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Are We Providing Optimal Pediatric Patient Care in Hemodialysis?
Christy Price Rabetoy, Department Editor
It Is a Dilemma, but Children Can Receive Care in an Adult Dialysis Unit
Louise Elpers, MSN, RN is Staff Nurse, Dialysis Affiliates East
Evansville, IN
Member, ANNA’s Kentuckiana Chapter
Donna McPhee, RN, CNN is Staff Nurse, Dialysis Affiliates East
Evansville, IN
Over the last few years, a dialysis dilemma has been developing.
Namely, children are being admitted into adult hemodialysis programs as
the standard of pediatric care. The situation has caught many nurses,
indeed many on the health care team, unprepared for providing
therapeutic care for children with chronic renal failure. There isn’t a
right or wrong answer for admitting children into adult hemodialysis
programs. However, the decision should be made with the input of the
nephrology nurses. The consequences of admitting these young patients
into an adult unit have implications for the patient and care providers.
Pediatric patients are defined as those patients 0 to 19 years old.
They accounted for less than 1% of the total patient population in
hemodialysis according to the National Kidney Foundation Kidney Disease
Outcome Quality Initiative (NKF-K/DOQI) 2000 Update. The prevalence of
pediatric patients with End Stage Renal Disease (ESRD) has increased
from 860 to 1,284, or 42%, from the 1994-1996 U.S. Renal Disease
Statistics (USRDS) compared to the information released in the 2003
USRDS Annual Report for the year 2001. The incidence of new pediatric
patients on hemodialysis is around 15/million/ year. Comparatively, the
number of new adult patients on ESRD is 122/million/year for people
20-44 years of age. While the numbers of new pediatric patients
entering hemodialysis may seem small, the implications on the ESRD
adult hemodialysis community raise many issues.
Pediatric patients on hemodialysis are settling for treatment in adult
hemodialysis facilities for many reasons, some that are obvious, and
others that are not. At the heart of the simplest argument not to
accommodate children in an adult hemodialysis program is the reality
that children are not small adults. The reasons children present with
renal failure can be very different from the aging processes and adult
diseases that result in adult ESRD. Another argument can be made that
not all nephrology nurses have adequate experience to justify their
place in the care of pediatric patients on hemodialysis. Medication
administration along with the emotional and psychological component
that comes with caring for children is different than for adults. The
NKF-K/DOQI Clinical Practice Guidelines are not as well defined for
children as for adults.
Adult hemodialysis units that agree to include pediatric patients in
their programs need to employ Life Specialists or trained volunteers to
help the child on dialysis with activities during the treatment.
Educational tutors must also be available to meet the needs of the
child. This allows the nursing team to focus on the clinical care of
the pediatric patient. Attention to the specific needs of children
takes on monumental importance in terms of growth, cognitive
development, and school performance, and generally these are not areas
of expertise for nephrology nurses, who exclusively care for adult
patients.
The American Society of Pediatric Nephrology (ASPN) has set priorities
for healthy children on dialysis in their goals for 2003. Establishing
pediatric nephrology programs is imperative and emergent in nature.
However, in the meantime, adult units that accept pediatric patients
must provide the necessary specialists to foster appropriate care for
children. Furthermore, these units must strive to create an environment
that encourages meeting the unique needs of pediatric patients.
References
Age of Children. (2003). Chapter 8, pp. 40, 140. Retrieved at www.usrds.org.com/2003.pdf/08_pediatrics_03.pdf
American Society of Pediatric Nephrology. (2003). Priorities of healthy
children on dialysis. Retrieved at www.aspneph.com/
newsitems.htm/#summary.
Genitourinary and kidney disorders. St. Louis, MO: St. Louis Children’s
Hospital. Retrieved at www.stlouischildrens.org/
articles/kids_parents.
National Kidney Foundation. (2000). K/DOQI update 2000 on adequacy.
Retrieved at www.kidney.org/professionals/
doqi/guidelines/doqiuphd_intro.html.
The dialysis experience: A day in the life of a patient. (2004).
Retrieved at www.kidneycarepartners.org/index.php/dialysis/patient.html.
United States Renal Data System (USRDS). (2003). USRDS annual data
report (p. 81). Washington, DC: Department of Health and Human
Services.
Warady, B.A., et al. (1999, March). Optimal care of the pediatric ESRD
patient on hemodialysis. American Journal of Kidney Disease, 33(3):
567-583. Retrieved from the National Library of Medicine, April 5,
2004. from www.ncbi.nlm.nih.gov/entrez/ query.
It’s Better to Hemodialyze Children in a Pediatric Dialysis Unit
Cyrena Gilman, MN, RN, CNN is Manager, Clinical Operations, Pediatric Dialysis
Riley Hospital for Children
Indianapolis, IN
Member, ANNA’s Hoosier Hills Chapter
As we all know, children aren’t
just small adults; they come in widely differing sizes, and have
different physiological and psychological needs based on their size and
developmental level. Any unit that undertakes hemodialysis of children
must be prepared to meet these varying needs.
