【持续性肾脏替代治疗crrt英文精品课件】neonatal and infant crrt

Neonatal and Infant CRRT,Jordan M. Symons, MD University of Washington School of Medicine Childrens Hospital & Regional Medical Center Seattle, WA ,Pediatric CRRT: Vicenza, 1984,CRRT Machines: Current Generation,Vascular Access for Pediatric CRRT,Smaller patients require smaller catheters Difficulty achieving access Difficulty maintaining access Limited access sites,Choices for Vascular Access,Access Sites for CRRT,Femoral veins Jugular veins Subclavian veins Umbilical vessels ECMO circuit,Prescribing CRRT for Small Kids,Modality Blood flow rate Hemofilter Solution(s) Ultrafiltration rate Anticoagulation Special considerations,CRRT Modality for Small Kids,Am J Kid Dis, 18:833-837, 2003,Hemofilters for Pediatric CRRT,Am J Kid Dis, 18:833-837, 2003,Ultrafiltration Rate for Infant CRRT,As tolerated by the patient Potentially limited by hemofilter, blood flow rates Small errors have a larger effect in a tiny patient,Anticoagulation for Infant CRRT,Heparin Citrate Nothing ? Other things ?,Other Special Considerations for CRRT in Infants,Large extracorporeal volume compared to small patient Blood prime (1:1 PRBC:Albumin 5%) at initiation frequently required Risk of thermic loss often requires heating system,Potential Complications of Infant CRRT,Volume related problems Biochemical and nutritional problems Hemorrhage Infection Technical problems Logistical problems Bradykinin release syndrome,Logistical Issues for Infant CRRT,Infrequently performed procedure in neonatal units Vascular access can be difficult to organize and obtain Neonatology staff may be unfamiliar with equipment, procedure, risks Written procedures may improve coordination and results of therapy,Bradykinin Release Syndrome,Mucosal congestion, bronchospasm, hypotension at start of CRRT Resolves with discontinuation of CRRT Thought to be related to bradykinin release when patients blood contacts hemofilter Exquisitely pH sensitive,Technique Modifications to Prevent Bradykinin Release Syndrome,Buffered system: add THAM, CaCl, NaBicarb to PRBCs Bypass system: prime circuit with saline, run PRBCs into patient on venous return line Recirculation system: recirculate blood prime against dialysate,Bypass System to Prevent Bradykinin Release Syndrome,Modified from Brophy, et al. AJKD, 2001.,Recirculation System to Prevent Bradykinin Release Syndrome,Recirculation Plan: Qb 200ml/min Qd 40ml/min Time 7.5 min,Based on Pasko, et al. Ped Neph 18:1177-83, 2003,Outcomes for Pediatric CRRT,Data are scant Most studies are single-center, retrospective No randomized controlled trials Small numbers limit power Extension from adult studies may not be appropriate,CRRT in Pediatric Patients 10Kg,Multi-center, retrospective study 5 pediatric centers 85 patients Demographic data Technique description Outcome,Am J Kid Dis, 18:833-837, 2003,Which Babies Require CRRT?,N=85,Am J Kid Dis, 18:833-837, 2003,Why do Babies Need CRRT?,N=85,Am J Kid Dis, 18:833-837, 2003,CRRT in Infants 10Kg: Outcome,Patients 10kg,Patients 3-10kg,Patients 3kg,38% Survival,41% Survival,25% Survival,Am J Kid Dis, 18:833-837, 2003,Survival by Diagnosis,Totals: N=85; Survivors=32,Am J Kid Dis, 18:833-837, 2003,Survival by Modality,p=NS,Am J Kid Dis, 18:833-837, 2003,Retrospective Study of Infant CRRT: Summary,Overall outcome acceptable 3 10kg: outcome similar to that for older patients Metabolic disorders: good outcome 3kg, selected diagnoses: poor outcome No clear advantage between modalities,Am J Kid Dis, 18:833-837, 2003,Prospective Pediatric CRRT Registry (ppCRRT),Multi-center registry of pediatric CRRT Currently eleven US centers participating Collecting demographic, technical and outcome data on all pediatric patients receiving CRRT Sub-analysis of infants 10kg presented at ASN and PAS/ASPN,ppCRRT Data of Infants 10kg: Demographic Information,28 children 10 kg 14 boys, 14 girls Median age 40 days old Range 3 days to 2.9 years Median weight 4.1 kg Range 1.3 to 9.5 kg,ppCRRT Data of Infants 10kg: Indications for CRRT,N=28,ppCRRT Data of Infants 10kg: Vascular Access Location,N=28,ppCRRT Infant Survival Data,41% Survival,64% Survival,50% Survival,Infant CRRT: Contin