Blood pump & infusion pumpsBlood pump & infusion pumpsManual CVVH Automatic machine

Anticoagulant Anticoagulant

Predisposing factors : blood flow, hemofilter Predisposing factors : blood flow, hemofilter type, coagulation pathway activation, convective type, coagulation pathway activation, convective mass transfermass transferSite of thrombus formationSite of thrombus formation

-- hemofilterhemofilter-- bubble trapbubble trap-- cathetercatheter-- Areas of turbulence resistanceAreas of turbulence resistance

Anticoagulant(2)Anticoagulant(2)

No anticoagulationNo anticoagulationTechnical aspects Technical aspects –– circuitcircuit–– Blood flow rateBlood flow rate–– FF / FF / predilutionpredilution

Saline flushSaline flushHemodilutionHemodilution

HeparinHeparin–– UnfractionatedUnfractionated–– LMWHLMWH

CitrateCitrateOthersOthers–– ProstacyclinProstacyclin–– DanaparoidDanaparoid–– HirudinHirudin

Heparin Heparin

Heparin infusion prior to filter and adjustment Heparin infusion prior to filter and adjustment based upon parametersbased upon parametersBolus with 10Bolus with 10--20 units/kg 20 units/kg Infuse at 10Infuse at 10--20 units/kg/hr20 units/kg/hrAdjust post filter Adjust post filter aPTTaPTT 1.21.2--1.5 time1.5 timeInterval of checking is local standard and varies Interval of checking is local standard and varies from 1from 1--4 hr increments4 hr increments

LMWHLMWH

Anticoagulant effect predominantly through Anticoagulant effect predominantly through AntifactorAntifactor XaXaLess bleeding complicationLess bleeding complicationLonger half life and cleared by the kidneysLonger half life and cleared by the kidneys

Citrate Citrate

Clotting is a Ca dependent mechanism, removal Clotting is a Ca dependent mechanism, removal of Ca from the blood will inhibit clottingof Ca from the blood will inhibit clottingAdding citrate to blood will bind the ionized Ca in Adding citrate to blood will bind the ionized Ca in the blood thus inhibiting clottingthe blood thus inhibiting clottingCitrate is infused at prefilter site and calcium is Citrate is infused at prefilter site and calcium is infused via independent line infused via independent line

Replacement fluid/DialysateReplacement fluid/Dialysate

Electrolyte Electrolyte compositioncompositionGlucose compositionGlucose compositionBuffer selectionBuffer selection-- LactateLactate-- AcetateAcetate-- BicarbonateBicarbonate-- CitrateCitrate

Replacement fluid/DialysateReplacement fluid/Dialysate

14414400--110110--15001500----Dextrose Dextrose (mg/dl)(mg/dl)

1.51.511--1.51.5--0.50.5--1.51.5----Mg Mg ------00----P P --2.82.8--3.53.51.51.52.52.5--3.53.53333Ca Ca ------2828--AcetateAcetate----4040--2828LactateLactate

25.925.93030--35353535------HCO3 HCO3 101.6101.6109109--116116106.5106.59696--102102109109109109ClCl3.83.80/2/40/2/4----4444K K

123.7123.7140140140140132132--134134130130130130Na Na

Costume Costume mademade

AccusolAccusolNormocarbNormocarb1.5%PD1.5%PDRARARLRL

Costume made : 0.45% NaCl 1000 ml + 7.5%NaCO3 30 ml + 15%KCl 2 ml + 20% NaCl 7.5 ml + 50% MgSO4 0.4 ml + 50% glucose 3 ml

Pre vs. Post dilutionPre vs. Post dilution

PrePre--dilution dilution Decrease filtration Decrease filtration fractionfractionDiminished solute Diminished solute clearance by diluting clearance by diluting blood reaching blood reaching hemofilterhemofilter

PostPost--dilutiondilutionNo effect on filtration No effect on filtration fractionfractionSolute conc. within Solute conc. within hemofilter hemofilter unchangeunchangefrom systemic conc. from systemic conc.

