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dialysis

Inside Pediatrics, Nephrology

Overflow at Children’s of Alabama’s Dialysis Unit

As the only pediatric dialysis unit in the state, Children’s of Alabama’s hemodialysis unit is used to being busy. But with COVID-19, “Our census has doubled,” said Children’s nephrologist Sahar Fathallah-Shaykh, M.D. One reason is that transplants were paused during the height of the pandemic, leaving many children who might have been able to stop dialysis forced to continue.  

Another reason is that more infants born with chronic kidney disease (CKD) are surviving because of new equipment capable of providing them dialysis. “We have seen many patients with CKD surviving who, just a few years ago, had no chance of surviving,” Dr. Fathallah-Shaykh said. Because these infants are so small, they must come to the hospital up to five times a week for the procedure, compared to three times a week for older children. Once infants are older, the team tries to transition them to peritoneal dialysis at home; but babies may have medical contraindications that require continuing on hemodialysis. 

The impact on the staff is significant, she said. “It’s a challenge.” Dialysis charge nurse Suzanne White, RN, ECP agrees. “It takes a lot of coordination to schedule treatments for 18 patients,” she said, particularly when treatment times last up to four hours. “Our days last 10 to 12 hours,” she said. 

One reason caring for infants on dialysis calls for intense attention, said Dr. Fathallah-Shayk, is that “nurses are at the bedside the entire time monitoring these babies. Babies move a lot, and if they move, the dialysis may not work as well.” The nurses console the babies, try to distract them and sometimes even hold them while they are dialyzed.  

The team includes a child life specialist who also tries to distract the infants during dialysis; social workers who support the families, including coordinating transportation and ensuring families keep their appointments; a dietician to help with nutrition and ensure proper growth; and a pharmacist to help with medications. “We all work as a team to make this happen,” Dr. Fathallah-Shayk said, “otherwise we couldn’t do it.”  

And, said White, “we have a good support system from the administration on down,” which helps avoid burnout. The unit also added more staff in anticipation of continued growth. “We are trying to coordinate their care to the best of our ability, troubleshoot and really communicate and work with each other,” she said. 

Inside Pediatrics, Nephrology

Welcoming the new PRISMAX Dialysis Machines to the PICU & CVICU

When you’re talking about continuous dialysis and plasmapheresis for sick kids, you want state-of-the-art technology. And that’s just what Children’s of Alabama got this year when hospital administrators approved a significant investment in the newest generation of the PRISMAX system for the Pediatric and Infant Center for Acute Nephrology (PICAN).  

The PICAN team is no stranger to these therapies; after all, the team has provided them for more than 500 children for over 10,000 days since 2013 in the pediatric, neonatal and cardiac intensive care units. In 2020, the newest PRISMAX became available, and Children’s became the first hospital in the state and one of the first children’s hospitals in the country to receive the new machines, said David Askenazi, M.D., who directs the PICAN. “We are very grateful to the hospital for making this available to us and our patients,” he said. “We know that patients will benefit.” 

But first, everyone had to be trained to use the new machines. While it sounds like replacing the old with the new should be a relatively simple switch, the staff required intense education. 

“The educational part of the rollout was very important,” said acute dialysis coordinator Daryl Ingram, RN, BSN, CDN. “We had to make sure the nurses and physicians were comfortable with them before they started using them on patients.” He was pleasantly surprised at how the entire team embraced the new technology and the groundbreaking opportunity the new machines offered, he said. 

One reason could be the improvements the new system brought. For instance, nurses no longer have to manually empty 5-liter effluent bags. “It definitely saves time,” said Suzanne Gurosky, RN, ECP, the dialysis charge nurse. She also touted the battery backup in the machines, which enables patients to ambulate and even do physical therapy while still connected. Another plus is the ability of the machines to decipher the cause for an alarm—because someone moved or jostled the fluids, or because there was a real issue going on. That helps avoid disruptive alarms and alarm fatigue. 

It does this through artificial intelligence, “so it understands what’s happening better than it used to,” said Dr. Askenazi.  

The new PRISMAX also sports improved safety features, such as correcting itself for fluid removal. In addition, it provides extensive data that can be integrated into the department’s quality-improvement initiatives. “We’re excited to dig into that information and incorporate it into our practice,” said Dr. Askenazi.  

After the training and the successful integration of the new PRISMAX machines into the unit, there was one more thing the team needed to do: name them. “We like to name our machines to help the kids feel more comfortable,” said Ingram. The winners were Rosie, Max, and Astro from the old “The Jetsons” cartoon, Johnny 5 from the movie “Short Circuit,” and C3PO from, of course, “Star Wars.” 

Nephrology

Children’s of Alabama Becomes First to Safely Provide Dialysis to Tiny Babies

Didactic and hands-on teaching on the use of CRRT using the Aquadex Pureflow.

Despite the frequent use of dialysis for critically ill children and adults, the procedure has historically been used sparingly in neonatal intensive care units (NICU) because dialysis  machines designed for adults can cause severe complications in babies. That’s no longer the case at Children’s of Alabama.

The problem is that continuous renal replacement therapy in these tiny patients requires at least 100 ml of blood to initiate the therapy. This can be half or even more of the baby’s entire blood volume, said David Askenazi, M.D., MSPH, who directs the Pediatric and Infant Center for Acute Care Nephrology. “Many times, when we started the machine, we had to open the crash cart to resuscitate infants who were coding,” he said.

That changed in 2013, when Askenazi realized that a machine designed to remove fluid and sodium from blood in adults with heart failure — the Aquadex FlexFlow® System — could be repurposed for neonate dialysis.

“If we could adapt a machine that requires one-third of the blood of the traditional machine volume to do what we needed, we knew we could improve our ability to support these babies,” he said. So the team learned as much as they could about the device, developed a safety net of processes to maximize the likelihood of success and convinced the hospital to buy its first machine.

Today, the hospital has fiveAquadex machines and two or three babies are typically receiving dialysis at any one time. “Now we have complete control over their fluids, electrolytes and waste products,” Askenazi said, “while the nurses feel comfortable doing the therapy and the babies don’t even know they’re on it.” Last year, babies in the NICU spent a total of 800 days on dialysis compared to just 30 days in 2013.

“For our babies born with diseased or absent kidneys, Aquadex has given them a chance at life,” said NICU nurse practitioner Kara Short, MSN, CRNP, “because in the past, there were no options to treat these patients.”

The team published the results of its first 12 patients in the journal Pediatric Nephrology in 2016. Since then, they have treated more than 90 patients, the smallest just 1.2 kg (2 pounds, 7 ounces) and taught nephrologists at several other children’s hospitals around the country to use the Aquadex. However, there are still only a handful of hospitals offering the procedure.

“We have shown we can now support these babies safely,” Askenazi said. “The impetus now is on us to make sure the patients who can benefit from this therapy make it to Children’s so we can give them a chance for life.”

And the machine’s manufacturer? It is now pursuing a pediatric indication for Aquadex.

A Team Effort

Learn more about the neonatology program and team at Children’s of Alabama.