PEDS8: Continuous Renal Replacement Therapy In Pediatric Extracorporeal Membrane Oxygenation: Life Span And Cost Of Filter Changes With Bivalirudin.

Abstract

Background: The utilization of additional extracorporeal support devices utilized in conjunction with Extracorporeal Membrane Oxygenation (ECMO) has increased with more complex and sicker patients. The use of Continuous Renal Replacement Therapy (CRRT) has increased five-fold over the past 3 years at our institution after implementing Pediatric Nephrology Stewardship (PNS) on ECMO. Bivalirudin is the primary anticoagulant used for ECMO and CRRT at our institution which has resulted in increased ECMO circuit and CRRT filter life. The Prismalflex HF1000 and HF20 filter has a prime volume of 165 ml and 58 ml, respectively, with prime components which include packed red blood cells (pRBC) and albumin. Manufacturer recommendations for changing the CRRT filter is defined as every 72 hours (3 days). We sought to extend the filter length by augmenting the indication for the CRRT filter change from manufacturer recommendation. Filter changes were determined based on monitoring the filter pressure, transmembrane pressure, and pressure drop to diagnosis clotting/clogging. CRRT filter was also changed out if disconnection from ECMO was warranted due to ECMO circuit change or travel. Methods: Retrospective ECMO and CRRT data was collected for pediatric veno-arterial or veno-venous ECMO patients at a tertiary care hospital from January 2021-December 2022. Results: CRRT was performed on 16% (7/44) of ECMO patients. 100% of the patients received bivalirudin as the anticoagulant. 71% (5/7) were supported by VA ECMO. 43% (3/7) were neonates. Mean ECMO duration was 14 days (3-133). Of the 7 ECMO patients on CRRT, 80% (265/332) of their time on ECMO included CRRT support. There was a total of 41 CRRT filter changes performed during 265 days on CRRT with an average filter change occurring every 6.46 days (table 1). Utilizing cost of CRRT filter set ($358.00) and approximate cost of 1 unit of pRBC ($200.00), there was a savings of $26,226 to the hospital ($22,878 vs. $49,104). Discussion: Utilization of an alternative indication versus manufacturer recommendation for CRRT filter change out prolonged filter length from 3 days to 6.46 days (110% decrease in filter change out). By reducing the number of CRRT filters and blood usage for a filter change, cost to the hospital and patients was significantly reduced even without considering labor for CRRT set up and blood preparation. With careful attention to detail and collaboration with Nephrology and Hematology services, it appears CRRT filter length can be safely extended past manufacturers recommendations.