Comparison of CRRTComparison of CRRT

small to small to large large

moleculemolecule

small small moleculemolecule

middle/ large middle/ large moleculemolecule

waterwaterEfficiency : Efficiency : removeremove

Pre or Pre or postdilutionpostdilution

--Pre or Pre or postdilutionpostdilution

--Replacement Replacement fluidfluid

++++±±++++++±±Convective Convective clearance clearance

++++++++++----Diffusive Diffusive clearanceclearance

88--121222--4488--252522--55UF rate (ml/min)UF rate (ml/min)

2020--40401414--36361212--3636±±Urea clearance Urea clearance (L/day)(L/day)

1010--20201010--2020----DF (ml/min)DF (ml/min)

5050--2002005050--2002005050--2002005050--100100BFR (ml/min)BFR (ml/min)

CC--HDFHDFCC--HDHDCC--HFHFSCUFSCUF

•• BFR: 4 BFR: 4 --10 ml/kg/min or lower10 ml/kg/min or lower•• Replacement fluid: 1Replacement fluid: 1--2 L/1.73 m2 L/1.73 m22/hr/hr•• Dialysate 1Dialysate 1--2 L/1.73 m2 L/1.73 m22/hr /hr

(for CH(for CH--D, CHD, CH--DF): DF): •• Net UF rate: Net UF rate: 11--2 ml/kg/hour or higher2 ml/kg/hour or higher•• Heparin: Heparin: ACT 1.5 ACT 1.5 –– 2 times2 times

Total UF rate: RF + Dialysate + Net UFR + HeparinTotal UF rate: RF + Dialysate + Net UFR + HeparinUF rate should not > 20% BFRUF rate should not > 20% BFR

CRRT PrescriptionCRRT Prescription

Monitoring Monitoring

ClinicalClinicalLaboratories Laboratories -- Na, K, Na, K, ClCl, HCO, HCO33, Ca, BS q 6, Ca, BS q 6--12 hrs12 hrs-- BUN, Cr, Mg, PO4, CBC, PT,PTT q 24 hrsBUN, Cr, Mg, PO4, CBC, PT,PTT q 24 hrsVenous pressure : keep < 200 mmHgVenous pressure : keep < 200 mmHg

Sign of hemofilter clottingSign of hemofilter clotting

Darkening of blood in extracorporeal circuitDarkening of blood in extracorporeal circuitSeparation of Separation of rbcrbc and plasma in circuitand plasma in circuitSustained reduction in volume of UFSustained reduction in volume of UFScreening : filtrate urea nitrogen : BUN ratio Screening : filtrate urea nitrogen : BUN ratio

if < 0.6 if < 0.6 --------------> clotting is imminent> clotting is imminent

CRRT (high volume)

Sepsis and MODSSepsis and MODS

Sepsis and MODSSepsis and MODS

CC--HF, CHF, C--HDF : ability to remove septic HDF : ability to remove septic mediators from circulation by adsorption and mediators from circulation by adsorption and convectionconvection

Use high volume Use high volume hemofiltrationhemofiltrationclearance dose 35 ml/kg/hrclearance dose 35 ml/kg/hr (sepsis dose)(sepsis dose)

BUN

IHDCRRT

Complications of CRRTComplications of CRRTHeparin associated : bleeding, HITHeparin associated : bleeding, HITCatheter related : sepsis, thrombosis, pain, arrhythmia, Catheter related : sepsis, thrombosis, pain, arrhythmia, pneumothoraxpneumothorax, line disconnection, line disconnectionHypothermia Hypothermia Anemia Anemia Hypovolemia Hypovolemia HypotensionHypotensionMembrane reaction (Membrane reaction (bradykininbradykinin release, anaphylaxis)release, anaphylaxis)Electrolyte abnormalities (hypoPOElectrolyte abnormalities (hypoPO44, hypo K, hypo K++))Metabolic acidosis or alkalosisMetabolic acidosis or alkalosisAir embolism Air embolism

CaseCase

Start CVVHStart CVVH

UF 600UF 600--700 700 mLmL/day/dayBUN/CR 69/5.1BUN/CR 69/5.1 42/3.1 (day 3)42/3.1 (day 3)

ProblemProblem clottedclotted changed changed

CaseCase

2nd CVVH (start day 3)2nd CVVH (start day 3)

Day 5Day 5BUN/CrBUN/Cr 50/350/3Na 132, K 3.4, Na 132, K 3.4, ClCl 87, HCO87, HCO33 1717Ca 9.7Ca 9.7 POPO44 3.03.0

CaseCase

Continue CRRTContinue CRRT นานนาน 15 15 วันวัน ชวงชวง 10 10 วนัแรกวนัแรก BUN/Cr BUN/Cr ลดลงดีลดลงดี (last 40/2)(last 40/2)

