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Complications of Pediatric CRRT

Learn about factors affecting hemodynamics in CRRT patients and how to address temperature instability, hemodynamic issues, anticoagulation risks, and circuit complications. Explore accurate ultrafiltration monitoring and vasopressor management for optimal patient care.

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Complications of Pediatric CRRT

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  1. Complications of Pediatric CRRT Theresa A. Mottes RN Pediatric Dialysis/Research Nurse C.S. Mott Children’s 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 • < 10 kg 80 ml/kg • e.g. 8 kg infant = 640 ml intravascular volume • > 10 kg 70 ml/kg • e.g. 20 kg child has 1.4 liter intravascular volumeBlood • Priming Hemofiltration Circuit • Recommended when circuit volume > 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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