study to support this- but easier
    to interpret lactic acidosis)
  • FDA approved ie. Normocarb (D only)
  • Cost effectiveness pharmacy/nursing costs

23
Anticoagulation
  • Heparin
  • Citrate
  • None
  • No good head to head studies comparing Heparin
    vs. Citrate in Pediatrics
  • Center specific and Comfort level

24
Other Considerations
  • Nutrition
  • CRRT allows optimization of nutritional
    supplementation (esp in high catabolic states-
    such as ARF)- but it also contributes to a
    negative nitrogen balance
  • Aim for anabolic state- 1.5 g/kg/day protein is
    inadequate 2-3 g/kg/day better, with 20-30
    increase in caloric intake over resting energy
    expenditure
  • Maxvold et.al. Crit Care Med 282000

25
Recommendations for Pediatric Prescription
  • CVVH/CVVHD/CVVHDFD useful when limited by
    membrane UF capacity
  • Pre/Post FRF or Dialysate
  • Combined UFdialysate flow rates 10-20 ml/min/m2
    (2000ml/1.72m2/hr) INCREASE WITH TOXINS)
  • At 0.45m2 540ml/hr (exceeds adult
    recommendations)
  • Net UF rate 1 ml/kg/hr
  • BFR (4-10 ml/kg/min)-Huge blood flow circulations
    in small infants

26
Recommendations Continued
  • Access-Dual lumen 8 Fr (triple Lumen if
    available)
  • Bicarbonate based Dialysate or FRF
  • Anticoagulation- based on patient circumstance
    and center experience
  • Maximize Nutrition (good communication among
    caregivers imperative)

27
  • ACKNOWLEDGEMENTS
  • MELISSA GREGORY
  • ANDREE GARDNER
  • JOHN GARDNER
  • THERESA MOTTES
  • TIM KUDELKA
  • LAURA DORSEY BETSY ADAMS
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