D13 D13 เริ่มมีปญหาบริเวณแผลผาตัดเริ่มมีปญหาบริเวณแผลผาตัด ตองเขาตองเขา OR OR ใหมใหม กลับจากกลับจาก OR try off CVVH OR try off CVVH แตมีปญหาแตมีปญหา pulmonary edema pulmonary edema และและ hyper Khyper K

CVVHCVVH

ทําไดนานแคไหนทําไดนานแคไหน

อะไรที่มักเปนสาเหตุใหตองหยุดทําอะไรที่มักเปนสาเหตุใหตองหยุดทํา

เมื่อไหรตองพิจารณาเปลีย่นเปนวิธีอื่นเมื่อไหรตองพิจารณาเปลีย่นเปนวิธีอื่น

รายนี้มีรายนี้มี indication indication อะไรที่ตองเปลี่ยนเปนอะไรที่ตองเปลี่ยนเปน hemodialysishemodialysisHemodialysis Hemodialysis ตองระวังอะไรตองระวังอะไร ทําตางจังหวัดไดไหมทําตางจังหวัดไดไหม เครื่องมือเครื่องมือ

ในผูใหญตางกันไหมในผูใหญตางกันไหม

Hemodialysis Hemodialysis Individual prescription is required.Individual prescription is required.Assessment and adjustment is needed regularly Assessment and adjustment is needed regularly esp. in small children.esp. in small children.Machine : adjustable blood pump, bicarbonate Machine : adjustable blood pump, bicarbonate buffer system, temperature controlled, volume buffer system, temperature controlled, volume accuracyaccuracyThe 1The 1stst dialysis session is the most critical, dialysis session is the most critical, therefore appropriate preparation is needed.therefore appropriate preparation is needed.

Hemodialysis prescriptionHemodialysis prescription

DialyzerDialyzer and blood lineand blood lineBlood flow rate (QBlood flow rate (QBB))Dialysate flow rateDialysate flow rateAnticoagulant Anticoagulant UltrafiltrateUltrafiltrate raterateDuration and frequencyDuration and frequency

DialyzerDialyzer and blood lineand blood line

Total extracorporeal blood volume should be Total extracorporeal blood volume should be less than 10% of blood volumeless than 10% of blood volumeDialyzerDialyzer should have low internal blood volumeshould have low internal blood volumeMembrane surface area should approximately Membrane surface area should approximately match the body surface areamatch the body surface area

20.520.51.51.59090SurfluxSurflux 1.51.517.817.81.31.37575SurfluxSurflux 1.31.35.55.51.31.38282F6F64.04.01.01.06363F5F52.82.80.70.74242F4F41.71.70.40.42828F3F3KKUFUFSurface areaSurface areaPriming Priming volvolDialyzerDialyzer

DialyzerDialyzer and blood line(2)and blood line(2)

DialyzerDialyzer and blood line(3)and blood line(3)Blood line (Blood line (KawasumiKawasumi RR))

888adult> 30 kg

648pediatric< 30 kg

Internal diameter(mm)

Internal volume(ml)

Type Patient size

Blood flow rate (QBlood flow rate (QBB))

Target BFR 150 Target BFR 150 –– 200 ml/min/m200 ml/min/m22

or 5 or 5 –– 7 ml/kg/min7 ml/kg/minIn small children can determine byIn small children can determine by

= (BW+10) x 2.5 ml/min= (BW+10) x 2.5 ml/minDetermine by urea clearance Determine by urea clearance

First session 2 ml/kg/minFirst session 2 ml/kg/minTarget 5 ml/kg/min Target 5 ml/kg/min

A child 10 year old, BW 29 kg, Ht 130 cmA child 10 year old, BW 29 kg, Ht 130 cmblood volume 80 ml/kg x 29 kg = 2320 mlblood volume 80 ml/kg x 29 kg = 2320 mlBSA = 130 cm x 29 kg = 1.02 mBSA = 130 cm x 29 kg = 1.02 m22

36003600Use F5 surface area 1 mUse F5 surface area 1 m22 priming vol.63 mlpriming vol.63 ml

pediatric blood line pediatric blood line priming vol. 48 mlpriming vol. 48 ml

Example Example

√

Example Example

Blood flow rate Blood flow rate urea clearance 2 ml/kg/minurea clearance 2 ml/kg/min

