1 prismaflex crrt intro - seg 1 (2007)

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Page 1: 1   prismaflex crrt intro - seg 1 (2007)

PrismaFlex STEPP

Basic CRRT Principles

®

Page 2: 1   prismaflex crrt intro - seg 1 (2007)

Course ObjectivesBy the end of the Gambro CRRT training course

the participant will be able to:

• Define CRRT and the associated therapies

• Discuss the basic CRRT principles

• Discuss the basic principles of the solute transport mechanisms

• Identify the clinical indications for administering CRRT, including

an overview of patient selection and therapy application

• Have a working knowledge of basic CRRT machine set up, run, end

treatment and troubleshooting skills.

• Describe the CRRT machine’s safety management features,

pressure monitoring and fluid balance principles.

Page 3: 1   prismaflex crrt intro - seg 1 (2007)

Continuous Renal Replacement Therapy (CRRT)

““Any extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours/day.”

Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, Nov 1996

Page 4: 1   prismaflex crrt intro - seg 1 (2007)

CRRT closely mimics the native kidney in treating ARF and fluid overload

Why CRRT?

Removes large amounts of fluid and waste products over time

Tolerated well by hemodynamically unstable patients

Page 5: 1   prismaflex crrt intro - seg 1 (2007)

CRRT Treatment Goals

Maintain fluid, electrolyte, acid/base balance

Prevent further damage to kidney tissue

Promote healing and total renal recovery

Allow other supportive measures; nutritional

support

Page 6: 1   prismaflex crrt intro - seg 1 (2007)

Determinants of Outcome

Initiation of Therapy• Ronco Study• Gettings Study• ADQI Consensus Initiative - Rifle Criteria

Dose• Ronco Study• Kellum Meta-Analysis• Saudan Study

Page 7: 1   prismaflex crrt intro - seg 1 (2007)

Risk

Injury

Failure

Loss

ESRD

GFR Criteria Urine Output Criteria

Increased creatinine x 1.5 or GFR decrease >25% UO <,0.5ml/kg/hr x 6 hours

Increased creatinine x 2 or GFR decrease >50%

UO <0.5 ml/kg/hr x 12 hours

Increased creatinine x 3 or GFR decrease >75% or

Serum Creatinine > 4mg/dlUO <0.3 ml/kg/hr x 24 hours

or anuria x 12 hours

Persistent ARF= complete loss of renal function >4 weeks

End-stage renal disease (>3 months)

EarlyInitiation

Page 8: 1   prismaflex crrt intro - seg 1 (2007)

Summary Evidenced Based Research reports that

patient survival is improved by:

•Early initiation: •Utilization of RIFLE Criteria

•Minimum dose delivery of 35 ml/kg/hr • eg. 70 kg patient = 2450 ml/h

Effects of different doses in CVVH on outcomes of ARF – C. Ronco M.D., R. Bellomo M.D. Lancet 2000; 356:26-30.

Page 9: 1   prismaflex crrt intro - seg 1 (2007)

Anatomy of a Hemofilter

• 4 External ports • blood and dialysis fluid

• Potting material • support structure

• Hollow fibers • Semi-permeable

membrane

• Outer casing

Page 10: 1   prismaflex crrt intro - seg 1 (2007)

CRRT Transport Mechanisms

Page 11: 1   prismaflex crrt intro - seg 1 (2007)

Molecular Transport Mechanisms

Ultrafiltration

Diffusion

Convection

Adsorption

Fluid Transport

Solute Transport}

Page 12: 1   prismaflex crrt intro - seg 1 (2007)

Ultrafiltration

•Movement of fluid through a semi-permeable membrane caused by a pressure gradient

•Positive, negative and osmotic pressure from non-permeable solutes

Page 13: 1   prismaflex crrt intro - seg 1 (2007)

Blood Out

Blood Into waste

(to patient)

(From patient)

HIGH PRESSLOW PRESS

Fluid VolumeReduction

Ultrafiltration

Page 14: 1   prismaflex crrt intro - seg 1 (2007)

Molecular WeightsDaltons

• Inflammatory Mediators (1,200-40,000)

“small”

“middle”

“large”

Page 15: 1   prismaflex crrt intro - seg 1 (2007)

Diffusion

•Movement of solutes from an area of higher concentration to an area of lower concentration.

•Dialysate is used to create a concentration gradient across a semi-permeable membrane.

Page 16: 1   prismaflex crrt intro - seg 1 (2007)

Hemodialysis: Diffusion

Dialysate In

Dialysate Out(to waste)

Blood Out

Blood In

(to patient)

(from patient)

HIGH CONCLOW CONC

Page 17: 1   prismaflex crrt intro - seg 1 (2007)

Convection

•Movement of solutes with water flow, “solvent drag”.

•The more fluid moved through a semi-permeable membrane, the more solutes that are removed.

•Replacement Fluid is used to create convection

Page 18: 1   prismaflex crrt intro - seg 1 (2007)

to waste

HIGH PRESSLOW PRESS

Repl.Repl.SolutionSolution

Hemofiltration: Convection

Blood Out

Blood In

(to patient)

(from patient)

Page 19: 1   prismaflex crrt intro - seg 1 (2007)

Electrolytes & pH Balance

Another primary goal for CRRT, specifically:• Sodium• Potassium• Calcium• Glucose• Phosphate• Bicarbonate or lactate buffer

Dialysate and replacement solutions are used in CRRT to attain this goal.

