Pediatric Renal Replacement Therapy in the Intensive Care Unit

Bridges, Brian C.; Askenazi, David; Smith, Jessimene; Goldstein, Stuart L.

doi:10.1159/000342129

Cited by 28 publications

(14 citation statements)

References 124 publications

(59 reference statements)

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“…The volume of the extracorporeal circuit is particularly critical in the neonatal population and often these neonates will require that the CRRT machine be primed with blood if the circuit volume exceeds 10% to 15% of the total blood volume. 96 In the United States, current CRRT machines are approved only for those weighing .20 kg, but these machines have been used offlabel in children ,5 kg. 97 There are a number of considerations when evaluating CRRT in a neonate, including center expertise, prescription, and error rates of current machines, which has been recognized and led to the development of neonatal CRRT machines.…”

Section: Neonatal Cardiac Surgerymentioning

confidence: 99%

Neonatal Acute Kidney Injury

et al. 2015

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In recent years, there have been significant advancements in our understanding of acute kidney injury (AKI) and its impact on outcomes across medicine. Research based on single-center cohorts suggests that neonatal AKI is very common and associated with poor outcomes. In this state-of-the-art review on neonatal AKI, we highlight the unique aspects of neonatal renal physiology, definition, risk factors, epidemiology, outcomes, evaluation, and management of AKI in neonates. The changes in renal function with gestational and chronologic age are described. We put forth and describe the neonatal modified Kidney Diseases: Improving Global Outcomes AKI criteria and provide the rationale for its use as the standardized definition of neonatal AKI. We discuss risk factors for neonatal AKI and suggest which patient populations may warrant closer surveillance, including neonates ,1500 g, infants who experience perinatal asphyxia, near term/ term infants with low Apgar scores, those treated with extracorporeal membrane oxygenation, and those requiring cardiac surgery. We provide recommendations for the evaluation and treatment of these patients, including medications and renal replacement therapies. We discuss the need for long-term follow-up of neonates with AKI to identify those children who will go on to develop chronic kidney disease. This review highlights the deficits in our understanding of neonatal AKI that require further investigation. In an effort to begin to address these needs, the Neonatal Kidney Collaborative was formed in 2014 with the goal of better understanding neonatal AKI, beginning to answer critical questions, and improving outcomes in these vulnerable populations.

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Section: Neonatal Cardiac Surgerymentioning

confidence: 99%

Neonatal Acute Kidney Injury

et al. 2015

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“…The placement of catheters can be complicated by vascular stenosis, thrombosis, air emboli, or hemorrhage. A smaller vascular access in combination with lower flow rates of the blood in children increase the risk of clotting (Basu et al 2011;Bridges et al 2012). Systemic anticoagulation can result in a higher risk of developing hemorrhage.…”

Section: Renal Replacement Therapymentioning

confidence: 99%

Treatment options for lactic acidosis and metabolic crisis in children with mitochondrial disease

Danhauser

Smeitink

Freisinger

et al. 2015

J of Inher Metab Disea

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The mitochondrial pyruvate oxidation route is a tightly regulated process, which is essential for aerobic cellular energy production. Disruption of this pathway may lead to severe neurometabolic disorders with onset in early childhood. A frequent finding in these patients is acute and chronic lactic acidemia, which is caused by increased conversion of pyruvate via the enzyme lactate dehydrogenase. Under stable clinical conditions, this process may remain well compensated and does not require specific therapy. However, especially in situations with altered energy demands, such as febrile infections or longer periods of fasting, children with mitochondrial disorders have a high risk of metabolic decompensation with exacerbation of hyperlactatemia and severe metabolic acidosis. Unfortunately, no controlled studies regarding therapy of this critical condition are available and clinical outcome is often unfavorable. Therefore, the aim of this review was to formulate expert-based suggestions for treatment of these patients, including dietary recommendations, buffering strategies and specific drug therapy. However, it is important to keep in mind that a specific therapy for the underlying metabolic cause in children with mitochondrial diseases is usually not available and symptomatic therapy especially of severe lactic acidosis has its ethical limitations.

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“…Therefore, in accordance with Institutional protocols, if a patient had <10 % of ECV and was clinically stable, a saline prime was used, while if a patient had an ECV ≥10 % the circuit was primed with pRBCs. To get the pRBC close to physiologic, the blood prime is diluted 1:1 with sodium bicarbonate (to correct low pH and decrease HCT), and 1 mL of 10 % calcium gluconate is infused to the patient (to compensate for the low ionized calcium level of banked blood) as we previously described [5]. If criteria for blood prime is met, and the circuit runs for 72 h, or a planned circuit change occurs, we cross-primed the new circuit with the blood of the expiring circuit, according to Institutional protocols.…”

Section: Methodsmentioning

confidence: 99%

Smaller circuits for smaller patients: improving renal support therapy with Aquadex™

et al. 2015

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Background Providing renal support for small children is very challenging using the machinery currently available in the United States. As the extra-corporeal volume (ECV) relative to blood volume increases, and the state of critical illness worsens, the chance for instability during continuous renal replacement therapy (CRRT) initiation rises. CRRT machines with smaller ECV could reduce the risks and improve outcomes. Methods 1) Case series of small children (n = 12) who received continuous veno-venous hemofiltration (CVVH) via Aquadex™ machine (ECV = 33 mL) with 30 mL/kg/h of pre-replacement fluids at Children’s of Alabama between December 2013 and April 2015. 2) In vitro assessment of fluid precision using the adapted CVVH system. Results We utilized 101 circuits over 261 days to provide CVVH for 12 children (median age = 30 days; median weight 3.4 kg). Median CVVH duration = 14.5 days (IQR = 10, 22.8 days). Most circuits were routinely stopped for change after 72 h. Only 5/101 (5 %) initiations were associated with mild transient change in vital signs. Complications were infrequent (three transient hypothermia; three puncture-site bleeding, one systemic bleeding, and one right atrial thrombus). Most patients (7/12, 58 %) were discharged from ICU, and 6/12 (50 %) were discharged home. Conclusions CRRT machines with low ECV can enable clinicians to provide adequate, timely, safe and efficient renal support to small critically ill infants.

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Pediatric Renal Replacement Therapy in the Intensive Care Unit

Cited by 28 publications

References 124 publications

Neonatal Acute Kidney Injury

Neonatal Acute Kidney Injury

Treatment options for lactic acidosis and metabolic crisis in children with mitochondrial disease

Smaller circuits for smaller patients: improving renal support therapy with Aquadex™

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