Continuous Renal Replacement Therapy
in the Pediatric Trauma Patient
Dawn Badach, RN,CCRN, Leslie Konyk, RN, CCRN
Richard Skweres, BSN,RN,CCRN,CFRN, Marcie Tharp, MSN,RN,CCRN
Abstract
What is CRRT?
Case Study 1 - Traditional
Case Study 2- Non-traditional
Pediatric trauma patients are generally a challenge
when it comes to fluid management and
thermoregulation. There is a delicate balance
between adequate and over–resuscitation, especially
during the acute post-traumatic phase. The addition
of an Acute Kidney Injury (AKI), whether directly
trauma related or from over-resuscitation, may
sometimes necessitate the initiation of dialysis, or in
the case of the two patients to follow, Continuous
Renal Replacement Therapy (CRRT). Traditional
dialysis requires the rapid removal of fluid in a short
period of time (usually 3- 4 hours) from the patient
who is hemodynamically stable, whereas the pediatric
trauma patients that require aggressive or on going
fluid resuscitation usually cannot tolerate the
efficiency of traditional dialysis thus requiring CRRT.
Continuous renal replacement therapy (CRRT) is any
extracorporeal blood purification therapy designed to substitute
for impaired renal function or Acute Renal Failure (ARF) over
an extended period for patients whose clinical state
contraindicates the use of traditional hemodialysis, and is
intended to be applied for up to 24 hours a day. Recently, a nontraditional method of rewarming the trauma patient has been
applied.
Pt. #1 was an 8 year old 27.2 kg male who fell onto the
handlebars of his bicycle. The patient walked into his
house and collapsed. He was transported to the local
ED where he was found to be short-of-breath and
somnolent. He arrested in the ED of the outlying
facility and was found to be in PEA for 3 min. He was
taken to the OR where they performed exploratory
laparotomy where he received a non anatomic resection
of the right lobe of his liver and a cholecystectomy
then was closed. His estimated blood loss was > 2 L for
which he received 3 units of PRBC’s, 3 units of FFP,
two 10 pack’s of Plts and 100 mL of Cryoprecipitate.
He became acidotic and coagulopathic and was
transferred to Children’s Hospital PICU. Upon arrival
he had an initial blood pressure of 40/13, an iCa of 0.6
and a Hgb of 3.6. He was aggressively resuscitated
again and subsequently developed abdominal
compartment syndrome potentiating Acute Renal
Failure and DIC post a splenic infarct.
Pt. #2 was a 6 year old 20 kg male who was injured in a
dirt bike accident. The patient was un-helmeted and
was struck by a larger dirt bike. Upon arrival to trauma
bay the patient was initially stable. Abdomen was
initially soft, however the patient gradually became
lethargic and pale. His abdomen became distended and
the patient was intubated due to declining mental status
and taken to the OR for exploratory surgery. The patient
was found to have a complete laceration of the left and
middle hepatic veins, partial laceration of his left portal
vein, and multiple deep liver lacerations (his caudate
lobe and left lobes were partially severed). During his
initial resuscitation and during damage control, he
received 11 units of PRBCs, 6 units of FFP and 3 L’s
NSS. He then returned to the PICU with blood
pressure’s of 48/30, oxygen saturation of 80%, and was
tachycardic to 276, with a temp. of 32.4° C. Pupils
5mm and minimally reactive.
Multi-organ trauma patients can create a unique
challenge as well related to direct organ trauma and
internal bleeding, Once damage control has been
performed and CRRT is required later in therapy, a
primary concern is the ability to maintain
anticoagulation for the CRRT circuit without causing
increased risk of internal bleeding. The use of heparin
can exacerbate this possibility so ACD-A Citrate is the
anticoagulant of choice for these patients.
Literature Review
-- In 2004, Lan, Fu and Lin investigated the effectiveness of CRRT therapy
on stress reaction in patients with severe trauma. The authors discuss how
their study demonstrates how CRRT “can eliminate effectively the stress
hormone and reduce stress reaction”.
