Pediatric CRRT Settings

Blood Flow Rate Settings

The American Academy of Pediatrics recommends blood flow rates for pediatric CRRT should be tailored according to patient size, with rates of 3-6 mL/kg/min 1
Higher blood flow rates improve filter longevity but must be balanced against hemodynamic stability of the patient 2
Access limitations, such as catheter size, and risk of excessive hemoconcentration should also be considered when determining blood flow rates 1, 3

The recommended replacement fluid rate for pediatric CRRT is 20-25 mL/kg/hr, according to the American College of Critical Care Medicine 1
For septic patients or those with high catabolic states, consider higher rates of 30-35 mL/kg/hr 2
Pre-dilution fluid administration is preferred for patients with frequent filter clotting or limited extracorporeal clearance 1

For CVVHD or CVVHDF modalities, dialysate flow rates should be 20-25 mL/kg/hr, as recommended by the American Society of Nephrology 1
Dialysate composition should use bicarbonate rather than lactate as buffer, especially in patients with circulatory shock, liver failure, or lactic acidemia 1
For small children, the dialysate rate may need to be adjusted to maintain acid-base balance and electrolyte homeostasis 2

Target a gradual reduction in fluid overload status, especially in hemodynamically unstable patients, as recommended by the American College of Critical Care Medicine 2

For neonates, an instilled volume of at least 1,100 mL/m² is recommended, according to the American Academy of Pediatrics 4

Monitor delivered dose frequently to ensure prescribed dose is achieved, and assess filter performance regularly to achieve electrolyte balance, acid-base balance, solute clearance, and fluid balance, as recommended by the American Society of Nephrology 1
Monitor for common complications, including electrolyte abnormalities, hemodynamic instability, and hypothermia 2, 5

The American Academy of Pediatrics and critical care societies recommend that after shock resuscitation, high-flux CRRT should be used for patients who are ≥10% fluid overloaded and unable to maintain fluid balance with native urine output/extrarenal losses 6, 7, 8
For critically ill children, fluid removal should be guided by clinical endpoints including perfusion, central venous pressure, echocardiographic determination of end-diastolic volume, and maintenance of normal perfusion pressure for age 6

Monitor the following parameters to ensure safe fluid removal: hemodynamic stability with maintenance of normal perfusion and blood pressure, urine output >1 mL/kg/h, normal mental status, cardiac index >3.3 and <6.0 L/min/m², ScvO₂ >70%, capillary refill ≤2 seconds, and normal pulses with no differential between peripheral and central pulses 6, 7, 8

Fluid removal should be adjusted based on hemodynamic tolerance, with close monitoring for signs of decreased perfusion, and for patients with septic shock, consider initiating CRRT within 48 hours of admission, as earlier initiation has been associated with better survival (61% vs 33%) 9, 10, 11
Avoid rapid fluid removal that could precipitate hemodynamic instability, particularly in patients with cardiac dysfunction or vasopressor dependence, and avoid high-volume hemofiltration (>35 mL/kg/hr) as it has not shown mortality benefit over standard hemofiltration rates and may increase the risk of complications such as hyperglycemia 9, 10