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Complications of Pediatric CRRT

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Complications of Pediatric CRRT. Theresa A. Mottes RN. Pediatric ... 1-2ml/kg/hour net ultrafiltration. absolute necessity to ... with femoral site ... – PowerPoint PPT presentation

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Title: Complications of Pediatric CRRT


1
Complications of Pediatric CRRT
  • Theresa A. Mottes RN
  • Pediatric Dialysis/Research Nurse
  • C.S. Mott Childrens Hospital
  • University of Michigan

2
Complications of Pediatric CRRT
  • Temperature instability
  • Hemodynamic instability
  • Anticoagulation Risk
  • Circuit/Access Complications

3
Factors effecting hemodynamics
  • Patient Volume Status
  • Ultrafiltration Rate
  • patients hemodynamic
  • typically vasopressor dependent
  • patients intravascular volume
  • Ultrafiltration Rate
  • 1-2ml/kg/hour net ultrafiltration
  • absolute necessity to control ultrafiltration
  • error of accurate ultrafiltration monitoring

4
RESULTS(Smoyer et al, CRRT 1997)
Trilogy Pump Accuracy over Range of Flow Rates
Error
IV Pump Flow Rate (ml/hr)
5
Ultrafiltration accuracy2.8 kg infant on PRISMA
Prescription BFR 30 mls/min Dx FR 300 mls/hr
Ccs/hr
Hour of Therapy
6
Factors effecting hemodynamics
  • What now?
  • Hourly assessment of Intake and Output
  • Hourly Ultrafiltration calculations
  • adjusting for pump error
  • Accurate measuring of Ultrafiltration
  • Close monitoring of hemodynamics
  • Accurate daily weight

7
Factors effecting hemodynamics
  • Calculation for Pump Error

8
Factors effecting hemodynamics
  • Vasopressor clearance
  • Vasopressor agents all have in common a small
    molecular weight and minimal protein binding
  • Epinephrine
  • Norepinephrine
  • Dopamine
  • Dobutamine

9
Factors effecting hemodynamics
  • Vasopressors
  • Due to proximity of infusion
  • be aware of infusing vasopressor agents in
    immediate proximity to the arterial port of the
    hemofiltration machine
  • potential for recirculation
  • effects delivery and clearance

10
Intravascular Blood Volume
  • lt 10 kg 80 ml/kg
  • e.g. 8 kg infant 640 ml intravascular volume
  • gt 10 kg 70 ml/kg
  • e.g. 20 kg child has 1.4 liter intravascular
    volumeBlood
  • Priming Hemofiltration Circuit
  • Recommended when circuit volume gt 10 of
    patients intravascular blood volume

11
Anticoagulation
  • Heparin
  • Citrate
  • None

12
Circuit Complications
  • Circuit Clotting
  • Inability to ultrafiltrate desired amount
  • Increasing Access/Return Pressure
  • Inadequate clearances
  • Observe clotting in filter/ tubing

13
Clotting with CVVH vs CVVHD(Mottes et al, CRRT
1999)
14
Flow Rates
  • Blood
  • 5-10 ml/kg/min keeping venous pressure under 200
    mm Hg
  • Dialysate/Replacement fluid
  • 2 liters/1.73 m2/hr
  • (extrapolation of adult data)

15
Access Complications
  • What is the correct access?
  • One that works

16
In Flow Difficulties
  • Obstruction or clot on the return line
  • high intrathoracic pressure with HIFI
  • up against the vessel wall
  • Clamp on inflow
  • Access kinked at skin site
  • Consider reversing or changing access

17
Out Flow Difficulties
  • Clamp on access/arterial line
  • Inflow port up against vessel wall
  • Patient dry eg with femoral site
  • High of blood flow requirements based upon flow
    ability of access
  • Consider
  • reverse flow, change access, decrease blood flow
    rates
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