What is family-centered care in a pediatric patient population?

The concept of family-centered care developed from an awareness that young patients’ emotional and developmental needs are best met by incorporating their families into the plan of care.

What are the staffing considerations for a pediatric hemodialysis population?

The hybrid of services that a pediatric dialysis facility provides necessitates a good method of matching resources to patient workload activity. The best choice is a time-motion study–based, statistically validated patient-dependency classification system. A patient-dependency system takes into account such factors as developmental age versus chronologic age and matches care requirements to the appropriate number of staff at each skill level. The patient-dependency system captures the care requirements of a patient who may be less ill but more dependent due to age, developmental level, or cultural requirements or who requires more frequent or different types of interventions than other patients with the same diagnosis. Because of the many pediatric patient-dependency categories, staffing requirements for pediatric care comprise a complex matrix that is most easily implemented with a staffing and scheduling system that targets staffing by skill level. As a patient’s dependency level increases, increased caregiver skills are usually required. The system must also recognize the potential for day-to-day variation in an individual child’s care requirements and in the staff required to provide that care. Determining staffing by matching caregiver-to-patient ratios to patient ages or sizes can be a disadvantage because ratios presume that all patients of the same age or weight necessarily require the same level of care every day.

How can a pediatric facility maximize operations when it has a small patient base?

Many pediatric dialysis facilities maximize operations by cross training nursing staff in both acute and chronic renal replacement therapy. During orientation the pediatric dialysis nurse learns how to manage all of the therapies furnished by a particular facility. Commonly these include the pediatric modalities of hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Some pediatric dialysis facilities offer additional extracorporeal therapies, such as hemoperfusion and plasmapheresis. Orientation can take anywhere from six weeks to three months, depending on prior experience and learning opportunities. Simulated clinical experiences in a skills laboratory can supplement learning experiences. A broad orientation plan and a gradual progression to independence with a designated preceptor guiding the progress toward acquisition of knowledge and mastery of skills have worked best in our experience.

Is there a place for technical support in the care of children on hemodialysis?

Some programs employ technicians for well-defined tasks, such as preparing equipment for dialysis or assisting registered nurses with children who are not developmentally delayed and who weigh more than 35 kg. A well-defined orientation plan, competency list, and method of documenting progress are important. Some states have specific stipulations for technical support personnel; check with the state department of health for specific state guidelines.

What are the causes of acute kidney injury in children?

Acute kidney injury in children usually results from hypoperfusion of the kidneys due to septic shock, hypotension, and severe dehydration from gastroenteritis or from acute blood loss from surgery or an accident. The pathology is that of acute tubular necrosis. Acute tubular necrosis can also occur after nephrotoxic drugs, especially aminoglycoside antibiotics and amphotericin B. The most common cause of primary acute kidney injury in children in North America is hemolytic uremic syndrome. Acute poststreptococcal glomerulonephritis, although common in children, rarely leads to acute kidney injury severe enough to warrant dialysis.

What are the causes of chronic kidney disease in children?

The causes of CKD are different in children than in adults. About two thirds of the cases in children are caused by congenital urinary tract anomalies, such as posterior urethral valves, obstructive uropathy, reflux nephropathy, renal dysplasia, and neurogenic bladder associated with spina bifida, or hereditary diseases, including cystinosis, hyperoxaluria, and autosomal recessive polycystic kidney disease. The other one third of cases in children are caused by acquired kinds of glomerulonephropathy, such as focal segmental glomerulosclerosis or membranoproliferative glomerulonephritis. Unlike CKD in adults, diabetic nephropathy, chronic hypertension, autosomal dominant polycystic kidney disease, and membranous glomerulonephritis are rarely causes of CKD in childhood and adolescence.

When is hemodialysis the right choice for pediatric patients requiring chronic replacement therapy?

