Hemodialysis in the NICU

[BrandNewBabyNurse]

Hey everyone,

I work in a Level IV NICU and we've run into an issue that's all uncharted waters for us. We have a 2 month old patient who was born with nonfunctional hypoplastic kidneys. We tried to manage her on peritoneal dialysis but her body was unable to achieve the desired fluid and electrolyte balance with the PD exchanges, and we ended up constantly needing to be either supplementing or attempting to purge electrolytes.

It was decided that she needed to be put on hemodialysis, which has been done on our unit only one time in the past, and it's been a rough road. I take care of this patient frequently due to my background experience in renal nursing, so I've been witness to a lot of her treatments. Trying to do hemodialysis on her is such a struggle. She screams herself purple nearly the entire time, randomly will start needing O2, and usually ends up on pressors due to bottomed out BPs. We give her back small fluid flushes to try to equalize her, but it's so difficult that we never end up coming close to our fluid removal goal. What's supposed to be a 60 min treatment always ends up lasting close to 3 hours because we're starting and stopping so much to troubleshoot.

I'm curious if any other NICU nurses out there have seen HD in your units, and if so, have you found any tips/tricks for helping improve tolerance to the treatment?

Thanks!

[NICU Guy, BSN, RN]

We have had several babies on peritoneal dialysis , but I have never seen them put a baby on hemodialysis.

[NicuGal, MSN, RN]

I've never had a hemodialysis baby, we've done peritoneal and we have a dialysis nurse who would come daily to check on things and make sure we were okay.

So are they going to keep on with this until she can have a transplant?

[adventure_rn, MSN, NP]

So this doesn't really answer your question, but it sounds like she needs CRRT if she isn't physiologically tolerating intermittent dialysis; is there another NICU with CRRT where she could be transferred? I second NicuGal's question, what is the end game?

[BrandNewBabyNurse]

So this doesn't really answer your question, but it sounds like she needs CRRT if she isn't physiologically tolerating intermittent dialysis; is there another NICU with CRRT where she could be transferred? I second NicuGal's question, what is the end game?

We have discussed putting her on CRRT on our unit, but the provider team is really not wanting to do it, I think in part because of her tiny size. For both hemo and CRRT a specially trained peds dialysis nurse is working alongside with the bedside RN, so it's not like there's logistical concern about management. I have been quite frustrated recently about the lack of discussion regarding the "end game." The conversations all seem so short term goal focused, but there hasn't really been any talk about long term feasibility/options. Right now they're wanting to try and grow her some more on HD so that we can attempt PD again when she has a larger surface area for fluid exchange. But I'm just having a hard time wrapping my head around the fact that she needs to be minimum 13kg for transplant and she's currently 5kg...still have a long long road. Interesting to hear that HD is not common practice in other NICUs either though, guess we really are just trying to figure it out as we go.

[adventure_rn, MSN, NP]

That sounds frustrating, I'm so sorry. The only other thing I can think would be to reach out to peds nurses who do HD? She's big enough and old enough that they may have some developmentally appropriate ideas. Maybe you could post on the peds forum, or better yet ask some peds nurses in your hospital.

[NicuGal, MSN, RN]

I was thinking about this last night. Have you tried some sedation prior to starting dialysis? A little something may help her tolerate it better. Maybe put the NC on with a little O2 prior also. Do you have a PICU that has done this on this size baby? It just all seems so frustrating.

[meanmaryjean, DNP, RN]

I like the sedation idea. Our PICU / NICU only do PD and CRRT (

Sounds like maybe a transfer is in order to a facility where this is common practice if they truly want to grow her to transplant size.

[BrandNewBabyNurse]

That sounds frustrating, I'm so sorry. The only other thing I can think would be to reach out to peds nurses who do HD? She's big enough and old enough that they may have some developmentally appropriate ideas. Maybe you could post on the peds forum, or better yet ask some peds nurses in your hospital.

Thank you, definitely a good idea. I'll reach out to some of the peds people at work and see if they have any thoughts.

[BrandNewBabyNurse]

I was thinking about this last night. Have you tried some sedation prior to starting dialysis? A little something may help her tolerate it better. Maybe put the NC on with a little O2 prior also. Do you have a PICU that has done this on this size baby? It just all seems so frustrating.

So the sedation idea has been a tricky concept for us. I was all in favor of it, but the peds dialysis team is against using pain meds or sedation for children too young to talk. Apparently inconsolable crying typically indicates hypoperfusion or too-rapid electrolyte shifts. They fear that sedation will suppress the physiologic/behavioral indications of complications. Their protocol is that when the crying/agitation turns to full on screaming, they pause the tx and assess, and then often will give some fluid back or increase blood pressure support. It really is hard to watch...when we did her treatment 2 days ago I begged them to give some midazolam and it did seem to help take the edge off, and the team was able to continue. We'll be cycling her again tomorrow and I'm planning on requesting it again, but I think it'll really depend on who comes from nephrology and peds dialysis.

Our PICU has done this on babies in the past, but she is the smallest and it sounds like at the end of the day, no matter what we do her small size is going to make things a challenge.

[NicuGal, MSN, RN]

I have a real problem with their thinking....so it's okay for this baby to get so out of control she is requiring other interventions. Thank you for advocating for her! Your unit team may need to step in and just say this is not acceptable.

[jennylee321]

Babies like this (hemodialysis, complex sedation and pain) need to be managed in picu because they really aren't neonates anymore so they need to be managed by pediatric intensivists rather than neonatalogists. I feel like work older babies get stuck in NICU they keep getting treated like newborns when they shouldn't be.