-- In 2006,McCunn, Reynolds, Reuter, McQuillan, McCourt and Stein
discuss in The Journal of Artificial Organs the use of CRRT following
traumatic injury. “The use of CRRT modalities for patients following
traumatic injuries is becoming more common, and this therapy may impact
the long term recovery of renal function and mortality.”
-- In 2008, Jelsma, Eding, Metz, Neumann, Steen, Oleniczak, Hackbarth
and Bunchman review case studies at the 5th International Pediatric
Continuous Renal Replacement Therapy Conference. Their abstract details
that “ CRRT is effective in the management of acute renal insufficiency in
patients with abdominal trauma”.
Special Thanks to the Children’s Hospital of Pittsburgh of UPMC CRRT Team
Why choose CRRT? :
- It closely mimics the native kidney in treating ARF and fluid volume
excess.
- It removes large amounts of fluid and waste products over longer time
periods.
- It is tolerated well by hemodynamically unstable patients.
Treatment Goals:
- Maintain fluid, electrolyte and acid/base balance.
- Prevent further damage to kidney tissue.
- Promote healing and total renal recovery.
- Allow other supportive measures/nutritional support.
- Controlled re-warming of the trauma patient.
Anticoagulation: What is the difference?
Citrate vs. Heparin
Citrate – Adding ACD-A Citrate to blood chelates iCa2+, thus inhibiting
clotting.
Citrate is currently the preferred method of anticoagulation because the
circuit can be locally anticoagulated (in the circuit) without systemic
effects to the patient. Following its mechanism of action, a separate
calcium infusion is given to the patient to maintain a normal systemic
ionized calcium levels. The concerns associated with citrate
anticoagulation in the pediatric population are the development of
metabolic alkalosis, hypocalcemia, hyperglycemia and "citrate lock" when the patient's total calcium level rises and ionized calcium
lowers. This is a direct result of infusing the citrate solution at a rate
that exceeds the patient's hepatic metabolism and CRRT clearance of
citrate.
Indications for CRRT
-Patient was extremely fluid positive, anuric, with a
BUN of 91 and Creatinine of 3.5 (extremely elevated),
hyponatremic in post arrest, and hypercalcemic (14.7).
-Renal failure developed secondary to abdominal
compartment syndrome.
Outcome based on Indication.
Pt survived and was transitioned to Hemodialysis after
6 days on CRRT once stable.
Indication for CRRT
After stabilization and failed attempts to re-warm the
patient with warm blood products, blankets and warm
saline gastric lavage, the patient was placed on CRRT
for re-warming purposes.
Outcome based on indication
Two hours after initiation of CRRT, his temp was 36.8°
C., pupils were 2mm and reactive. He had left arm
movement, and was opening his eyes and reacting to
painful stimuli.
Heparin – Potentiates AT3 by 1000 fold resulting in inhibition of factors
IIa (thrombin) and Xa.
References:
Heparinization involves infusing a heparin solution via the CRRT circuit
to maintain an ACT of 1-1.5x normal. It is an effective method of
anticoagulating the circuit, however, the patient is also systemically
anticoagulated which often times is contraindicated, depending on the
injury or failure of body system. This has an overall greater risk of
bleeding potentiating secondary injuries.
- McCunn,M., Reynolds, H.N., Reuter,J.,. McQuillan,K., McCourt, T., and Stein, D.. Continuous Renal Replacement Therapy in patients following
traumatic injury, The Journal of Artificial Organs. 2006; 29 (2):166-186.
- Lan, GN., Fu,QH., Lin,AL.. Effect of Continuous Renal Replacement treatment on stress reaction in patients with severe trauma, 2004;16 (2):106-108.
- Jelsma, L., Eding, D., Metz, C., Neumann, A., Steen,V., Oleniczak,M., Hackbarth , R.,and Bunchman, T., Children Requiring Continuous Renal
Replacement Therapy, 2008, 5Th International Pediatric Continuous Renal Replacement Therapy Conference.