The preferred modality of treatment for most pediatric patients who require maintenance dialysis is renal transplantation. If a pediatric patient needs chronic dialysis, home peritoneal dialysis is the usual choice, but may not always be possible. Some family situations are unable to support chronic peritoneal dialysis. Some patients may have lost peritoneal function from previous abdominal surgery or peritonitis. Currently younger children, including infants and toddlers with CKD, who have failed peritoneal dialysis and who are not yet eligible for transplantation or who are waiting on the deceased donor transplantation list, require chronic hemodialysis. The U.S. Renal Data System found that, in 2007, there were 1263 prevalant hemodialysis patients, 877 peritoneal dialysis patients, and 5396 transplant patients who were 19 years or younger. Technical advances in equipment and vascular access catheters have made chronic hemodialysis possible even in small children. Some adolescents may choose hemodialysis because of concerns about body image or their ability to comply with the discipline of chronic peritoneal dialysis and the need for daily treatment.

What is the significance of body surface area to renal function in pediatrics?

Normal serum creatinine concentration increases with age and body mass. The normal serum creatinine level in a 2-year-old is 0.4 mg/dL, whereas in an adult it is about 1.0 mg/dL. If it were 1.0 mg/dL in a 2-year-old, that child would have renal failure with about a 60% reduction in renal function. To compare parameters of renal function in different-size pediatric patients from infancy to adolescence, creatinine clearance and other measures of glomerular filtration rate are usually normalized to the average adult body surface area of 1.73 m². The normal range for creatinine clearance in a pediatric patient older than 2 years is 100 to 120 mL/min/1.73 m². When the creatinine clearance decreases to less than 10 mL/min/1.73 m², the pediatric patient has stage 5 chronic kidney disease.

Is there a preferred measure of weight for children?

The preferred measure of weight for children is metric because most therapies are prescribed per weight in kilograms. Consistent use of the metric system to measure weight in children lessens calculation error. If a kilogram scale is not available, convert pounds to kilograms by dividing by a factor of 2.2.

Are there particular considerations when choosing a hemodialysis station location for the child dialyzing in an integrated pediatric and adult care facility?

Because of the higher dependency of the pediatric hemodialysis patient, especially those weighing less than 35 kg, the station for hemodialysis should be within easy access and centrally visible. In the event of an emergency in another patient, every effort should be made to protect the child from viewing the stressful event.

Do children ever require isolation?

Communicable diseases, such as varicella (chickenpox), are common in childhood. In addition to isolation for blood-borne pathogens, children may need to be isolated during periods when they are at risk of manifesting communicable diseases after recent exposure. Each facility should develop general recommendations for isolation for children exposed to communicable diseases like varicella to avoid exposure of susceptible adult patients.

What is the safe limit for extracorporeal volume in a child?

The safe limit for extracorporeal volume in a child is 10% or less of the child’s blood volume (Table 21-1). This blood is returned to the patient at the end of the treatment, unless it is needed for laboratory tests. In this case, no more than 3% to 5% of the child’s blood volume should be removed on a given day. Many laboratories have microcontainers for blood sampling for small children or use minimal blood volumes for tests to help avoid excess blood loss in pediatric patients.

Table 21-1 Approximate Blood Volume by Age

How does one calculate extracorporeal volume?

Extracorporeal volume is the total volume of the dialyzer plus the bloodlines. Specific values are available from product manufacturers.

Can hemodialysis treatment be done when the extracorporeal volume exceeds the safe limits?

When extracorporeal volume is 10% to 12.5% of blood volume, the system must be primed with a volume expander such as 5% albuminized saline. When extracorporeal volume exceeds 12.5% of blood volume, reconstituted whole blood may be the safest for priming and is imperative when extracorporeal volume is 15% or more. There are specific dialysis products designed to minimize extracorporeal blood volume for small children, and these must be used to avoid the expense and risk of using blood products routinely. The pediatric nephrologist decides how much, if any, of the system prime is returned to the patient at the end of the treatment, based on the patient’s specific albumin or hemoglobin deficit.

How is replacement blood transfusion volume calculated if a pediatric hemodialysis patient suffers an acute blood loss (i.e., clotted system)?

To replace acute blood loss associated with hemodynamic instability, transfuse packed red blood cells at 10 mL/kg body weight or more, depending on the estimated amount of blood lost and the child’s hemoglobin before the loss.