1. Putting it all together: When resources are scarce Mignon McCulloch Associate Professor Department of Paediatric Critical Care Red Cross Children’s Hospital (RXH) University of Cape Town

2. Acknowledgements Thanks to Stuart and Tim Including all forms of CRRT Disclosures Passionate about PD Access for children with AKI in poorly resourced areas

3. 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?

6. Less than 1km down the road…

7. 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?

9. Goal directed therapy Study of Emergency Department Management

10. Rivers et al, N Engl J Med, 2001

12. de Oliveira CF et al, Intensive Care Med, 2008

14. Severe sepsis and septic shock guidelines 2008

15. FEAST Trial ?

17. 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)

18. Maitland et al, N Engl J Med, 2011

20. 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

21. 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?

22. 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???

23. Renal Replacement Therapy What we have done in Cape Town?

24. 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

25. “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

26. IPNA/ISN Training for Africa Nigeria BeninUganda Kenya Ghana

28. Challenges on Return Poor Staffing100% Lack of Facilities & Equipment86% Radiology – Ultrasound only86% Support from Home Institutions71% Histology support57%

29. Paradise ?

32. ISN Sister Program PD Workshop Accra, Ghana 04.12.2011

33. 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

34. Devices for Peritoneal Dialysis

35. New Generation Cook Catheters

36. Kimal ‘Peel-away’ Tenchkoff

37. 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

38. Automated Dialysis Home choice machine

39. Manual Dialysis with Fluid Warmer

40. Post Abdominal Surgery 8Fr Cook PD Catheter 8Fr Cook Pigtail multi-purpose drainage device

41. Improvised equipment and solution used in the procedure 5/9/2015Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH 41

42. 5-yr old with HUS PD duration - 8 days 5/9/2015 Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH 42

43. PD progress in 1 st 24 hrs 5/9/201543 Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH

44. PD in session 5/9/201544 Dr S. Antwi: Paediatric Nephrologist - KNUST-SMA/KATH

45. 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

46. PRACTICAL SKILLS WORKSHOP IPNA/ISN/SKCF/Saving Young Lives …..and all other supporters 12-16 Nov 2012

47. Thank you to all my colleagues @ RXH Thank you for your time and attention !