DesiredDesired QQBB == 200 ml/min200 ml/minDesiredDesired ClClUreaUrea 170 ml/min170 ml/minDesiredDesired QQBB == 200 ml/min200 ml/min

2 ml/kg/min x 29 kg 170 ml/min2 ml/kg/min x 29 kg 170 ml/minDesiredDesired QQBB == 68.2 ml/min68.2 ml/min

Dialysate flow rate Dialysate flow rate

Bicarbonate buffer Bicarbonate buffer Not less than 1.5 of BFRNot less than 1.5 of BFRIn general practice : 500 ml/minIn general practice : 500 ml/minIn children < 10 kg In children < 10 kg ---------- risk to hypothermia risk to hypothermia should be adjusted dialysate temperature to 39 should be adjusted dialysate temperature to 39 CC

Anticoagulant Anticoagulant

Minimize risk of clotting formationMinimize risk of clotting formationRisk factor : Risk factor :

Small lumen diameter and large contact Small lumen diameter and large contact surface areasurface areaLow blood flow rateLow blood flow rate

Heparin remains standard anticoagulantHeparin remains standard anticoagulantLoading dose : 25Loading dose : 25--40 U/kg40 U/kgMaintenance dose : 15Maintenance dose : 15--30 U/kg/hr30 U/kg/hr

should be stopped some 30 min or so prior to should be stopped some 30 min or so prior to the end of dialysis the end of dialysis Monitoring : Monitoring :

activated clotting time 1.25 activated clotting time 1.25 –– 1.5 times1.5 timesaPTTaPTT 120 120 –– 160 sec160 sec

Anticoagulant(2) Anticoagulant(2)

Low molecular weight heparinLow molecular weight heparinMore effective in reducing fibrin deposit in More effective in reducing fibrin deposit in dialyzerdialyzer membrane and extracorporeal clottingmembrane and extracorporeal clottingFewer hemorrhagic complicationsFewer hemorrhagic complicationsEnoxaparinEnoxaparin 1 mg/kg 1 mg/kg

Anticoagulant(3) Anticoagulant(3)

Amount and rate of UF Amount and rate of UF

Adjust to toleranceAdjust to toleranceTotal amount should no more than 5 Total amount should no more than 5 –– 10% BW 10% BW per sessionper sessionRate should not exceed 1.5 Rate should not exceed 1.5 –– 2% BW per hour2% BW per hourUse sequential UF or sodium modeling if large Use sequential UF or sodium modeling if large amount of fluid must be removed amount of fluid must be removed

Duration and frequencyDuration and frequency

11stst session 1session 1-- 2 hours2 hoursIdeal : daily Ideal : daily hemodialysishemodialysisUsually 3 times/week, duration 4 Usually 3 times/week, duration 4 –– 6 hours6 hoursIn small children : 4 In small children : 4 –– 5 times/ week5 times/ week

Pediatric HD PrescriptionPediatric HD PrescriptionPriming: Priming: NSS, 5% albumin, plasma, bloodNSS, 5% albumin, plasma, bloodExtracorporeal volume: < 10 % blood volumeExtracorporeal volume: < 10 % blood volumeFluid removal: Fluid removal: < 5 < 5 -- 10 % body weight/treatment10 % body weight/treatmentBlood Flow Rate: per urea clearance neededBlood Flow Rate: per urea clearance neededDialysate Flow Rate: 1.5 to 2 times BFRDialysate Flow Rate: 1.5 to 2 times BFRHeparinizationHeparinization: ACT 1.5 : ACT 1.5 -- 2 times 2 times Osmotic agent: Osmotic agent: –– 20% 20% mannitolmannitol 0.250.25--0.5 g/kg continuous IV drip0.5 g/kg continuous IV drip–– Indication : Indication : 11stst treatment, BUN > 100 mg/dltreatment, BUN > 100 mg/dl

Hemodialysis adequacyHemodialysis adequacy

Urea kinetic modeling has been accepted as a Urea kinetic modeling has been accepted as a method for assessmentmethod for assessmentUrea Urea dialyticdialytic clearance in children is usually low clearance in children is usually low in comparison with high Kin comparison with high Kieie

Kt / VKt / VK = K = dialyzerdialyzer urea clearanceurea clearancet = durationt = durationV = patientV = patient’’s urea distribution volume or s urea distribution volume or

total body water total body water

Volume of distribution of urea in Volume of distribution of urea in childrenchildren

