RRT in pediatric Heart Surgery :
Specific indications
1) Fluid overload control
(unbalance infusion requirements/pt weight)
2)Cytokine Clearance
(CPB associated SIRS , post op sepsis)
3) Capillary leak syndrome
(extracorporeal surface contact, RAAS/BNP disequilibrium,
hypothermia, cyanosis)
4) Cardiorenal-renocardiac syndromes
RRT in pediatric Heart Surgery :
Specific modalities
CPB with UF
CPB with CRRT
CRRT during ECMO
“Traditional” CRRT
POTENTIAL ROLE OF ULTRAFILTRATION IN
POST CPB CAPILLARY LEAK SYNDROME
UF/HF
ULTRAFILTRATION
During CPB
NOMENCLATURE
•Conventional Ultrafiltration
•Modified Ultrafiltration
•High Volume Zero Balanced UF
Conventional Ultrafiltration
•
•
•
•
•
After aortic declamp
During rewarming
UF in parallel with CPB
Inlet after the oxygenator
Ultrafiltered blood returns into
venous reservoire
 Advantages:
 It does not delay surgical times
 It removes UF during highest
mediator production phase
 Disadvantages:
 It might quickly empty reservoire
volume
From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998
Modified Ultrafiltration
 Advantages:
 Significantly higher
efficiency
 Disadvantages:
 Cumbersome procedure
 Patient cooling
 Hemodynamic instability
From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998
POTENTIAL ROLE OF ULTRAFILTRATION IN
POST CPB CAPILLARY LEAK SYNDROME
• Inflammation mediators removal
- C3a, C5a, IL-6a, IL-8a, TNF, MDF, ET-1
• Total body water reduction
–
–
–
–
Tissue edema decrease
Hematocrit increase
Coagulation factors concentration
Decreased need of hemoderivates
UF ON LEFT VENTRICULAR FUNCTION
1.
2.
3.
4.
Myocardial edema decrease
DO2 increase
Left ventricular compliance
increase
Systolic and diastolic function
improvement
Davies MJ. J Thorac Cardiovasc Surg 1998
HIGH-VOLUME, ZERO BALANCED
ULTRAFILTRATION (Z-BUF)
• Twenty children undergoing cardiac surgery assigned to Z-BUF
or a control group.
• C3a, IL-1, IL-6, IL-8, IL-10, TNF, myeloperoxidase, and
leukocyte count were measured before (T1) and after (T2)
hemofiltration and 24 h later (T3).
• Isovolumetric UF during rewarming with high UF volumes and
equivalent amount of reinfusion solution (average 4.972 ml/m2)
• MUF after CPB weaning in both groups in order to remove
excess fluids
Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976
MEMBRANES (NOT UF) CLEAR MEDIATORS
in CHILDREN UNDERGOING CVVH
– Decrease of body temperature at
T2 and T3
– Decrease of neutrophils count
– Decrease of inotropic support
– Decrease of blood loss at T2 and
T3
– Decrease of postoperative
ΔAaO2 (320 vs. 551 mmHg)
– Positive correlation between
ΔAaO2 and UF/TBV ratio.
– Decrease of time to extubation
(10.8 vs. 28.2 h)
Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976
Removal of prostaglandin E2 and increased intraoperative blood
pressure during modified ultrafiltration in pediatric cardiac surgery
Kazuto Yokoyama et al JTCVS 2009
Removal of prostaglandin E2 and increased intraoperative blood
pressure during modified ultrafiltration in pediatric cardiac surgery
Kazuto Yokoyama et al JTCVS 2009
Intraoperative Continuous Venovenous Hemofiltration during
Coronary Surgery
CVVH post
35 mL/kg/h
Qb 150
ml/min
No heparin.
Bicarbonate
buffer
Net UF rate
500–1000
mL/h
Roscitano et al, Asian Cardiovasc Thorac Ann 2009
Intraoperative Continuous Venovenous Hemofiltration during
Coronary Surgery
Antonino Roscitano, MD, Umberto Benedetto, MD, Massimo Goracci, Fabio Capuano, MD, Remo Lucani, MD1,
Riccardo Sinatra, MD
Roscitano et al, Asian Cardiovasc Thorac Ann 2009
Reduction of Early Postoperative Morbidity in Cardiac Surgery
Patients Treated With Continuous Veno–Venous Hemofiltration
During Cardiopulmonary Bypass
VAM in thetreatedgroup:
CVVH group 3.55 ± 0.85 h
vs control group 5.8 ± 0.94 h, P < 0.001
ICU STAY:
CVVH group 29.5 ± 6.7 vs. control group
40.5 ± 6.67 h, P < 0.001.
