Pediatric Hemodialysis Unit Research Articles

Doing 'Technological' Time in a Pediatric Hemodialysis Unit

Study objectives: For Canadian children living with end-stage renal disease, hemodialysis is a common intervention and usually received in a specialized ambulatory hospital-based unit. Although children spend up to 12 hours a week receiving hemodialysis, little is known about how they perceive and respond to hospital-based hemodialysis. The study’s purpose is to describe and interpret the children’s embodied situatedness in the temporal, spatial and technological regimes and relations of a pediatric hospital-based hemodialysis unit.Methods: An ethnography was undertaken at a Canadian urban pediatric hospital. Time, space, and technology are viewed as significant interrelated aspects of the hemodialysis unit and the unit is conceived as nested in the broader contexts of the children’s everyday lives. The theoretical framework merges concepts of human embodiment and contemporary human geographical perspectives and philosophy of technology.Results: The dominant theme emerging from the study findings is the notion of the children doing ‘technological’ time. The pervasiveness and reach of hemodialysis technologies upon the children profoundly textures their situations, shapes their perspectives, evaluations and expectations and impacts how they are seen by caregivers in the unit.Conclusions: Crucial changes in practices are essential to envision ways to create with children an overall positive place that merges and balances technological care with child focused care. The inclusion of children’s views is critical because many settings typically occupied by children have been designed and designated by authoritative or professional adults as “places for children” (Rasmussen, 2004, p. 155) without children being involved. Exploration of the findings may contribute to the ways that healthcare providers, funders, administrators and policy-makers can facilitate the inclusion of children in the design and care provision of hemodialysis units as well as other high-tech hospital-based units.ReferencesRasmussen, K. (2004). Places for children – children’s places. Childhood, 11(2), 155-173.

The mothers' experiences in the pediatrics hemodialysis unit.

The need for hemodialysis exerts a deep impact on the lives of children and adolescents with end-stage kidney chronic failure and their mothers, who predominantly assume the care related to treatment. The hemodialysis requires that the mother accompanies the child during sessions at least three times a week and, since it is not a healing practice, they also experience the waiting for a kidney transplant, attributing different meanings to this experience. To understand what it means for the mothers to accompany the child in a Pediatric Hemodialysis Unit and to construct a theoretical model representing this experience. The Symbolic Interactionism was adopted as a theoretical model and the Grounded Theory as a methodological framework. Data were collected through interviews with 11 mothers. The comparative analysis of the data enabled the identification of two phenomena that compose the experience: "Seeing the child´s life being sucked by the hemodialysis machine" expresses the experiences of the mothers that generates new demands to comprehend the new health conditions of their children and "Giving new meaning to the dependence of the hemodialysis machine" that represents the strategies employed to endure the experience. The relationship of these phenomena allowed the identification of the main category: "Having the mother's life imprisoned by the hemodialysis machine", from which we propose a new theoretical model. The results of the study allow us to provide a theoretical ground for planning an assistance that meets the real needs of the mothers, identifying aspects that require intervention.

Using noninvasive hemoglobin measurements to estimate measured hemoglobin in a pediatric hemodialysis unit

Maintaining a dialysis patient's hemoglobin (Hgb) within a very narrow range can be challenging. Relying on Hgb measurements only once or twice a month can cause large fluctuations in their measurements. Utilizing the Hgb measurement from noninvasive modalities has been studied in adult populations. Our study focused on a pediatric hemodialysis population where blood volumes are much smaller to see if these measurements would adequately work for adjusting erythropoietin dosages. We reviewed our patients' data over a 6-month time period and collected simultaneous measurements of Hgb performed in the laboratory, as well as the initial Crit-Line measurement. We then analyzed the correlation of the two estimates of the patient's Hgb using linear regression as well as Bland-Altman plot and ROCs. There were 407 simultaneous measurements of Hgb in our 32 pediatric hemodialysis patients during this time. Linear regression showed good correlation with an R value of 0.85 (P value < 0.0001). The Bland-Altman plot showed excellent agreement between the two methods. The ROC analysis showed that the performance of the noninvasive Hgb measurement was very good at predicting low measurements. Predicting Hgb less than 10 g/dL had an area under the curve of 0.94. Predicting Hgb greater than 12 g/dL had an area under the curve of 0.91. There were 100 simultaneous measurements of hematocrit. The analysis revealed similar results as the hemoglobin. Noninvasive in-line monitoring of Hgb can be a very useful way of assessing the patient's response to erythropoietin on a day-to-day time frame. Utilizing this methodology should help reduce the variability in the pediatric patients' Hgb measurements.

