Nursing Assessment, Education, and Care of Extremely Premature Neonates with Patent Ductus Arteriosus.

The care of extremely premature neonates with suspected or confirmed diagnosis of patent ductus arteriosus (PDA) is a frequent challenge for pediatric nurses. It is important for nurses to have adequate knowledge of the normal postnatal changes in cardiovascular and pulmonary function to recognize any adverse symptoms. Nurses caring for these vulnerable neonates must have a thorough understanding of the pathophysiology of a PDA in order to assess, plan, and implement patient-centered care. Recognition of characteristic symptoms of PDA in a timely manner is essential for optimal management and outcomes. Understanding the science behind treatment options is also imperative for pediatric nurses to provide the best care and effectively educate parents. Pediatric nurses are a significant resource in managing extremely premature neonates through comprehensive assessment, effective parent education, and high-quality patient-centered care.

Innovative techniques to decrease blood exposure and minimize interruptions in pediatric continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) allows gradual, precise removal of excess fluid and solutes. Special considerations are necessary for children who require CRRT because of their smaller circulating blood volumes and the potential for hemodynamic instability associated with the initiation of CRRT. In critically ill children, the CRRT circuit is often primed with blood rather than saline to prevent excessive hemodilution. Two innovative techniques have been designed to limit repeated exposure to donated blood, reduce hemodynamic instability associated with priming of the circuit with blood, and limit interruptions in CRRT. A circuit-to-circuit exchange technique offers a safe, effective alternative method for CRRT circuit changes in small children and infants. A concurrent technique that combines CRRT with plasmapheresis is effective in preventing interruptions of therapy when patients require multiple modes of supportive treatment.

Zero balance ultrafiltration (Z-BUF) in blood-primed CRRT circuits achieves electrolyte and acid-base homeostasis prior to patient connection.

Infants requiring CRRT present a unique challenge due to the large circuit volume to blood volume ratio. Blood priming is often used, but some patients can become unstable during the initiation of CRRT due to electrolyte and acid-base imbalance. We postulated that using Z-BUF we could normalize electrolytes and improve the acid base status of the prime prior to patient connection. To test this we set up a circuit using the Baxter BM-25 CRRT pump, a polysulfone or AN-69 membrane, and a three-way stopcock. The circuit was primed with a 60/40 mix of expired autologous donor pRBCs and 5% albumin. The modalities of CVVH, CVVHD, and CVVHDF were compared for relative efficacy. Electrolytes, lactate, pH, cytokines (TNF-alpha, IL-1beta, bradykinin, and IL-6) were measured. Plasma hemoglobin levels were also measured before and after the Z-BUF procedure. Bradykinin production and elimination in AN-69 membrane circuits were assessed. All lab values equilibrated by 35 minutes. All CRRT modalities were equally efficacious for Z-BUF. Cytokine production or significant hemolysis was not found. In addition, no bradykinin accumulation occurred in AN-69 membrane-containing circuits. We conclude that Z-BUF is a simple and effective way to normalize electrolyte and acid-base status in the CRRT circuit when blood priming is required.