Bringing acute care nephrology services to the NICU
Care of neonates with renal failure after birth remains a significant clinical challenge. Decisions related to providing dialysis in a newborn relies on a partnership between the parents and treatment team, including nephrologists and neonatologists.
In 2022, the Pediatric Nephrology Department and Pediatric Neonatal Department at Children’s Health ℠ made key progress in this care by working together to provide advanced neonatal continuous renal replacement therapies (CRRT) in the hospital’s Level IV NICU. This included the addition of three Carpediem™ dialysis machines and two Aquadex Smartflow® ultrafiltration systems as part of the Nephrology Department’s ongoing commitment to expand acute care services to infants with kidney disease.
“It took a collaborative, multidisciplinary effort to implement these innovative treatments in the NICU, as well as the development of institutional treatment guidelines,” says Jyothsna Gattineni, M.D., Division Director of Pediatric Nephrology at Children’s Health and Associate Professor at UT Southwestern. “It’s our hope that our experiences can aid other centers who are new to these technologies or are considering them at their institution.”
New advances in neonatal dialysis and renal therapy
The Cardio-Renal Pediatric Dialysis Emergency Machine (Carpediem) provides CRRT for infants with AKI, kidney failure and/or hypervolemia (fluid overload). Approved by the FDA in 2020, Carpediem is the first dialysis system designed specifically for pediatric patients.
“We have been treating small infants with dialysis machines designed for adults,” says Keri Drake, M.D., Pediatric Nephrologist at Children’s Health and Assistant Professor at UT Southwestern. “Carpediem is a huge improvement because it was specifically designed for neonates, offering the possibility of compatibility with smaller catheters, more precision with each treatment and reduced risks seen with the previous modalities.”
Aquadex is an ultrafiltration system that removes excess fluid that can cause organ damage and organ failure. The device has been used since 2007 to treat adults, as well as children who weigh at least 44 pounds. However, its use has been recently expanded to newborns and smaller infants who need nephrology care in NICUs.
Using a team approach to delivering renal therapies in the NICU
Previously, neonates requiring renal replacement therapy were transferred to the pediatric intensive care unit (PICU). However, with the implementation of Carpediem and Aquadex in the NICU, the continuity of their care will remain in this specialized unit.
“Because the use of these technologies is new to our NICU, we had to create our own institutional guidelines for using them,” says Dr. Gattineni.
The nephrology and neonatology teams dedicated six months to accomplishing this and training nurses and providers on the new technologies. Their “homework” involved:
Participating in online educational sessions with centers already using the technologies to learn more about their treatment experiences, as well as their institutional practices and guidelines
Reviewing materials developed by an American Society of Pediatric Nephrology (ASPN) interest group to share best practices and provide guidance about these technologies
Tapping into the expertise of other Children’s Health departments like hematology, urology and surgery, as well as the PICU and CICU, to ensure a multidisciplinary approach to the care of these complex patients
Completing multiple training sessions with device manufacturers
From there, the teams created and standardized institutional guidelines that:
- Integrated information gleaned from other medical centers and the ASPN interest group
- Established inclusion and exclusion criteria to determine the appropriate use of Carpediem or Aquadex, such as gestational age, infant weight and other health conditions
- Created order sets and flow sheets in Epic
Forming an advanced modalities team of NICU nurses
The preparation didn’t end there. To determine what the NICU team needed in order to feel confident providing CRRT, Sushmita Yallapragada, M.D., Medical Director of the NICU at Children’s Health and Assistant Professor at UT Southwestern, spoke to nursing leadership.
“We decided to form an advanced modalities team (AMT) comprised of 15 day shift and 15 night shift NICU nurses who expressed interest in receiving training on all types of advanced technologies, including Carpediem and Aquadex,” says Dr. Yallapragada.
The team completes regular stimulation training and continuing medical education to ensure they’re ready to use the technology at all times.
“We also have a nurse educator in place for all modalities across the NICU, PICU and CICU to streamline training and processes for all three units,” says Dr. Yallapragada.
Using CRRT to help an infant
In 2022, the nephrology and neonatology teams used Aquadex in the NICU in an infant admitted to Children’s Medical Center Dallas, the flagship hospital of Children’s Health, for fluid overload. This treatment is only available at a handful of centers in Texas.
“We initiated treatment with Aquadex in the NICU and stopped treatment a few days later,” says Dr. Gattineni. “The infant was discharged home and is doing remarkably well.”
Setting a new standard for acute renal care
After the successful treatment of each NICU patient, the nephrology and neonatology teams take part in debriefing sessions to discuss treatment successes, challenges and opportunities for improvement.
As the largest nephrology program in North Texas and one of the top nephrology departments in the country, Children’s Health is dedicated to helping other pediatric medical centers succeed at providing these neonatal renal treatments.
“We’re continuing to share our experiences and what we’ve learned with other centers to ensure we’re being as thorough and thoughtful as possible in how we use these technologies,” says Dr. Drake.
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