Surveillance System of Hemodialysis-Associated Infections in a Pediatric Unit

The bloodstream infection surveillance system proposed by the Centers for Disease Control and Prevention (CDC) was prospectively conducted in a pediatric hemodialysis unit. Thirty patients were included; 73% had a catheter for vascular access at enrollment. Vascular access infection rate was 21.1 per 100 patient-months, well above those observed in adult patient surveys. Staphylococcus aureus was most frequently isolated (23%).

Catheter‐related bacteremia in a pediatric hemodialysis unit

Tunneled‐cuffed hemodialysis catheters are frequently used as long‐term vascular access in children due to the technical difficulties in constructing a fistula. Catheter‐related bacteremia (CRB) is still a major complication contributing to patient morbidity and loss of vascular access. Objective: To investigate the microbiological characteristics of CRB in children on hemodialysis. Methods: Chart review of 63 children who received hemodialysis with a tunneled‐cuffed catheter between January 1999 and December 2003 was performed. CRB was diagnosed when positive blood cultures were obtained in patients with symptoms of bacteremia, and without an identifiable source. Results: During the 5 year period, a total of 251 CRB were detected with 313 bacterial and 2 candidal growths in the blood cultures. The distribution of gram positive (Gr+) and gram negative (Gr−) microorganisms and their sensitivity patterns are shown in the table. Coagulase negative Staphylococcus was the most common microorganism, and constituted 62% of all bacterial isolates. All Gr+ microorganisms were sensitive to vancomycin except one isolate of Enterococcus fecalis. Enterobacter cloacae was the most common Gr− microorganism, followed by Klebsiella pneumonia. The sensitivity of Gr− microorganisms to levofloxacin was 100%. The treatment course was complicated by the growth of a second microorganism in subsequent blood cultures in 24% of infections; 54% of these consisted of both Gr+ and Gr− isolates. The etiology of ESRD or the use of immunosuppressive agents had no effect on the occurrence of CRB. The average number of infections were 5.8/1000 catheter days, and the recurrence of CRB was more likely in patients who had two or more CRB in a year. 1999 2000 2001 2002 2003 Gr+ growth 80% 88% 87% 85% 73% Oxacillin resistance 84% 73% 82% 68% 75% Gr− growth 20% 12% 13% 15% 27% Tobramycin resistance 21% 50% 25% 20% 13% Conclusions: Empiric initial treatment for CRB should include both Gr+, and Gr− coverage. Oxacillin and first generation cephalosporins are not good choices due to high incidence of resistance. Levofloxacin is a good alternative for Gr CRB. Novel preventive measures should be sought in patients who have a tendency to have recurrent CRB.

Experience with the Gambro Phoenix Hemodialysis Machine using Diascan and Exalis in a Pediatric Hemodialysis Unit