BoyBoyHt < 132.7 cm Ht < 132.7 cm

V = 1.927 + 0.465/BW + 0.0045/HtV = 1.927 + 0.465/BW + 0.0045/HtHt > 132.7 cm Ht > 132.7 cm

V = V = --21.1933 + 0.406/BW + 0.209/Ht21.1933 + 0.406/BW + 0.209/HtGirl Girl Ht < 110.8 cm Ht < 110.8 cm

V = 0.076 + 0.507/BW + 0.013/HtV = 0.076 + 0.507/BW + 0.013/HtHt > 110.8 cm Ht > 110.8 cm

V = V = --10.313 + 0.252/BW + 0.154/Ht10.313 + 0.252/BW + 0.154/Ht

Kt / V Kt / V = = --ln(Cln(C11/C/Coo--0.008* t)+(40.008* t)+(4--3.5*C3.5*C11/C/Coo)* UF/BW)* UF/BWMinimum Kt / V level of 1.2 Minimum Kt / V level of 1.2 –– 1.4 is 1.4 is desirabledesirable

Hemodialysis adequacyHemodialysis adequacy

ComplicationsComplications

IntradialyticIntradialytic hypotensionhypotensionMuscle crampMuscle crampAir embolismAir embolismDialysis disequilibriumDialysis disequilibriumCatheterCatheter--related blood related blood stream infectionstream infectionSudden deathSudden death

Nutrition Nutrition Catabolic state :Catabolic state :-- Negative nitrogen balanceNegative nitrogen balance-- Insulin resistanceInsulin resistance-- AcidosisAcidosis-- Excessive secretion of catecholamines, Excessive secretion of catecholamines,

glucocorticoids, glucagonglucocorticoids, glucagon-- Inflammatory mediators and protease Inflammatory mediators and protease

from activated leukocytesfrom activated leukocytes

Energy intake 35 kcal/kg (60% from CHO, 40% Energy intake 35 kcal/kg (60% from CHO, 40% from lipids)from lipids)Protein 1Protein 1--1.5 g/kg/day depend on catabolic state 1.5 g/kg/day depend on catabolic state and RRT modalityand RRT modalityEnteralEnteral feeding is preferablefeeding is preferableSupplement of water soluble vitamin is Supplement of water soluble vitamin is recommended, esp. in RRT recommended, esp. in RRT Fortification of feeds with glutamine, arginine,nucleotides, and Omega 3 fatty acids is used forimmune enhancement

Nutrition Nutrition

Understand natural history of AKI

Identify children at high risk of AKI- Underlying CKD- Undergoing CVS surgery- Those requiring contrast for imaging

Understand ass. AKI and poor outcome- Improve severity of illness scoring in PICU- Identify risk factors for poor outcome- Identify factors influence renal recovery

Strategies to improve pediatric AKI outcome• Prevent AKI in those at risk

• NaHCO3, Fluid resuscitation, Pharmacy, Avoid nephrotoxic drugs

• Alter natural course of AKI• Early identification of AKI : IL-18, NGAL, KIM-1• Blood pressure support : drugs to provide adequate

renal perfusion, assess intravascular volume• Goal-oriented strategies to support children with AKI

• Fluid management strategies• Blood pressure support• Ventilation support• Renal replacement therapy Kidney Kidney IntInt 20072007

Outcome Outcome Overall mortality : vary (24Overall mortality : vary (24--89%)89%)Factor associated with mortality in ARFFactor associated with mortality in ARFARF (with minor problem) mortality < 4ARF (with minor problem) mortality < 4--8%8%

+ oliguria + oliguria + younger age (preterm) increased up to 89%+ younger age (preterm) increased up to 89%+ assisted ventilator+ assisted ventilator+ Multiorgan failure+ Multiorgan failure+ surgery for congenital heart disease+ surgery for congenital heart disease+ sepsis/CVS failure and + sepsis/CVS failure and

hypoalbuminemia(< 3g/dl)hypoalbuminemia(< 3g/dl)

Outcome Outcome N=245

CKD stage 2N = 4

MicroalbuminuriaHyperfiltrationHTNMicroscopic hematuria

AskenaziAskenazi, et al. Kidney , et al. Kidney IntInt 20062006

Non survivorsN=71

32 died afterdischarge

16 ESRD

3 died13 alive

CKD stage 1N = 9

69 unable to locate28 refused29 subject

SurvivorsN=174

126 potential subjects