Page 20: 1   prismaflex crrt intro - seg 1 (2007)

Adsorption

Molecular adherence to the surface or interior of the membrane.

Page 21: 1   prismaflex crrt intro - seg 1 (2007)

0

20

40

60

80

100

Cle

aran

ce in

%

35.000 55.00020.0005.0002.500Urea(60)

Albumin(66.000)

Myoglobin(17.000)

65.000Creatinine

(113)

Kidney

Convection

Diffusion

Small vs. Large Molecules Clearance

Page 22: 1   prismaflex crrt intro - seg 1 (2007)

What is the transport mechanism associated

with dialysate and replacement solutions?

Page 23: 1   prismaflex crrt intro - seg 1 (2007)

Effluent

Pre Blood Pump Replacement: Convection

Blood

Flow Control Unit – Pumps

Dialysate: Diffusion

Page 24: 1   prismaflex crrt intro - seg 1 (2007)

Effluent Flow Rate

Effluent = Total Fluid Volume:

•Patient Fluid Removal•Dialysate Flow•Replacement Flow•Pre-Blood Pump Flow

Page 25: 1   prismaflex crrt intro - seg 1 (2007)

CRRT Modes of Therapy

SCUF - Slow Continuous Ultrafiltration

CVVH - Continuous Veno-Venous Hemofiltration

CVVHD - Continuous Veno-Venous HemoDialysis

CVVHDF - Continuous Veno-Venous HemoDiaFiltration

Page 26: 1   prismaflex crrt intro - seg 1 (2007)

SCUFSlow Continuous UltraFiltration

Primary therapeutic goal:•Safe and effective management of

fluid removal from the patient

Page 27: 1   prismaflex crrt intro - seg 1 (2007)

SCUFSlow Continuous UltraFiltration

EffluentPump

Infusion or Anticoagul

ant

Blood Pump

PBPPump

Effluent

Access

Return

Page 28: 1   prismaflex crrt intro - seg 1 (2007)

CVVHDContinuous VV HemoDialysis

Primary therapeutic goal:• Small solute removal by diffusion• Safe fluid volume management

Dialysate volume automatically removed through the Effluent pump

Solute removal determined by Dialysate Flow Rate.

Page 29: 1   prismaflex crrt intro - seg 1 (2007)

CVVHDContinuous VV HemoDialysis

Hemofilter

EffluentPump

Effluent

Access

Return

DialysatePump

Dialysate

Fluid

Blood Pump

Infusion or Anticoagul

ant

PBPPump

Page 30: 1   prismaflex crrt intro - seg 1 (2007)

Dialysate Solutions

• Flows counter-current to blood flow

• Remains separated by a semi-permeable membrane

• Drives diffusive transport • dependent on concentration gradient and flow rate

• Facilitates removal of small solutes

• Physician prescribed

• Contains physiologic electrolyte levels

• Components adjusted to meet patient needs

Page 31: 1   prismaflex crrt intro - seg 1 (2007)

CVVH: Continuous VV Hemofiltration

Primary Therapeutic Goal: • Removal of small, middle and large sized solutes • Safe fluid volume management

• Replacement solution is infused into blood compartment pre or post filter• Drives convective transport• Replacement fluid volume automatically removed

by effluent pump

Solute removal determined by Replacement Flow Rate.

Page 32: 1   prismaflex crrt intro - seg 1 (2007)

CVVHContinuous VV Hemofiltration

EffluentPump

Blood Pump

Effluent

Access

Return

ReplacementPump 1

Replacement

Pump 2

Replacement 1

Replacement 2

Infusion or Anticoagul

ant

PBPPump

Page 33: 1   prismaflex crrt intro - seg 1 (2007)

Pre-Dilution Replacement Solution

•Decreases risk of clotting

•Higher UF capabilities

•Decreases Hct. In filter

Hemofilter

EffluentPump

Blood Pump

PBPPump

Effluent

Access

Return

ReplacementPump

Replacement

Fluid

Infusion or Anticoagul

ant

Page 34: 1   prismaflex crrt intro - seg 1 (2007)

Post-Dilution Replacement Solution

•Consider lowering replacement rates (filtration %)

•Higher BFR (filtration %)

•Higher anticoagulation

•More efficient clearance (>15%)

Hemofilter

EffluentPump

Blood Pump

Effluent

Access

Return

ReplacementPump

Replacement

Fluid

ReplacementPump

Replacement

Fluid

PBPPump

Infusion or Anticoagul

ant

Page 35: 1   prismaflex crrt intro - seg 1 (2007)

Replacement Solutions

• Infused directly into the blood at points along the blood pathway

• Drives convective transport• Facilitates the removal of small middle and

large solutes• Physician Prescribed • Contains electrolytes at physiological levels • Components adjusted to meet patient needs

Page 36: 1   prismaflex crrt intro - seg 1 (2007)

CVVHDFPrimary therapeutic goal:

• Solute removal by diffusion and convection• Safe fluid volume management• Efficient removal of small, middle and large

molecules

Replacement and dialysate fluid volume automatically removed by effluent pump

Solute removal determined by Replacement + Dialysate Flow Rates.

Page 37: 1   prismaflex crrt intro - seg 1 (2007)

CVVHDFContinuous VV HemoDiaFiltration

EffluentPump

Effluent

Access

Return

DialysatePump

Dialysate

Fluid

Blood Pump

ReplacementPump

Replacement

Fluid

PBPPump

Infusion or Anticoagul

ant