Introduction: In 2001 our Renal Dialysis Unit underwent a major renovation to five stations. The new space and funding allowed for acquisition of new state‐of‐the‐art hemodialysis machines. We describe our experience with the Gambro Phoenix with Diascan and Exalis. Prior to the move an evaluation was undertaken. Criteria for selection with a scoring tool were utilized to rate machine performance for use in children. The decision for the Gambro Phoenix machine was based on: the performance rated highly due to ease of set up; large viewing touch screen; compatibility with existing equipment; benefits of online clearance monitoring (Diascan); network data management system (Exalis) and the future availability of blood volume monitoring (Hemoscan). Our program was the first center to dialyze a pediatric patient on the Phoenix machine in Canada.Patients and results: 13 patients (age 2–23 years) were hemodialyzed between May 2002 and September 2003 for periods of 2 week to 16 months, greater than 5000 h of dialysis time. The move was not uneventful. During the first months of operation issues such as inadequate electrical supply for the new machines, reverse osmosis (RO) pump failure, leaks, and no emergency power to the RO were prevalent. The new software also exposed glitches. Subsequent Phoenix use proceeded uneventfully. Staff were able to problem solve easily with clinical and technical support from Gambro Canada. Education for the online clearance monitoring, Diascan and Exalis, was necessary. No major problems with dialysis were encountered. The benefits and reliability of Diascan have been previously described (Lindsay RM, Sternby J, Semin Dial. 2001; 14:300). Diascan readings provided real‐time measurement of sodium (Na), which correlated well with laboratory values. Automatic readouts of Kt/V allowed for monitoring of dialysis adequacy which was consistent with calculated percent reduction in urea (PRU). At this point, use of the Phoenix has been demonstrated to work well in a pediatric facility.

Effective Adherence Contest to Improve Albumin, Phosphorus, and Fluid Levels in Pediatric Hemodialysis Unit

Low serum albumin, high serum phosphorus, and fluid overload are common issues in dialysis patients. This can be attributed to many causes such as inadequate understanding and lack of accountability in the patients' care. These abnormal levels contribute to increased medical complications and increased mortality.Objective: (i) Improve patient education of albumin, phosphorus, and fluid maintenance. (ii) Improve patients' albumin, phosphorus, and fluid levels by 25 percent.Methods: A baseline level was collected on all patients by averaging last 3 laboratory findings. All patients were educated recognizing several different learning styles. Educational posters were displayed, one‐on‐one education was provided, as well as educational games on the role of albumin, phosphorus, and fluid. Patients were also educated on the role of diet in these levels. Positive reinforcement, peer pressure, and intensive team approach were used through the 8‐week incentive contest. Feedback on progress was provided in written and verbal format. Prizes were awarded for best shift levels and shift with most improvements.Results: Levels measured at the end of the educational period and contest showed a 71% improvement in albumin levels, 52% improvement in phosphorus levels, and a 42% improvement in fluid levels.Conclusion: Significant improvements found in all areas are attributed to three factors: education, consistent, individual, intensive attention, and incentives. Peer pressure was found not to be as effective but that individual tracking for incentives may be more effective if done ongoing. Our follow up several months later found a slight decrease in improvements, and we recognize a need for an ongoing intervention. Yet, we found an overall improvement of level of understanding and commitment to their overall health.

Use of a Computer-Based Application in a Pediatric Hemodialysis Unit: A Pilot Study

This report describes preliminary efforts to implement a computer-based application, called Zora, in a pediatric hemodialysis unit. The feasibility and safety of establishing a virtual community in the hemodialysis unit are explored. Zora allows users to design and inhabit a graphical virtual city where they create characters, stories and spaces while communicating in real-time. Over a 5-month period, 7 hemodialysis patients and 4 unit staff found Zora enjoyable and safe. The results support the premise that computational environments may offer an opportunity for pediatric patients and their caregivers to participate in virtual communities that promote coping with chronic physical illnesses.

Intradialytic parenteral nutrition in malnourished children treated with hemodialysis

