1) Fluid overload control(unbalance infusion requirements/pt weight)

2) Cytokine Clearance(CPB associated SIRS , post op sepsis)

3) Capillary leak syndrome (extracorporeal surface contact, RAAS/BNP disequilibrium,

hypothermia, cyanosis)

4) Cardiorenal-renocardiac syndromes

RRT in pediatric Heart Surgery :RRT in pediatric Heart Surgery :Specific indicationsSpecific indications

RRT in pediatric Heart Surgery :RRT in pediatric Heart Surgery :Specific modalities Specific modalities

CPB with UFCPB with CRRTCRRT during ECMO“Traditional” CRRT

POTENTIAL ROLE OF ULTRAFILTRATION IN POST POTENTIAL ROLE OF ULTRAFILTRATION IN POST

CPB CAPILLARY LEAK SYNDROMECPB CAPILLARY LEAK SYNDROME

UF/HF

ULTRAFILTRATIONULTRAFILTRATIONDuring CPBDuring CPB

•Conventional Ultrafiltration•Modified Ultrafiltration•High Volume Zero Balanced UF

NOMENCLATURENOMENCLATURE

Conventional UltrafiltrationConventional Ultrafiltration• After aortic declamp• During rewarming • UF in parallel with CPB• Inlet after the oxygenator• Ultrafiltered blood returns into

venous reservoire

Advantages: It does not delay surgical times It removes UF during highest

mediator production phase

Disadvantages: It might quickly empty reservoire

volume

From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998

Modified UltrafiltrationModified Ultrafiltration

From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998

Advantages: Significantly higher

efficiency

Disadvantages:Cumbersome procedurePatient coolingHemodynamic instability

• Inflammation mediators removal Inflammation mediators removal

- C3a, C5a, IL-6a, IL-8a, TNF, MDF, ET-1

• Total body water reductionTotal body water reduction– Tissue edema decrease– Hematocrit increase – Coagulation factors concentration– Decreased need of hemoderivates

POTENTIAL ROLE OF ULTRAFILTRATION IN POST POTENTIAL ROLE OF ULTRAFILTRATION IN POST

CPB CAPILLARY LEAK SYNDROMECPB CAPILLARY LEAK SYNDROME

UF ON LEFT VENTRICULAR FUNCTIONUF ON LEFT VENTRICULAR FUNCTION

1. Myocardial edema decrease2. DO2 increase3. Left ventricular compliance

increase4. Systolic and diastolic function

improvement

Davies MJ. J Thorac Cardiovasc Surg 1998

HIGH-VOLUME, ZERO BALANCED HIGH-VOLUME, ZERO BALANCED ULTRAFILTRATION (Z-BUF)ULTRAFILTRATION (Z-BUF)

• Twenty children undergoing cardiac surgery assigned to Z-BUF or a control group.

• C3a, IL-1, IL-6, IL-8, IL-10, TNF, myeloperoxidase, and leukocyte count were measured before (T1) and after (T2) hemofiltration and 24 h later (T3).

• Isovolumetric UF during rewarming with high UF volumes and equivalent amount of reinfusion solution (average 4.972 ml/m2)

• MUF after CPB weaning in both groups in order to remove excess fluids

Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976

MEMBRANES (NOT UF) CLEAR MEDIATORSin CHILDREN UNDERGOING CVVH

Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976

– Decrease of body temperature at T2 and T3

– Decrease of neutrophils count– Decrease of inotropic support– Decrease of blood loss at T2 and

T3– Decrease of postoperative

ΔAaO2 (320 vs. 551 mmHg)– Positive correlation between

ΔAaO2 and UF/TBV ratio. – Decrease of time to extubation

(10.8 vs. 28.2 h)

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgeryKazuto Yokoyama et al JTCVS 2009

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgeryKazuto Yokoyama et al JTCVS 2009

Roscitano et al, Asian Cardiovasc Thorac Ann 2009

Intraoperative Continuous Venovenous Hemofiltration during Coronary Surgery

CVVH post 35 mL/kg/hQb 150 ml/minNo heparin.Bicarbonate buffer Net UF rate 500–1000 mL/h

Intraoperative Continuous Venovenous Hemofiltration during Coronary Surgery

Antonino Roscitano, MD, Umberto Benedetto, MD, Massimo Goracci, Fabio Capuano, MD, Remo Lucani, MD1, Riccardo Sinatra, MD

Roscitano et al, Asian Cardiovasc Thorac Ann 2009

Reduction of Early Postoperative Morbidity in Cardiac Surgery Patients Treated With Continuous Veno–Venous Hemofiltration

During Cardiopulmonary Bypass

VAM in thetreatedgroup: VAM in thetreatedgroup: CVVH group 3.55 ± 0.85 hvs control group 5.8 ± 0.94 h, P < 0.001

ICU STAY:ICU STAY:CVVH group 29.5 ± 6.7 vs. control group 40.5 ± 6.67 h, P < 0.001.

