David Askenazi MD, MSPHAssociate Professor of Pediatrics

2Smaller Circuits for Smaller PatientsImproving Renal Support with Aquadex™

Machine

Potential conflict of interest

Speaker for AKI foundation

Small children are dialyzed differently!

< 5kg

N = 170

> 5kg

N = 251Anticoagulation Protocol

<0.001

Citrate 76 (45%) 155 (62%)Heparin 94 (55%) 96 (38%)

Prime <0.001

Blood 164 (96.5%) 202 (80%)Saline 5 (3%) 29 (12%)Albumin 1 (0.5%) 20 (8%)

Blood Flow *(ml/kg/min) 12 (7.9-15.6) 6.6 (4.8-8.8) <0.001

Daily Effluent Volume*(ml/hr/1.73m2) 3328 (2325-4745)

2321 (1614-2895)

<0.001

Circuit LIfe 28 (11-67) 37 (16-67) 0.15

Askenazi et al. Journal of Pediatrics 2013;162:587-92.

<10 kg >10 kg0%

10%

20%

30%

40%

50%

60%

70%P< 0.001

Survival in ppCRRT Reg-istry

Neonatal CRRT Circuit Priming

Smaller patients require blood priming to prevent hypotension/hemodilution Circuit volume > 10-15% patient blood

volume Example

4 kg infant : Blood Volume = 320 cc (80/kg) Circuit (extracorporeal volume = 165 ml) Therefore ≈ 50% extracorporeal volume

Added Risk for PRBC prime Packed RBCs

HYPOCALCEMIC Citrate

HYPERKALEMIC LYSIS OF CELLS

ACIDICThere are no Plts in packed pRBC’s

Every prime you start CRRT you should expect for your plts count to drop

There are no coagulation factors in pRBC’s Every prime you start CRRT you should expect

for your coagulation factor to drop.

What if you did that to me?

4 kg 70 kg

Blood Volume 320 ml 5000 ml

Extracorporeal volume

165 ml (50% of ECV)

2.5 L

Blood Flow 12 ml/kg/min 840 ml/min

Clearance 100 ml /kg/hr 7000 ml/hr

Filter 5 times BSA 8.6 m2

We must then acknowledge Its amazing we do CRRT in babies…. Even with the best practices….this

approach exposes the smallest children to added risk

BenefitRISK≠

We must then acknowledge Its amazing we do CRRT in babies…. Even with the best practices….this

approach exposes the smallest children to added risk

You have reason to be nervous… What about the 1-2 kg baby?

Do we just ignore him/her….? If we believe that critically ill patients do

better with renal support…we must strive to do better?

Lets adapt a machine

• Aquadex – • FDA approved for

ultrafiltration in 2007

• 33 cc circuit volume

• 4 kg = 10 % ECV

In 2012, received a Impact Grant from Children’s of Alabama

Lets adapt a machine

Rx• Blood flow = 40

ml/min• Prismasol with

additives at 30 ml/kg/hr

• Heparin anti-coagulation

12 children received CVVH on Aquadex™ 5 in CICU and 7 in NICU 9 for AKI and 3 for severe congenital CKD median age at initiation = 30 days (IQR = 13, 38 days) median weight at initiation was 3.4 kg (IQR = 3.0 – 4.3 kg)

The median duration = 14.5 days (IQR = 10, 22.8 days).

Access double lumen vascular access (n=9) (4 = 8F; 4 = 7F; 1 =

6F) 2 x single lumen catheters in 3 with congenital heart

disease had 2 single lumen catheters.

Children’s of Alabama (Dec 2013 – April 2015)

Can we use umbilical lines?

101 circuits – 261 days 12 new starts 89 restarts

59 (61%) circuits lasted 72 hours

Prime 80% Blood Prime

ECV > 10% (<4 kg) pRBC + NaHC03 + CaCl 80% for Saline prime in 20% Cross prime circuit for routine change out

20% Saline Prime

Children’s of Alabama (Dec 2013 – April 2015)

Clearance

1 2 30

1

2

3

4

5

6

Changes in SCr over the first 3 days of CRRT

Days of CRRT

Seru

m C

reati

nine

(mg/

dl)

7/12 survived to come off CVVH 6/12 survived to hospital discharge

1 died before hospital discharge for non-renal complications 5 died due to progressive cardiac/pulmonary disease

Complications from CVVH 4/101 (4%) initiation associated with need for increased BP

support All very mild and transient

3 hypothermia 4 bleeding 1 had a right atrial thrombus

Children’s of Alabama (Dec 2013 – April 2015)

Summary Aquadex – CRRT experience

Nephrologist Like it! Renal Support Goals Achieved Steady reduction in BUN / Cr Excellent control of electrolytes balance. Fluid goals achievable No crashes on initiation!

Critical Care Docs Like it! Dialysis Nurses Like it! Bedside Nurses Like it! Babies hardly know they are on it!

Limitations

Small retrospective case series IV infusion system does not

communicate to machine We probably can, but haven’t tried

citrate anti-coagulation No counter-current dialysis A circuit <24 ml would mean all

saline primes in our case series!

Smaller circuits will revolutionize how neonatal ICU care!

Acknowledgements

• Pediatric Nephrologist Colleagues• Dan Feig MD• Sahar Fathallah MD• Monica Cramer MD• Frank Tenney MD

• Critical Care Faculty• Dialysis Nurses

• Lynn Dill RN• Daryl Ingram RN

• Bedside Nurses