1. Multiorgan failure, nutrition and PCRRT Bernhard Frey Dep. of Intensive Care and Neonatology University Children‘s Hospital Zürich 4th International Conference on PCRRT

2. Structure of the talk APCRRT in MOF: Do not focus on technology only BThe benefits of PCRRT in MOF CSome practical aspects of CVVH

3. Cascade effects of medical technology Critically ill child Missing clinical skills Fluid overload Organ dysfunction (lungs, brain, heart) CVVH Side effects of CVVH Deyo RA, Annu Rev Public Health, 2002 A Do not focus on technology only

4. Side effects of PCRRT (CVVH) Complications with vascular access Thrombosis Infection Air embolism Bleeding (anticoagulation) Increased lactate (Barenbrock M, Kidney, 2000) Filtration of essential molecules Systemic inflammatory response syndrome (SIRS) A Do not focus on technology only

5. CVVH: Unintended consequencies? No prospective studies demonstrating benefit of PCRRT (relating to relevant end-points) Renal replacement therapy independently associated with increased mortality (Metnitz P, Intensive Care Med, 2004) Experience with invasive technologies impacts on outcome (Tilford JM, Pediatrics, 2000) Invasive technologies may be dangerous in „threshold“ countries A Do not focus on technology only

6. CVVH: Unintended consequencies ? Invasive therapies in low risk patients (Earle M, Crit Care Med, 1997)

7. How to avoid PCRRT Avoid fluid overload Prevention of ARF in MOF A Do not focus on technology only

8. Fluid overload in MOF A Do not focus on technology only

9. Fluid overload in MOF Stress, pain, nausea Vasopressin Morphine, barbiturates Capillary leak A Do not focus on technology only

10. Fluid overload in MOF Brain: brain swelling Lungs:higher fluid balance independent risk of mortality in ALI (Sakr Y, Chest, 2005) A Do not focus on technology only

11. Fluid overload: brain swelling A Do not focus on technology only

12. Fluid overload: cerebral herniation A Do not focus on technology only ICP Intracranial volume

13. Maintenance fluid Holliday MA and Segar WE, Pediatrics, 1957: Fluid requirements calculated by caloric expenditure However: Sick children need much less fluids: lower caloric intake lower urinary excretion decreased insensible losses A Do not focus on technology only

14. How to order maintenance fluids Total body water: weight, edema/dehydration, fluid balance Blood volume: microcirculation, diuresis, heart rate, (CVP, BP) Electrolytes: Na Analysis of: A Do not focus on technology only

15. Fluid requirements in ventilated children < 10 kg50 ml / kg / d > 10 kg1200 ml / m 2 / d + extra boluses (NaCl 0.9%) to increase cardiac output Give enteral feeds instead of „free water drips“ A Do not focus on technology only

16. Volume to optimize preload A Do not focus on technology only (Michard F, Crit Care, 2000)

17. Prevention of ARF in MOF Optimize perfusion pressure and O 2 -delivery O 2 -delivery = Cardiac Output x Hb x SaO 2 Avoid intraabdominal hypertension A Do not focus on technology only

18. Measurement of intraabdominal pressure A Do not focus on technology only

19. PCRRT

20. The benefits of PCRRT in MOF Indication Fluid overload ARF Inadequate nutrition B Benefits of PCRRT

21. The benefits of PCRRT in MOF Commencing PCRRT early may be beneficial (Goldstein S, Pediatrics, 2001) B Benefits of PCRRT

22. Enteral nutrition in PICU Early enteral nutrition: decreased length of hospital stay less infections improved wound healing B Benefits of PCRRT

23. Enteral nutrition in PICU (Rogers EJ, Nutrition, 2003) B Benefits of PCRRT

24. Enteral nutrition in PICU Energy supply is often inadequate Reasons:Fluid restriction Interruption of nutrition Measures:start enteral feeds early Give feeds, not water drips early jejunal nutrition favor enteral feeds PCRRT B Benefits of PCRRT

25. Practical aspects of PCRRT (CVVH) Vascular access Nutrition Drug dosing (Review: Norma Maxvold, Timothy Bunchman, Crit Care Clin, 2003) C Practical aspects

26. Vascular access C Practical aspects Neonate, 2.5 kg MEDCOMP® 7 F, 10 cm Filling volume: 0.8 + 0.8 ml

27. Vascular access Neonate, 2.5 kg MEDCOMP® 7 F, 10 cm C Practical aspects

28. Nutrition in CVVH The filter is highly permeable to water and other small molecules: amino acids trace elementsDouble intake water soluble vitamins C Practical aspects

29. Nutrition in CVVH The net ultrafiltration rate has to be set to allow adequate nutrition < 1 year: EBM / infant formula + trace elements + vit. > 1 year: Formula (Frebini®) + trace elements + vit. (Whole protein formula) C Practical aspects

30. Drug dosing: Factors affecting drug elimination FactorImportance Ultrafiltration ratelow Molecular sizelow Drug-protein bindinghigh (sieving coeff.) Volume of distributionhigh Physiological eleminationhigh C Practical aspects

31. Drug dosing: Drug specific numbers Sieving coefficient (Sc) Sc = C uf / C p (0 – 1) C uf : drug concentration in ultrafiltrate C p : drug concentration in plasma Volume of distribution (Vd) C Practical aspects

32. Drug dosing: practical approach Clinical signs of response or intoxication Drug concentration monitoring (whenever possible) C Practical aspects