Luciani et al Artif Organs 2009

Anti-inflammatory modalities: Their current use in pediatric cardiac surgery in the United Kingdom and Ireland

Allen et PCCM 2009

“…there are still widespread variations in practice. Rather than reflecting poor clinical practice, we believe this reflects a lack of good evidence supporting clinical benefit”

Neonates Children

Acute kidney injury and renal replacement therapy independently predict mortality in neonatal and pediatric noncardiac patients on

extracorporeal membrane oxygenation

Askenazi et al PCCM 2010

PCRRT and ECMO• Especially in the smaller children and infants solute

clearance on ECMO is greater then standard PCRRT due to the relatively high blood flow rates

• Ultrafiltration error may not be easily recognized due to the maintenance of hemodynamic stability that ECMO gives

• Excessive ultrafiltration due to ultrafiltration controller error ECMO-CVVH machines “interaction“

Courtesy of Norma J Maxvold (modified)

N = 4 pts with AKI(2 neonates +2 children)

1 neonate and 1 child required pCRRT+ECMO1 neonate a 1 child required pCRRT alone

ECMO and NGALECMO and NGALBambino Gesù experienceBambino Gesù experience

surv non surv0

1

2

mg

/dl

creatinine

surv non surv-2.5

0.0

2.5

5.0

7.5

10.0

12.5

ml/k

g/h

Urine output

Ricci Z, unpublished, 2010

surv non surv

-500

0

500

1000

ml

Fluid balance

ECMO and NGALECMO and NGALBambino Gesù experienceBambino Gesù experience

surv non surv0

100

200

300

400

500

600

700

ng

/ml

NGAL

* *

Ricci Z, unpublished, 2010

day

1

day

2

day

3

day

4

day

5

day

6

day

7

0

100

200

300

400

500

600

700

survivednon surv

ng

/ml

NGAL

Ricci Z, unpublished, 2010

CASE REPORT 1CASE REPORT 1

1,5

1,8

2,1

2,4

2,7

3

250

300

350

400

450

CVVH + Berlin Heart: 1) Cardiac index2) REDVI

Body water distribution

0

20

40

60

80

100

1° D 2° D 3° D 4° D 5° D

BW TBW ECW ICW

CASE REPORT 1CASE REPORT 1

CASE REPORT 2CASE REPORT 2Patient on ECMO for dilative cardiomyopathy, 35 kgPatient on ECMO for dilative cardiomyopathy, 35 kg•AnuricAnuric•Fenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressorsFenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressors

•Ischemic/thromboembolic event to right inferior limb (previous Ischemic/thromboembolic event to right inferior limb (previous femoral artery cannulation): Right inferior limb compartment femoral artery cannulation): Right inferior limb compartment syndrome (no surgery). syndrome (no surgery). Serum myoglobin > 50000 ng/mlSerum myoglobin > 50000 ng/ml

•CVVHDF 50 ml/kg/hCVVHDF 50 ml/kg/h

After 3 ECMO days, Htx.After 3 ECMO days, Htx.Need for CVVHDF for 22 POD daysNeed for CVVHDF for 22 POD daysICU discharge on POD 25 with normal renal functionICU discharge on POD 25 with normal renal function

Ricci et al, Blood Purif 2010

•Need for up to 12 grams/day of iv phosphate Need for up to 12 grams/day of iv phosphate replacementreplacement•Need for KCl correction in the replacement/dialysate Need for KCl correction in the replacement/dialysate bagsbags(about 500 mEq/day)(about 500 mEq/day)•Vancomycine continuous infusion (7 days) increased Vancomycine continuous infusion (7 days) increased from 50 mg/kg/die to 100 mg/kg/die on serum levelsfrom 50 mg/kg/die to 100 mg/kg/die on serum levels•Immunosuppression with iv continuous cyclosporine Immunosuppression with iv continuous cyclosporine increased from 100 to 150 mg/die on serum levelsincreased from 100 to 150 mg/die on serum levels

Ricci et al, Blood Purif 2010

CASE REPORT 2CASE REPORT 2

Patient n. Age Weight Preoperative diagnosis Presence of ECMO (yes/no)

1 4 days 3.5 HLHS Y

2 2 years 9 Dilated miocardiopathy N

3 35 days 4 AoCo+SubAoSt Y

4 45 days 4.2 TGA with coronary restenosis Y

5 28 days 3.8 PA with IS N

6 25 days 3.1 TGA Y

7 5 days 2.8 HLHS Y

8 10 days 3.5 HLHS Y

9 1 year 6 Dilated miocardiopathy Y

10 2 months 5.2 CAVC N

All that glitters is not goldAll that glitters is not gold

BNP

BNPBNP

CONCLUSIONSCONCLUSIONS

1.1. AKI in pediatric cardiac surgery is AKI in pediatric cardiac surgery is frequent.frequent.

2.2. UF during CPB is beneficial.UF during CPB is beneficial.3.3. Application of CRRT to extracorporeal Application of CRRT to extracorporeal

circulatory devices is possible.circulatory devices is possible.4.4. High expertise, safe machines and High expertise, safe machines and

trained staff is mandatory.trained staff is mandatory.5.5. Dedicated equipment and prospective Dedicated equipment and prospective

studies are dramatically lackingstudies are dramatically lacking