putting it all together: when resources are scarce mignon mcculloch associate professor department...
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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
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Acknowledgements Thanks to Stuart and Tim
Including all forms of CRRT
Disclosures Passionate about PD Access for children with AKI in poorly
resourced areas
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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?
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Less than 1km down the road…
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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?
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Goal directed therapy
Study of Emergency Department Management
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Rivers et al, N Engl J Med, 2001
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de Oliveira CF et al, Intensive Care Med, 2008
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de Oliveira CF et al, Intensive Care Med, 2008
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Severe sepsis and septic shock guidelines 2008
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FEAST Trial ?
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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)
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Maitland et al, N Engl J Med, 2011
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Maitland et al, N Engl J Med, 2011
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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
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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?
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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???
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Renal Replacement Therapy
What we have done in Cape Town?
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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
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“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
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IPNA/ISN Training for Africa
Nigeria
Nigeria Benin
Uganda
Kenya
Ghana
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Challenges on Return
Poor Staffing 100% Lack of Facilities & Equipment 86% Radiology – Ultrasound only 86% Support from Home Institutions 71% Histology support 57%
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Paradise ?
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ISN Sister ProgramPD WorkshopAccra, Ghana
04.12.2011
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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
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Devices for Peritoneal Dialysis
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New Generation Cook Catheters
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Kimal ‘Peel-away’ Tenchkoff
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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
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Automated DialysisHome choice machine
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Manual Dialysis with Fluid Warmer
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Post Abdominal Surgery
8Fr Cook PD Catheter
8Fr CookPigtail multi-purpose drainage device
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Improvised equipment and solution used in the procedure
04/18/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH
41
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5-yr old with HUSPD duration - 8 days
04/18/23Dr S. Antwi: Paediatric Nephrologist -
KNUST-SMA/KATH42
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PD progress in 1st 24 hrs
04/18/23 43Dr S. Antwi: Paediatric Nephrologist -
KNUST-SMA/KATH
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PD in session
04/18/23 44Dr S. Antwi: Paediatric
Nephrologist -KNUST-SMA/KATH
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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
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PRACTICAL SKILLS WORKSHOP
IPNA/ISN/SKCF/Saving Young Lives…..and all other supporters
12-16 Nov 2012
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Thank you to all my colleagues @ RXH
Thank you for your time and attention !