Luciani et al Artif Organs 2009
Anti-inflammatory modalities: Their current use in pediatric cardiac
surgery in the United Kingdom and Ireland
Allen et PCCM 2009
“…there are still widespread variations in practice. Rather
than reflecting poor clinical practice, we believe this
reflects a lack of good evidence supporting clinical benefit”
Acute kidney injury and renal replacement therapy independently
predict mortality in neonatal and pediatric noncardiac patients on
extracorporeal membrane oxygenation
Neonates
Children
Askenazi et al PCCM 2010
PCRRT and ECMO
• Especially in the smaller children and infants solute
clearance on ECMO is greater then standard PCRRT due
to the relatively high blood flow rates
• Ultrafiltration error may not be easily recognized due to
the maintenance of hemodynamic stability that ECMO
gives
• Excessive ultrafiltration
 due to ultrafiltration controller error
 ECMO-CVVH machines “interaction“
Courtesy of Norma J Maxvold (modified)
N = 4 pts with AKI
(2 neonates +2 children)
1 neonate and 1 child required pCRRT+ECMO
1 neonate a 1 child required pCRRT alone
ECMO and NGAL
Bambino Gesù experience
2
12.5
7.5
mg/dl
ml/kg/h
10.0
5.0
1
2.5
0.0
surv
non surv
-2.5
Urine output
0
surv
non surv
creatinine
Ricci Z, unpublished, 2010
ECMO and NGAL
Bambino Gesù experience
*
700
600
500
500
ml
ng/ml
*
1000
400
300
0
200
100
-500
0
surv
non surv
NGAL
surv
non surv
Fluid balance
Ricci Z, unpublished, 2010
survived
non surv
700
600
ng/ml
500
400
300
200
day 7
day 6
day 5
day 4
day 3
day 2
0
day 1
100
NGAL
Ricci Z, unpublished, 2010
CASE REPORT 1
CVVH + Berlin Heart:
1) Cardiac index
2) REDVI
3
2,7
2,4
2,1
1,8
1,5
450
400
350
300
250
CASE REPORT 1
Body water distribution
BW
TBW
ECW
ICW
100
80
60
40
20
0
1° D
2° D
3° D
4° D
5° D
CASE REPORT 2
Patient on ECMO for dilative cardiomyopathy, 35 kg
•Anuric
•Fenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressors
•Ischemic/thromboembolic event to right inferior limb (previous
femoral artery cannulation): Right inferior limb compartment
syndrome (no surgery). Serum myoglobin > 50000 ng/ml
•CVVHDF 50 ml/kg/h
After 3 ECMO days, Htx.
Need for CVVHDF for 22 POD days
ICU discharge on POD 25 with normal renal function
Ricci et al, Blood Purif 2010
CASE REPORT 2
•Need for up to 12 grams/day of iv phosphate
replacement
•Need for KCl correction in the replacement/dialysate
bags
(about 500 mEq/day)
•Vancomycine continuous infusion (7 days) increased
from 50 mg/kg/die to 100 mg/kg/die on serum levels
•Immunosuppression with iv continuous cyclosporine
increased from 100 to 150 mg/die on serum levels
Ricci et al, Blood Purif 2010
All that glitters is not gold
Patient n.
Age
Weight
Preoperative diagnosis
Presence of ECMO (yes/no)
1
4 days
3.5
HLHS
Y
2
2 years
9
Dilated miocardiopathy
N
3
35 days
4
AoCo+SubAoSt
Y
4
45 days
4.2
TGA with coronary restenosis
Y
5
28 days
3.8
PA with IS
N
6
25 days
3.1
TGA
Y
7
5 days
2.8
HLHS
Y
8
10 days
3.5
HLHS
Y
9
1 year
6
Dilated miocardiopathy
Y
10
2 months
5.2
CAVC
N
BNP
BNP
CONCLUSIONS
1. AKI in pediatric cardiac surgery is
frequent.
2. UF during CPB is beneficial.
3. Application of CRRT to extracorporeal
circulatory devices is possible.
4. High expertise, safe machines and
trained staff is mandatory.
5. Dedicated equipment and prospective
studies are dramatically lacking