2 Smaller Circuits for Smaller Patients Improving Renal

2 Smaller Circuits for Smaller Patients Improving Renal Support with Aquadex™ Machine David Askenazi MD, MSPH Associate Professor of Pediatrics

Potential conflict of interest n Speaker for AKI foundation

Small children are dialyzed differently! < 5 kg N = 170 Anticoagulation Protocol Citrate Heparin > 5 kg Survival in pp. CRRT Registry N = 251 <0. 001 76 (45%) 94 (55%) 155 (62%) 96 (38%) Prime 164 (96. 5%) 5 (3%) 1 (0. 5%) 202 (80%) 29 (12%) 20 (8%) 12 (7. 9 -15. 6) 6. 6 (4. 8 -8. 8) 3328 (2325 -4745) 28 (11 -67) 2321 (16142895) 37 (16 -67) 60% 50% <0. 001 Blood Saline Albumin Blood Flow * (ml/kg/min) Daily Effluent Volume* (ml/hr/1. 73 m 2) Circuit LIfe P< 0. 001 70% 40% 30% 20% <0. 001 10% <0. 001 0. 15 0% <10 kg Askenazi et al. Journal of Pediatrics 2013; 162: 587 -92. >10 kg

Neonatal CRRT Circuit Priming n Smaller patients require blood priming to prevent hypotension/hemodilution n n Circuit volume > 10 -15% patient blood volume Example n n n 4 kg infant : Blood Volume = 320 cc (80/kg) Circuit (extracorporeal volume = 165 ml) Therefore ≈ 50% extracorporeal volume

Added Risk for PRBC prime n Packed RBCs n HYPOCALCEMIC n n HYPERKALEMIC n n n LYSIS OF CELLS ACIDIC There are no Plts in packed p. RBC’s n n Citrate Every prime you start CRRT you should expect for your plts count to drop There are no coagulation factors in p. RBC’s n 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 m 2

We must then acknowledge n n Its amazing we do CRRT in babies…. Even with the best practices…. this approach exposes the smallest children to added risk ≠ RISK Benefit

We must then acknowledge n n n 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 n In 2012, received a Impact Grant from Children’s of Alabama • Aquadex – • FDA approved for ultrafiltration in 2007 • 33 cc circuit volume • 4 kg = 10 % ECV

Lets adapt a machine Rx • Blood flow = 40 ml/min • Prismasol with additives at 30 ml/kg/hr • Heparin anti-coagulation

Children’s of Alabama (Dec 2013 – April 2015) n 12 children received CVVH on Aquadex™ n n n 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 n n double lumen vascular access (n=9) (4 = 8 F; 4 = 7 F; 1 = 6 F) 2 x single lumen catheters in 3 with congenital heart disease had 2 single lumen catheters.

Can we use umbilical lines?

Children’s of Alabama (Dec 2013 – April 2015) n 101 circuits – 261 days n n 12 new starts 89 restarts n n 59 (61%) circuits lasted 72 hours Prime n 80% Blood Prime n n ECV > 10% (<4 kg) p. RBC + Na. HC 03 + Ca. Cl 80% for Saline prime in 20% Cross prime circuit for routine change out 20% Saline Prime

Clearance Serum Creatinine (mg/dl) Changes in SCr over the first 3 days of CRRT 6 5 4 3 2 1 0 1 2 Days of CRRT 3

Children’s of Alabama (Dec 2013 – April 2015) n n n 7/12 survived to come off CVVH 6/12 survived to hospital discharge n 1 died before hospital discharge for non-renal complications n 5 died due to progressive cardiac/pulmonary disease Complications from CVVH n 4/101 (4%) initiation associated with need for increased BP support n All very mild and transient n 3 hypothermia n 4 bleeding n 1 had a right atrial thrombus

Summary Aquadex – CRRT experience n n n Nephrologist Like it! Renal Support Goals Achieved n Steady reduction in BUN / Cr n Excellent control of electrolytes balance. n Fluid goals achievable n 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 n n n 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