Most patients on hemodialysis can safely spare 10% or less of their
total circulating blood volume to an extracorporeal circuit
(Kjellstrand et. al., 1971), which is challenging in the smaller
patient. Smaller bodies also need less clearance so a smaller
artificial kidney membrane surface area, and slower blood pump speeds
(400 ml/min/1.73m2) are appropriate (Goldstein & Jabs, 2004).
Different sizes of artificial kidney and bloodlines can be matched to
create an extracorporeal circuit of a desired volume and efficiency. Of
course, smaller dialyzers and bloodlines are more expensive than
adult-sized ones.
It’s hard to determine “dry weight” in children. They have a higher
total body water to body mass ratio. This ratio varies with age and
growth. Furthermore, food and fluid consumed varies widely from day to
day. Thus, the UF goal will change with each dialysis. A dialysis unit
needs volumetric hemodialysis machines and non-invasive volumetric
measuring (NIVM) devices to ensure optimal fluid removal during each
hemodialysis treatment (Goldstein & Jabs, 2004).
Dose of dialysis and all medications need to be administered based on
the patient’s dry weight. The typical adult “standard dose” of
medication does not exist in pediatrics – unless you are talking about
mg/kg of body weight. A dialysis unit should meet children’s
psychosocial needs as well as their physical needs. It is essential to
establish a child-friendly environment that acknowledges that children
have different interests than adults, and provides supplies and
equipment for many different types of play and diversions. Just parking
a TV in front of the child is not sufficient; interactions between
children, family members and staff are crucial. Furniture, including
toilets and sinks, that fits many different sizes, or adaptive devices
to permit use by all sizes of patient is very important (Gilman &
Frauman, 1998).
Another part of psychosocial care is involving children in their own
care. They should give their assent for and participate in their
treatment at a developmentally appropriate level, or at the very least
cooperate while someone else performs the treatment. Like adults,
children need to feel that they have some control over their
environment (Gilman & Frauman, 1998).
Patient safety must be a primary consideration when dialyzing
children. Preventing falls; limiting children’s access to sharp
instruments, electrical cords and hazardous chemicals; and isolating
infectious patients are just a few pediatric patient safety issues.
Keeping an active younger child safe can be a difficult task.
Every dialysis unit needs a renal dietitian and a social worker with
renal experience, but those working with children and their families
need additional skills and training to be most helpful. In addition, a
Child Life specialist and a teacher can really help the child progress
toward their appropriate developmental milestones. A psychologist with
expertise in human growth and development can also help recognize which
child needs assistance achieving milestones, and identify what
interventions will facilitate that progress. The nurse to patient ratio
should be 1:1, or at least 1:2 for appropriate clinical care,
especially of nonverbal children. Finally, if the physician in charge
of the child’s renal care is not a pediatric nephrologist, regular
consultations with a pediatrician or pediatric nephrologist should be
arranged so that pediatric concerns, such as growth rate or
immunizations, are not overlooked.
Pediatric dialysis, especially hemodialysis of smaller children, is not
cost effective. Units reimbursed on an adult dialysis composite rate
will probably not break even. Units dialyzing children need to be aware
of alternatives to deal with that financial reality.
The challenges identified here make dialysis of pediatric patients
fairly difficult for a dialysis unit that is primarily for adult
patients. It takes significantly more planning, more staff, and more
finances to be successful in this endeavor. Therefore, preferably
children are better hemodialyzed in a pediatric dialysis unit.
References
Gilman, C.M., & Frauman, A.C. (1998). The pediatric patient. In J.
Parker (Ed.) Contemporary nephrology nursing. Pittman: American
Nephrology Nurses’ Association.
Goldstein, S.L., & Jabs, K. (2004). Hemodialysis. In E.D.
Avner, W. E. Harmon, & P. Niaudet (Eds.), Pediatric Nephrology (5th
ed.) (pp. 1395-1410). Philadelphia: Lippincott Williams and Wilkins.
Kjellstrand, C.M., Shideman, J.R., Santiago, E.A., Mauer, S.M.,
Simmons, R.L., & Buselmeier, T.J. (1971). Technical advances in
hemodialysis of very small pediatric patients. Proceedings of the
Dialysis and Transplant Forum, 124-132.
The Controversies in Nephrology Nursing
department focuses on exploring ethical and clinical issues within the
nephrology clinic practice in a point/counterpoint format. Address
correspondence to: Christy Price Rabetoy, Department Editor, through
the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ
08071-0056; (856) 256-2320; or by emailing her at
christycpr@comcast.net. You may also log onto this column at
www.nephrologynursingjournal.net (clink on Department link) and email
your comments to the Editor (see Discussion Area). The opinions and
assertions contained herein are the private views of the contributors
and do not necessarily reflect the views of the American Nephrology
Nurses' Association.
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Copyright 2004, American Nephrology Nurses' Association. Anthony J. Jannetti, Inc., publisher. An iNurse Web site.
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