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ACUTE PERITONEAL DIALYSISALTERNATIVE FORM OF CRRT
Mignon McCullochDepartments of Paediatric Nephrology & PICURed Cross Children’s Hospital & University of
Cape Town
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Paediatric Modified RIFLE (pRIFLE) Criteria
eCreatinine clearance
(eCCL)*
Urine output
1 eCCL by 25 % <0.5 ml/kg/hr for 8 hrs
2 eCCL by 50 % <0.5 ml/kg/hr for > 16hrs
3 eCCL by 75 % <0.3 ml/kg/hr for > 24 hr or anuria for 12 hr
*eCCL = 40 x height (cm) / s-creatinine (μmol/L)
Akcan-Arikan A et al Kidney Int 2007; 71: 1028-1035
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AKI: Treatment Modality Selection
Ashita Tolwani, M.D., M.Sc.University of Alabama at Birmingham
Critical Care Nephrology – Vicenza June 2015
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Use of Peritoneal Dialysis in AKI: A Systematic Review
Ashita Tolwani
24 studies identified 19/24 from Asia, Africa, and
South America 13 studies with PD only 11 studies with PD and EBP
7 observational 4 randomized
Chionh CY et al. Clin J Am Soc Nephrol 8: 1649–1660, 2013
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Clinical Problems Produced By AKI
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H
L
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
Fri 9Mar 2007
Sat 10 Sun 11 Mon 12
Potassium Level
mm
ol/L
PAYNE, JONTY
Potassium Level (mmol/L)
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PD as CRRT Alternative to Extracorporeal systems Difficult Venous access Small infants “Challenged” resources
No equipment No surgical back-up appropriate
Not about Chronic PD
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London
Peritoneal Dialysis in PICU RRT in PICU
Dr Mignon McCullochEvelina Children’s Hospital, Guy’s & St Thomas’ NHS
Trust
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Evelina Children’s HospitalAndrew Durward Personal Communication
PICU 8818 Admissions
413 deaths Mortality 4.7%
20 Beds
Staffing: 7 Consultants 20 Fellows 150 Nurses
Training in nurses: CVVH 30% trained PD in 100% nurses
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Evelina Children’s Hospital PICU 2002 – 2009
CVVH PD
Nos of Cases 119 188139 Cardiac
Age in months 30 7.8Med 0.22
Weight in kg -- 5.3Med 3.3
Mortality 30% 17%
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Red Cross Children’s Hospital(RXH)University of Cape Town Experience
Increasing incidence in association with multi-organ failure in paediatric ICU’s
1 200 – 1 400 admissions per year Acute medical cases 600/yr Cardiac cases 250/yr Burns 50/yr Head injuries 50/yr Other Rest
Mortality 6% predicted 10-12% Dialysis 3.5%
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Causes of Acute Kidney Injury
Sepsis 46(22%)
Post-cardiac surgery 36(17%)
Undiagnosed chronic renal disease
21(10%)
Gastroenteritis 19(9%)
Haemolytic uraemic syndrome
19(9%)
Necrotizing enterocolitis 15(7%)
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Causes of Acute Kidney Failure
Leukaemia/Lymphoma 14(6%)
Myocarditis 11(5%)
Rapidly progressive nephritis
10(5%)
Trauma/Burns 8(4%)
Toxin ingestion 7(3%)
Kwashiorkor** 6(3%)
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Practicalities of PD Quick – really quick – 20 mins K+ 9! Bed-side insertion by Paeds
Nephrologist/Intensivist/Surgeons (Surgeons as backup) Cook/Peel Away Tenckhoff/Formal
Tenckhoff Empty Bladder Sedation + Local Anaesthetic
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Practicalities of PD Prescription
10-20ml/kg increase as tolerated to 50ml/kg Dialysis fluid
1.5%/2.5%/4.25% Dianeal(Lactate buffered) or Bicarb based
Cycles: Fill/Dwell/Drain 10/30-90/20mins
Manual or Cycling Home choice > 3kg Adapted to ventilatory requirements
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PD Catheters Art of Medicine? Innovative and
Creative Cannulaes Naso-gastric tubes/Chest Drains Venous Central lines Rigid ‘Stick’ catheters ‘Peel away’ Tenckhoff Flexible Multi-purpose drainage catheters
Auron A et al Am J Kidney Dis 2007
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New Generation Cook Catheters
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Kimal ‘Peel-away’ Tenckhoff
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Complications of PD Dysequilibration Syndrome (rare in acute) Hypotension Infection Blocked / Displaced catheter Respiratory difficulties Diaphragmatic leak Hyperglycaemia
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Equipment – Audit at RXHTotal catheters used 260
Cook - 5 Fr Neonatal- 8 Fr Paediatric- 11 Fr Adult
(62%)531064
Kimal “peel away” Percutaneous Tenckhoff
46 (18%)
Surgical inserted Tenckhoff 51 (20%)
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Automated DialysisHome choice machine
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Manual Dialysis with Fluid Warmer
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Acute Peritoneal Dialysis January 1999 to January 2004
TOTAL NUMBER OF PATIENTS
212
Male: Female 102:110
Age at dialysis:< 3 months3 months - 1yr1 – 6 years6 – 12 years> 12 years
79(38%)45(21%)38(18%)30(14%)20(9%)
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Acute PDLong term outcome
Survival following Acute PD
130(61% )
Chronic PD required following Acute PD
26(12%)
Total nos of patients requiring CVVHD (PD not possible) Survival following CVVHD
