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Fluid overload control (unbalance infusion requirements/pt weight) 2) Cytokine Clearance (CPB associated SIRS , post op - PowerPoint PPT Presentation


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RRT in pediatric Heart Surgery : Specific indications. 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,

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slide2

RRT in pediatricHeartSurgery :

Specificindications

  • 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
slide4

RRT in pediatricHeartSurgery :

Specificmodalities

  • CPB with UF
  • CPB with CRRT
  • CRRT during ECMO
  • “Traditional” CRRT
slide6

ULTRAFILTRATION

During CPB

NOMENCLATURE

  • Conventional Ultrafiltration
  • Modified Ultrafiltration
  • High Volume Zero Balanced UF
conventional ultrafiltration
Conventional Ultrafiltration
  • Afteraorticdeclamp
  • Duringrewarming
  • UF in parallelwith CPB
  • Inletafter the oxygenator
  • Ultrafilteredbloodreturnsintovenousreservoire
  • Advantages:
    • Itdoesnotdelaysurgicaltimes
    • Itremoves UF duringhighestmediator production phase
  • Disadvantages:
    • Itmightquicklyemptyreservoire volume

From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998

modified ultrafiltration
Modified Ultrafiltration
  • Advantages:
    • Significantlyhigherefficiency
  • Disadvantages:
    • Cumbersome procedure
    • Patientcooling
    • Hemodynamicinstability

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 syndrome1
POTENTIAL ROLE OF ULTRAFILTRATION IN POST CPB CAPILLARY LEAK SYNDROME
  • Inflammationmediatorsremoval

- C3a, C5a, IL-6a, IL-8a, TNF, MDF, ET-1

  • Total body water reduction
    • Tissue edema decrease
    • Hematocritincrease
    • Coagulationfactorsconcentration
    • Decreasedneedofhemoderivates
uf on left ventricular function
UF ON LEFT VENTRICULAR FUNCTION
  • 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
HIGH-VOLUME, ZERO BALANCED ULTRAFILTRATION (Z-BUF)
  • Twentychildrenundergoingcardiacsurgeryassignedto Z-BUF or a controlgroup.
  • C3a, IL-1, IL-6, IL-8, IL-10, TNF, myeloperoxidase, and leukocytecountweremeasuredbefore (T1) and after (T2) hemofiltration and 24 h later (T3).
  • Isovolumetric UFduringrewarmingwith high UF volumes and equivalentamountofreinfusionsolution (average 4.972 ml/m2)
  • MUF after CPB weaning in bothgroups in ordertoremoveexcessfluids

Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976

slide12

MEMBRANES (NOT UF) CLEAR MEDIATORS

in CHILDREN UNDERGOING CVVH

  • Decreaseof body temperature at T2 and T3
  • Decreaseofneutrophilscount
  • Decreaseofinotropicsupport
  • Decreaseofblood loss at T2 and T3
  • DecreaseofpostoperativeΔAaO2 (320 vs. 551 mmHg)
  • Positive correlationbetweenΔAaO2 and UF/TBV ratio.
  • Decreaseoftimetoextubation (10.8 vs. 28.2 h)

Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976

slide13

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgery

Kazuto Yokoyama et al JTCVS 2009

slide14

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgery

Kazuto Yokoyama et al JTCVS 2009

slide15

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

slide16

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

slide17

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 controlgroup 5.8 ± 0.94 h, P < 0.001

ICU STAY:

CVVH group 29.5 ± 6.7 vs. controlgroup 40.5 ± 6.67 h, P < 0.001.

Luciani et al Artif Organs 2009

slide18

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”

slide19

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
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)

slide22

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

slide23

ECMO and NGAL

Bambino Gesù experience

Urine output

creatinine

Ricci Z, unpublished, 2010

slide24

ECMO and NGAL

Bambino Gesù experience

*

*

Fluid balance

NGAL

Ricci Z, unpublished, 2010

slide25

NGAL

Ricci Z, unpublished, 2010

slide29

CVVH + Berlin Heart: 1) Cardiac index2) REDVI

3

2,7

2,4

2,1

1,8

1,5

450

400

350

300

250

body water distribution

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

slide32

CASE REPORT 2

  • Patient on ECMO fordilativecardiomyopathy, 35 kg
  • Anuric
  • Fenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressors
  • Ischemic/thromboemboliceventto right inferiorlimb (previousfemoralarterycannulation): Right inferiorlimbcompartmentsyndrome (no surgery). Serummyoglobin > 50000 ng/ml
  • CVVHDF 50 ml/kg/h
  • After 3 ECMO days, Htx.
  • Needfor CVVHDF for 22 POD days
  • ICU discharge on POD 25 withnormalrenalfunction

Ricci et al, Blood Purif 2010

slide33

CASE REPORT 2

  • Needfor up to 12 grams/dayofivphosphatereplacement
  • NeedforKClcorrection in the replacement/dialysatebags
  • (about 500 mEq/day)
  • Vancomycinecontinuousinfusion (7 days) increasedfrom 50 mg/kg/dieto 100 mg/kg/die on serumlevels
  • Immunosuppressionwithivcontinuouscyclosporineincreasedfrom 100 to 150 mg/die on serumlevels

Ricci et al, Blood Purif 2010

slide34

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

Allthatglittersisnotgold

slide38

CONCLUSIONS

AKI in pediatriccardiacsurgeryisfrequent.

UF during CPB isbeneficial.

Applicationof CRRT toextracorporealcirculatorydevicesispossible.

High expertise, safemachines and trained staff ismandatory.

Dedicatedequipment and prospectivestudies are dramaticallylacking