Objective: To examine the feasibility and effectiveness of intradialytic parenteral nutrition (IDPN) in children on hemodialysis. Design: Prospective experimental study with a single intervention group. Setting: A pediatric hemodialysis unit. Subjects: Four malnourished children on hemodialysis (3 girls and 1 boy) 4 to 18 years of age were studied during a period of 1 year. Intervention: IDPN, which is composed of amino acids (8.5% solution), glucose (as 10% to 15% dextrose), and 20% fat emulsion, was administered at every dialysis session (3 times a week, during 4 hours each time) for 7 to 12 weeks. Main outcome measure: Oral caloric intake (evaluated by using a 3-day diet history), dry weight (weight after dialysis), body mass index, percent ideal body weight, total lymphocyte count, and serum levels of albumin before, immediately after cessation of IDPN, and 3 months after cessation of IDPN. Results: Oral caloric intake increased markedly after IDPN administration, from 5 to 63 kcal/kg/d (mean, 33 kcal/kg/d) before IDPN administration to 35 to 177 kcal/kg/d (mean, 86 kcal/kg/d) at the time of cessation. Weight did not change during the treatment period but it did increase from 9.5 to 36.4 kg (mean, 25 kg) to 11 to 39 kg (mean, 26.7 kg) 3 months later. Percent ideal body weight increased from 73% to 88% (mean, 78.5%) to 79% to 90% (mean, 85.1%), and body mass index increased from 12.2 to 15 kg/m2 (mean, 13.5 kg/m2) to 13.4 to 15.5 kg/m2 (mean, 14.6 kg/m2). Total lymphocyte count increased from 538 to 2,041 cells/mm3 (mean, 1,403 cells/mm3) to 724 to 2,884 cells/mm3 (mean, 2,066 cells/mm3). Plasma levels of albumin increased in 1 patient but remained unchanged in others. Conclusion: Short-term IDPN treatment may serve as a safe and effective nutritional intervention in malnourished children on hemodialysis. © 2002 by the National Kidney Foundation, Inc.

Bacteremia in a pediatric hemodialysis unit secondary to Enterococcus fecalis.

Bacteremia is often a serious and recurring problem in children with hemodialysis catheters. We report an outbreak of Enterococcus bacteremia in a pediatric hemodialysis unit occurring from June 1992 to June 1993. During this period, 18 episodes of bacteremia occurred in eight children; 11 infections were polymicrobial. Enterococcus fecalis was associated with 13 infections in five patients (8 polymicrobial). Other pathogens included Enterobacter cloacae (5 infections), Staphylococcus (3), Staphylococcus epidermidis (2), and Klebsiella pneumoniae (2). All Enterococcus infections occurred in patients with dual-lumen subclavian venous catheters. Skin and catheter sites were culture negative, except in one patient. Rectal swabs were positive for Enterococcus in five patients. Enterococcus was not isolated from any source within the unit. Serotypes of all Enterococcus isolates were different, except for 2 isolates in the same patient. Starting in June 1993, catheters were flushed after dialysis with vancomycin or ampicillin. Since initiating this procedure, further episodes of Enterococcus bacteremia have not occurred. A questionnaire sent to other pediatric hemodialysis units failed to identify Enterococcus among 26 cases of bacteremia. (1) Enterococcus is an unusual pathogen for hemodialysis-related bacteremia in children; (2) patients with dialysis catheters were predisposed to this infection; (3) a common source for Enterococcus could not be identified by either culture or by serotyping; (4) flushing catheters with antibiotics after dialysis was effective prevention.

VACCINE AGAINST HEPATITIS B IN CHILDREN WITH RENAL FAILURE

To prevent hepatitis B (HB) infection in the pediatric hemodialysis unit, 8 children with chronic renal failure were immunized by means of a vaccine. Three children dialysed in the same unit were hepatitis B surface antigen (HBsAg) chronic carriers and represented a permanent high risk of HB infection for the whole unit. The vaccine was prepared by purification of HBsAg from human sera and was formalin inactivated. The children received 3 injections of vaccine at one month interval. Monthly screening of seric transaminases (ALT, AST) and markers of HB virus (HBsAg, anti-HBs, anti-HBc) was performed. The 8 vaccinated children were followed from 3 to 17 months after vaccination. All of them seroconverted for anti-HBs. None of the children evidenced clinical, biological or serological sign of active HB infection. Hepatitis B vaccine in children with chronic renal failure appeared to be safe and its potency satisfactory. Presence of anti-HBs and absence of HB infection in vaccinated children suggest that this vaccine represents an efficient method of prevention against HB infection in high risk setting.