20(9%)
11(55%)
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Acute PD in PICU 1999-2009 Presented IPNA Aug 2010 New York
Red Cross Children’s Hospital, Cape Town SA
Total 406 cases/10years Wt range 900g – 70kg Age 1 day – 16yrs Diphtheria – Liver Transplant
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PD IN PICU Total Nos 406 Neonates(<1mth) 85(21%) Infants(<1yr) 221(54%) Cardiac 95(23%)
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Overall Mortality Rate
0
10
20
30
40
50
60
7020
00
2001
2002
2003
2004
2005
2006
2007
2008
2009
Overall 42%
Rat
e %
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Vesna Stojanović, MD, PhD
Institute for Child and Youth Health Care of Vojvodina, Intensive Care
Unit
Novi Sad, Serbia
Peritoneal Dialysis in NICU
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Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country
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Specific Paeds Management IssuesVery Low Birth Weight InfantsKoralkar R et al. Ped Research 2011;69:4:354-8
AKI reduces survival in infants <1500g Independent risk factor
Very low glomerular filtration rate Mild exposure – high degree of injury High rates of infection Nephrotoxic drugs
Premature infants <1000g Increase SCr of 1.0mg/dL(88.5umol/l) Doubles the odds of death
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Duration Of Dialysis
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OUTCOME 15/25(60%) Infants survived to
come off dialysis No bleeding complications 2/15 catheters blocked - day 3 & 4
on dialysis Nil required long term dialysis
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Manual Dialysis with Fluid Warmer
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PD Paed system
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Quick and Easy
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Post Cardiac Surgery Nitric Oxide, Oscillator & PD
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Contra-indication?Post Abdominal Surgery
8Fr Cook PD Catheter
8Fr CookPigtail multi-purpose drainage device
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Improvised equipment and solution used in the procedure
04/22/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH
44
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CFPD• Performed with two
bedside placed catheters:▫ the first
conventionally placed in the midline below the umbilicus
▫ the second one placed midway between the superior iliac crest and the umbilicus
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Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8
CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007
Especially in children Especially if small haemodynamically infant Developing and Developed countries
Future Larger studies in Paeds Higher flow volumes Improved catheter technology
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Patient
PD Solution
Blue pump BM 14
Fluid Heater
Venous bubble trap
transducer toBM 11
Air detector
Pressure transducer to BM
11
Yellow pump
BM 14
BM 14
Waste Bag
Schematic drawing of CFPD
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Overall recommendations: Critically ill patient with AKI
Early fluid resuscitation in acute hypovolaemia + septic shock states
Early consultation and assessment of %FO Early initiation of CRRT + Inotropes over fluid
administration to maintain BP Appropriate expertise in management of
RRT DO what you are good at! Do not delay Call a friend
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Take Home Message
PD is available in resource poor environment PD is appropriate in acute setting in PICU
Not dependant on large nos and well trained staff members
Certain patient groups more suitable for PD Practical for small infants – access + stability
Even in ‘resource rich’ hospital settings, there is a role for acute PD
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CLINICAL SKILLS COURSEIn conjunction with Saving Young Lives (SYL)
Including Airway & Resuscitation, Vascular Access, Acute Peritoneal Dialysis
Aimed at Pairs of Doctor and Nurse Team9 – 12 March 2015
Registration: www.surgicalskills.co.za
Surgical Skills Training CentreUniversity of Cape Town
Red Cross War Memorial Children’s HospitalDepartments of Paediatrics, Anaesthetics & Paediatric Surgery
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2015
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Surgical Support
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Learning is fun !
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Doctor Nurse Teams
Bloemfontein, SA
Ghana
Malawi + Zambia
KenyaNigeria
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Foreign Faculty
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Nursing Training
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Tim Bunchman pic
IMG_5847.JPG
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Thank you to all my colleagues @ RXH
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Acute Kidney Injury:The Future is now
The past of acute kidney injury was observation,
and the present is intervention with renal replacement therapy,
but perhaps the future is the use of biomarkers to identify AKI sooner and intervene early.Bunchman TE. Oct 2009. Nephrology Times 15-16.