2Smaller Circuits for Smaller Patients
Improving Renal Support with Aquadex™ Machine
David Askenazi MD, MSPH
Associate Professor of Pediatrics
Potential conflict of interest

Speaker for AKI foundation
Small children are dialyzed differently!
< 5kg
N = 170
Anticoagulation
Protocol
Citrate
Heparin
> 5kg
Survival in ppCRRT 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/1.73m2)
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

Smaller patients require blood priming to
prevent hypotension/hemodilution

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Circuit volume > 10-15% patient blood
volume
Example

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
4 kg infant : Blood Volume = 320 cc (80/kg)
Circuit (extracorporeal volume = 165 ml)
Therefore ≈ 50% extracorporeal volume
Added Risk for PRBC prime

Packed RBCs

HYPOCALCEMIC
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
HYPERKALEMIC
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LYSIS OF CELLS
ACIDIC
There are no Plts in packed pRBC’s


Citrate
Every prime you start CRRT you should expect for
your plts count to drop
There are no coagulation factors in pRBC’s

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 m2
We must then acknowledge


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





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

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)

12 children received CVVH on Aquadex™
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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


double lumen vascular access (n=9) (4 = 8F; 4 = 7F; 1 = 6F)
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)

101 circuits – 261 days

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12 new starts
89 restarts

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59 (61%) circuits lasted 72 hours
Prime

80% Blood Prime

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ECV > 10% (<4 kg)
pRBC + NaHC03 + CaCl 80% for Saline prime in 20%
Cross prime circuit for routine change out
20% Saline Prime
Clearance
Changes in SCr over the first 3 days of CRRT
Serum Creatinine (mg/dl)
6
5
4
3
2
1
0
1
2
Days of CRRT
3
Children’s of Alabama
(Dec 2013 – April 2015)


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7/12 survived to come off CVVH
6/12 survived to hospital discharge
 1 died before hospital discharge for non-renal complications
 5 died due to progressive cardiac/pulmonary disease
Complications from CVVH
 4/101 (4%) initiation associated with need for increased BP support
 All very mild and transient
 3 hypothermia
 4 bleeding
 1 had a right atrial thrombus
Summary
Aquadex – CRRT experience

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Nephrologist Like it! Renal Support Goals Achieved
 Steady reduction in BUN / Cr
 Excellent control of electrolytes balance.
 Fluid goals achievable
 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

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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