Post on 12-Jan-2016
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 :RRT in pediatric Heart Surgery :Specific indicationsSpecific indications
RRT in pediatric Heart Surgery :RRT in pediatric Heart Surgery :Specific modalities Specific modalities
CPB with UFCPB with CRRTCRRT during ECMO“Traditional” CRRT
POTENTIAL ROLE OF ULTRAFILTRATION IN POST POTENTIAL ROLE OF ULTRAFILTRATION IN POST
CPB CAPILLARY LEAK SYNDROMECPB CAPILLARY LEAK SYNDROME
UF/HF
ULTRAFILTRATIONULTRAFILTRATIONDuring CPBDuring CPB
•Conventional Ultrafiltration•Modified Ultrafiltration•High Volume Zero Balanced UF
NOMENCLATURENOMENCLATURE
Conventional UltrafiltrationConventional 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 UltrafiltrationModified Ultrafiltration
From Chang AC, Hanley FL, Wernovsky G, Wessel DL. Pediatric Cardiac Intensive Care ed W&W 1998
Advantages: Significantly higher
efficiency
Disadvantages:Cumbersome procedurePatient coolingHemodynamic instability
• Inflammation mediators removal Inflammation mediators removal
- C3a, C5a, IL-6a, IL-8a, TNF, MDF, ET-1
• Total body water reductionTotal body water reduction– Tissue edema decrease– Hematocrit increase – Coagulation factors concentration– Decreased need of hemoderivates
POTENTIAL ROLE OF ULTRAFILTRATION IN POST POTENTIAL ROLE OF ULTRAFILTRATION IN POST
CPB CAPILLARY LEAK SYNDROMECPB CAPILLARY LEAK SYNDROME
UF ON LEFT VENTRICULAR FUNCTIONUF ON LEFT VENTRICULAR FUNCTION
1. Myocardial edema decrease2. DO2 increase3. Left ventricular compliance
increase4. Systolic and diastolic function
improvement
Davies MJ. J Thorac Cardiovasc Surg 1998
HIGH-VOLUME, ZERO BALANCED HIGH-VOLUME, ZERO BALANCED ULTRAFILTRATION (Z-BUF)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 MEDIATORSin CHILDREN UNDERGOING CVVH
Journois et al, Anesthesiology: Volume 85(5) November 1996 pp 965-976
– 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)
Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgeryKazuto Yokoyama et al JTCVS 2009
Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgeryKazuto Yokoyama et al JTCVS 2009
Roscitano et al, Asian Cardiovasc Thorac Ann 2009
Intraoperative Continuous Venovenous Hemofiltration during Coronary Surgery
CVVH post 35 mL/kg/hQb 150 ml/minNo heparin.Bicarbonate buffer Net UF rate 500–1000 mL/h
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: VAM in thetreatedgroup: CVVH group 3.55 ± 0.85 hvs control group 5.8 ± 0.94 h, P < 0.001
ICU STAY: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”
Neonates Children
Acute kidney injury and renal replacement therapy independently predict mortality in neonatal and pediatric noncardiac patients on
extracorporeal membrane oxygenation
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+ECMO1 neonate a 1 child required pCRRT alone
ECMO and NGALECMO and NGALBambino Gesù experienceBambino Gesù experience
surv non surv0
1
2
mg
/dl
creatinine
surv non surv-2.5
0.0
2.5
5.0
7.5
10.0
12.5
ml/k
g/h
Urine output
Ricci Z, unpublished, 2010
surv non surv
-500
0
500
1000
ml
Fluid balance
ECMO and NGALECMO and NGALBambino Gesù experienceBambino Gesù experience
surv non surv0
100
200
300
400
500
600
700
ng
/ml
NGAL
* *
Ricci Z, unpublished, 2010
day
1
day
2
day
3
day
4
day
5
day
6
day
7
0
100
200
300
400
500
600
700
survivednon surv
ng
/ml
NGAL
Ricci Z, unpublished, 2010
Body water distribution
0
20
40
60
80
100
1° D 2° D 3° D 4° D 5° D
BW TBW ECW ICW
CASE REPORT 1CASE REPORT 1
CASE REPORT 2CASE REPORT 2Patient on ECMO for dilative cardiomyopathy, 35 kgPatient on ECMO for dilative cardiomyopathy, 35 kg•AnuricAnuric•Fenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressorsFenoldopam 0,4 mcg/Kg/min, no diuretics, no vasopressors
•Ischemic/thromboembolic event to right inferior limb (previous Ischemic/thromboembolic event to right inferior limb (previous femoral artery cannulation): Right inferior limb compartment femoral artery cannulation): Right inferior limb compartment syndrome (no surgery). syndrome (no surgery). Serum myoglobin > 50000 ng/mlSerum myoglobin > 50000 ng/ml
•CVVHDF 50 ml/kg/hCVVHDF 50 ml/kg/h
After 3 ECMO days, Htx.After 3 ECMO days, Htx.Need for CVVHDF for 22 POD daysNeed for CVVHDF for 22 POD daysICU discharge on POD 25 with normal renal functionICU discharge on POD 25 with normal renal function
Ricci et al, Blood Purif 2010
•Need for up to 12 grams/day of iv phosphate Need for up to 12 grams/day of iv phosphate replacementreplacement•Need for KCl correction in the replacement/dialysate Need for KCl correction in the replacement/dialysate bagsbags(about 500 mEq/day)(about 500 mEq/day)•Vancomycine continuous infusion (7 days) increased Vancomycine continuous infusion (7 days) increased from 50 mg/kg/die to 100 mg/kg/die on serum levelsfrom 50 mg/kg/die to 100 mg/kg/die on serum levels•Immunosuppression with iv continuous cyclosporine Immunosuppression with iv continuous cyclosporine increased from 100 to 150 mg/die on serum levelsincreased from 100 to 150 mg/die on serum levels
Ricci et al, Blood Purif 2010
CASE REPORT 2CASE REPORT 2
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
All that glitters is not goldAll that glitters is not gold
CONCLUSIONSCONCLUSIONS
1.1. AKI in pediatric cardiac surgery is AKI in pediatric cardiac surgery is frequent.frequent.
2.2. UF during CPB is beneficial.UF during CPB is beneficial.3.3. Application of CRRT to extracorporeal Application of CRRT to extracorporeal
circulatory devices is possible.circulatory devices is possible.4.4. High expertise, safe machines and High expertise, safe machines and
trained staff is mandatory.trained staff is mandatory.5.5. Dedicated equipment and prospective Dedicated equipment and prospective
studies are dramatically lackingstudies are dramatically lacking