Single Pass Albumin Dialysis (SPAD).

Peritoneal Dialysis.

During our 2008 trip to Nairobi on a Cardiac Surgery mission one of our post op children went into acute renal failure. I improvised a PD set, as well as made our own bicarbonate dialysis fluid. The advantage of taking a dinosaur like me along is that I remember how we used to have to do things twenty+ years ago!

Take a one litre bag of sterile 0.9% Saline for IV use and remove 350ml using an aseptic technique. Discard this 350ml.

Using an aseptic technique add the following to the remaining 650ml bag of 0.9% Saline; 300ml Glucose 5%, 10ml Glucose 50% and 40ml Sodium Bicarbonate.

Properties of this solution are as follows Sodium 140mmol/L, Glucose 2% and Bicarbonate 40%. PLEASE NOTE THIS SOLUTION CONTAINS NO POTASSIUM! Normally one would add 4mmol/L of Potassium Chloride depending on the patient's serum K+ level; however if the patient is hyperkalaemic use a reduced amount, eg if their potassium level is 5-7 add just 2mmol/L, and if the patient's level is >7 add no potassium to the solution.

Start with Fill Volumes of 10ml/kg. In over 5 minutes, dwell 10 min and drain over 15 min. And repeat the cycle. This will draw off some excess water as well as correct the patient's electrolytes and acidosis. Monitor patient's fluid balance and serum electrolytes regularly until the patient's kidneys recover. Until they do recover restrict the patient's fluid intake to 2ml/kg/hour if they weigh less than 10kg, and if they are upto 20kg give 1ml/kg/hour.

For larger patients give a maximum of 40ml/hr if they weigh more than 20kg (please note this is NOT 40ml/kg/hr but 40ml total volume per hour!)

The Age of Aquarius!

Among the wide range of gadgets we use in PICU to help support the sick kids we have is this one. It is an "Aquarius" haemofilter produced by 'Edwards Lifesciences Services GMBH'. We use this for Continuous Venous Venous Haemofiltration (CVVH). We generally use this when the children are in acute renal failure and need excess fluid removing &/or their chemistry correcting. Occasionally we will have children who need a drug dialysing out.

In essence we draw blood out from the patient through a large intra-vascular catheter called a 'vascath' by means of the "blood pump" which is the red roller pump [top left]. The patient's blood is pre-diluted with a dialysis solution [Multi-Bic] drawn from a reservoir bag slung beneath the machine by the green pumps before entering the blood filter in the centre of the picture. Excess water is drawn out from the filter by the yellow pump into a waste bag also underneath the machine (not shown). The filter will also correct the patient's blood chemistry and pull out any other waste products too.

Depending on the size of the patient (and they can be infants all the way up to teenagers!) we will select the appropriate size filter and the various parameters for an effective treatment. This is programmed into the computer screen at the top of this picture.

Renal Replacement Therapies is one of my 'specialities'.