Putting it all together:When resources are scarce

Mignon McCullochAssociate Professor

Department of Paediatric Critical Care

Red Cross Children’s Hospital (RXH)

University of Cape Town

Acknowledgements Thanks to Stuart and Tim

Including all forms of CRRT

Disclosures Passionate about PD Access for children with AKI in poorly

resourced areas

Clinical Patients 2.5kg boy Complex Congenital

Heart Post-op surgical No urine output x

8hrs What next?

12year old boy Meningococcal Sepsis Shocked needing

inotropic support Poor urine output x

12hrs What next?

Less than 1km down the road…

Role of Fluid FO >20% @ time of CRRT initiation

%FO = (Fluid In – Fluid Out) x 100% (PICU Admission weight)

Goldstein et al(2005). KI 67:653-658

But what happens before?

Goal directed therapy

Study of Emergency Department Management

Rivers et al, N Engl J Med, 2001

de Oliveira CF et al, Intensive Care Med, 2008

de Oliveira CF et al, Intensive Care Med, 2008

Severe sepsis and septic shock guidelines 2008

FEAST Trial ?

FEAST Study(Fluid Expansion as Supportive Therapy)NEJM June 30, 2011 Maitland et al

Severe febrile illness & impaired perfusion randomised to: Bolus 5% Albumin 20-40ml Bolus 0,9% Saline No bolus

Halt recruitment 3141/3600 48hour mortality 10.6% bolus vs 7.3% non-bolus(p=0.003)

Maitland et al, N Engl J Med, 2011

Maitland et al, N Engl J Med, 2011

Criticisms - NEJM Oct 6, 2011 Severely anaemic children - 32% Hb<5mg/dl Acute haemodilution in pre-existing anaemia Impaired oxygen delivery leading to organ failure Malaria – 57% thus have sequestration of red

cells in microcirculation Shock – not all forms are the same – related to

high CO or diminished O2 Compromised oxygen delivery – 77% thus

worsening cellular dysoxia Malnutrition

Plans Rapid triage and treatment Monitoring in a low resource setting

What is possible? CVP What is physiologic fluid best for bolusing

Blood vs fluid boluses Choice of fluids BMJ 2010;341 Maitland, Colloids vs Crystalloids for fluid resuscitation Cochrane 2012 –

Perel P

Low-volume fluid resuscitation insufficient for patients in shock – Inotropes?

Needed:Observational Trial in Septic Shock

Fluid challenge – 10-20ml/kg…then Observe response:

Heart rate and BP, Resp rate, Oxygen sats Cardiac output in response to fluid

Portable Uscom/Echocardiography validation Pulmonary oedema – Lung impedance High flow Oxygen/CPAP/Ventilation Inotropes – peripheral/central

AKI???

Renal Replacement Therapy

What we have done in Cape Town?

Initial Management Urine output:

Aim for > 1ml/kg/hr Fluid challenge

10ml/kg 0.9% Saline over 30 minutes and reassess urine output

If no improvement & no signs of fluid overload, repeat bolus

Clinical assessment regarding intravascular volume status +/- invasive assessment

“Encouraging Agents” Fluid and Perfusion Furosemide ivi

Boluses 1 - 5mg/kg or Infusion 0.1 – 1mg/kg

Mannitol/Metolazone Aminophylline 1 - 5mg/kg ivi if stable **Dopamine 2 – 5mcg/kg/min infusion

IPNA/ISN Training for Africa

Nigeria

Nigeria Benin

Uganda

Kenya

Ghana

Challenges on Return

Poor Staffing 100% Lack of Facilities & Equipment 86% Radiology – Ultrasound only 86% Support from Home Institutions 71% Histology support 57%

Paradise ?

ISN Sister ProgramPD WorkshopAccra, Ghana

04.12.2011

PD Catheters Art of Medicine? Innovative and

Creative Cannulas Naso-gastric tubes/Chest Drains Venous Central lines Rigid ‘Stick’ catheters ‘Peel away’ Tenchkoff Flexible Multi-purpose drainage catheters

Auron A et al Am J Kidney Dis 2007

Devices for Peritoneal Dialysis

New Generation Cook Catheters

Kimal ‘Peel-away’ Tenchkoff

Tips for Success Size matters…keep skin nick at minimum or nil at all

Else will leak!!! Avoid metal needle that comes with pack

Rather Jelco/Venous access catheter Withdraw needle 0.5mm as go thru peritoneum and

advance plastic sheath Run fluid in freely to fill abdomen before wire and

catheter If not free-flowing pull needle back slightly May be in bowel?....role of ultrasound Don’t forget to empty bladder

Automated DialysisHome choice machine

Manual Dialysis with Fluid Warmer

Post Abdominal Surgery

8Fr Cook PD Catheter

8Fr CookPigtail multi-purpose drainage device

Improvised equipment and solution used in the procedure

04/18/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH

41

5-yr old with HUSPD duration - 8 days

04/18/23Dr S. Antwi: Paediatric Nephrologist -

KNUST-SMA/KATH42

PD progress in 1st 24 hrs

04/18/23 43Dr S. Antwi: Paediatric Nephrologist -

KNUST-SMA/KATH

PD in session

04/18/23 44Dr S. Antwi: Paediatric

Nephrologist -KNUST-SMA/KATH

CONCLUSION

Peritoneal dialysis as a form of acute renal replacement therapy is: Practical Appropriate for developing countries

Results reflected suggest that due to ease of use, it may also be appropriate for centers where access to CVVH/D may not be available due to lack of equipment or trained staff

PRACTICAL SKILLS WORKSHOP

IPNA/ISN/SKCF/Saving Young Lives…..and all other supporters

12-16 Nov 2012

Thank you to all my colleagues @ RXH

Thank you for your time and attention !