1. When fluids go wrong: CRRT in fluid overload
Michael Zappitelli MD, MSc

2. Objectives Early evidence of fluid overload importance in CRRT
Fluid overload in non-CRRT patients in the PICU
Definition considerations
Management considerations

3. ppCRRT registry: Higher FO, worse outcome
Pre-ppCRRT: Goldstein and colleagues:
% Fluid overload = (total L in – total L out)/ weight kg X 100
%FO at CRRT start
Independent of
Oncology Dx
MODS
Convective clearance
PRISM
Inotrope #

4. FO in the PICU
FO occurs early in PICU
15 – 20% threshold

5. Physicians prescribe a lot of fluid
FO - oxygenation
Cumulative fluid balance worse in
nonsurvivors
FO: longer ventilation and
worse O2 saturation
Similar findings several other studies, e.g.:
Sinitsky et al, Ped Crit Care Med, 2015
Bhaskar et al, 2014
Seguin et al, 2013, Cardiac surgery
Selewski et al, ECMO

6. Fluid overload definition
FO differs
Mortality
associations
same
FO, balance-based definition most experience.
Use what you think is most accurate in YOUR PICU

7. Oxygenation parameters improved
Does reducing FO with CRRT help?
As FO decreased,
Oxygenation parameters improved

8. Should we be starting CRRT “earlier”?
Non-survivors
started later

9. Is a trial feasible? What trial?
Timing? Based on what criteria?
Renal function?
Fluid overload?
Use of other FO corrective measures?
Biomarkers?
What markers should we use to guide treatment effectiveness?
FO definition
Oxygenation
Non-renal outcomes
Should we be doing a diuretic trial?
Goldstein et al: NCT Using NGAL and FO to guide CRRT
initiation and discontinuation

10. What to do?
12 year old girl with sepsis, on pressors, post initial resuscitation, develops tripling of SCr, positive fluid balance.
Begins with awareness: “fluid is a drug” (Goldstein)
Explicit effort to measure FO and follow.
Speak in terms of that measure and changes in oxygenation (e.g.).

11. What to do Patient develops XXX% FO and decision to initiate CRRT.
Don’t let that “xxx” be more than you want it to be!
Quantify the amount of fluid to remove in L: nephro- PICU discuss and agree.
Decide on how quickly:
CV stability, urgency, bleeding risk (heparin)
~1-2 ml/kg/hour at most; 1 ml/kg/hour to be safe.
Avoid > 3-5% BW removal/day if unstable.
One way to harm is to do too aggressive UF.
nephro-PICU discuss and agree!

12. What to do You agree that the girl is 5 L positive.
She is 40 kg, so 12.5% FO.
e.g.
You calculate that 1-2 ml/kg/hour ~UF /hr, or 1-2L per day.
~5% of BW is about 2L.
She is needing significant pressor support, unstable.
You choose wisely: -40 ml/hour, ~1L a day

13. What to do MD – reassess at least twice a day.
Nurse: hourly in/out/balance calculation.
Consider having an hourly negative limit to call MD.
Accept may need to increase pressors, use 25% albumin, to achieve removal.
Constant evaluation of removing excess fluids (non-resusc)
No need to use diuretics

14. CRRT stops? Intentional or not
Do not allow all of the hard work to be gone.
Immediately reassess fluid in to at least achieve
neutral balance: guide diuretic therapy.
Keep goals in mind: nutrition, lung function.
No need to let get very positive.

15. Summary It makes sense that FO contributes to poor outcome.
There is observational data: PICU, PICU-cardiac,
ECMO, HSCT which shows this association.
Though there are not trials yet, makes sense to:
-actively attempt to avoid FO
-think about CRRT/RRT for FO earlier, rather than later
CRRT fluid removal plan must be:
-group effort, planned, continuously revised
-SAFE

16. THANK YOU pCRRT conference organizers
Montreal Children’s Hospital AKI research team
Collaborators/mentors:
Stuart Goldstein, Prasad Devarajan, Chirag Parikh
The Kidney Injury During Membrane Oxygenation group