A New Protocol for Dialysis Catheter Use in Neonates After Cardiac Surgery

Dr. Tennille Webb is a pediatric nephrologist at Children’s of Alabama.

Cardiac surgery-associated acute kidney injury (CS-AKI) is a common complication following heart surgery involving cardiopulmonary bypass (CPB). One multicenter study found it occurred in 54% of neonates after the procedure. One option to reduce negative outcomes is to start prophylactic peritoneal dialysis (PD) immediately after surgery, which numerous studies have found improves outcomes. Children’s of Alabama is one of only a few pediatric hospitals in the country that provides prophylactic PD in this population. However, there is no consensus on the optimal time to initiate it.

To learn more about which neonates are most likely to benefit from prophylactic PD after cardiac surgery involving CPB, Children’s pediatric nephrologists Tennille Webb, M.D., MSPH, and David Askenazi, M.D., MSPH, reviewed four years of data from patients who developed CS-AKI to identify common characteristics. They also collaborated with cardiac intensivists to gain their perspective.

The team collected baseline data, which showed that about 13% of patients who needed PD didn’t receive it in the operating room (OR), while 51% of those who received PD didn’t need it. “This is undesirable,” Webb said, “because having a PD catheter is not without risks, such as infection.”

Based on their findings, Webb and Askenazi identified three risk factors that were independently associated with the need for PD:

1. Pre-operative serum creatinine levels
2. Day-of-surgery weight
3. Having an open chest post-operatively
    

Using that information, they implemented a new prophylactic PD protocol. After implementing the new protocol, all neonates who eventually needed PD had the catheter inserted in the OR. “This is significant in avoiding delays in initiating PD, therefore mitigating worse outcomes,” Webb said. In addition, the number of unnecessary PD catheters fell by half. “This has huge implications in care delivery, including resources used and exposing children to therapies that are not needed,” she said.

Webb attributes the success to the team effort between nephrologists, cardiothoracic surgeons and cardiac intensivists. The team will continue to assess the impact of prophylactic PD on outcomes such as the duration of mechanical ventilation and fluid overload. “We are excited that we were able to develop and implement an evidence-based prophylactic PD protocol that has improved our ability to provide PD to this neonatal population,” Webb said.