Post on 08-Feb-2016
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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
04/22/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH
41
5-yr old with HUSPD duration - 8 days
04/22/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 42
PD progress in 1st 24 hrs
04/22/23 43Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH
PD in session
04/22/23 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 !