Current Technology for Current Technology for

CRRTCRRT

Dr. Peter Skippen, PICU. BC Children’s Hospital,Dr. Peter Skippen, PICU. BC Children’s Hospital,

Vancouver. CANADA.Vancouver. CANADA.

CRRT TechnologyCRRT Technology

OutlineOutline

• The ideal CRRT machineThe ideal CRRT machine

• Hardware optionsHardware options

– HomemadeHomemade

– Dedicated fully integratedDedicated fully integrated

• ConclusionsConclusions

CRRT TechnologyCRRT Technology

The Ideal Machine for CRRT: IThe Ideal Machine for CRRT: I

• Inexpensive / user friendly / flexibleInexpensive / user friendly / flexible

• Accurate / dedicated pumpsAccurate / dedicated pumps

• Accurate scalesAccurate scales

• Blood flows 5-300mls/minBlood flows 5-300mls/min– increments of 1 ml/minincrements of 1 ml/min

• Continuous independent flow measurementsContinuous independent flow measurements

• Servo controlledServo controlled

• ThermoregulationThermoregulation

• Full range of safety featuresFull range of safety features

CRRT TechnologyCRRT Technology

The Ideal Machine for CRRT: IIThe Ideal Machine for CRRT: II

• Safety featuresSafety features

– Audible / visual alarms with over-rideAudible / visual alarms with over-ride

– Air / clot detectorsAir / clot detectors

– Blood leak detectorsBlood leak detectors

– Continuous display of circuit pressuresContinuous display of circuit pressures

– Continuous Uf urea concentrationContinuous Uf urea concentration

– Continuous circuit HctContinuous circuit Hct

• Minimal alarms - maximum patient safetyMinimal alarms - maximum patient safety

CRRT TechnologyCRRT Technology

The Ideal Circuit for CRRTThe Ideal Circuit for CRRT

• Minimal priming volume / low resistanceMinimal priming volume / low resistance

• Easy priming / recirculation procedureEasy priming / recirculation procedure

• Exchangeable componentsExchangeable components

• BiocompatibleBiocompatible– Non inflammatoryNon inflammatory

– Hemodynamic stabilityHemodynamic stability

– Non thrombogenicNon thrombogenic

CRRT TechnologyCRRT Technology

Integrated Hardware OptionsIntegrated Hardware Options

• Home made devicesHome made devices• Dedicated “all in one” machineDedicated “all in one” machine

– Edwards M 25Edwards M 25– PRISMAPRISMA– Braun DIAPACTBraun DIAPACT

– Fresenius Fresenius

• 2 integrated modules2 integrated modules

– Blood module (BM 11)Blood module (BM 11)

– Balancing module / Balancing module / scales (BM 14)scales (BM 14)

Edwards BM 25Edwards BM 25

Edwards BM 25: Edwards BM 25: Blood Pump ModuleBlood Pump Module

• Blood monitorBlood monitor

– pediatric flows:pediatric flows:

• 5 - 150mls / min5 - 150mls / min

– Increments of 1mlIncrements of 1ml

Edwards BM 25: Edwards BM 25: Effluent / Replacement Pump ModuleEffluent / Replacement Pump Module

• Balancing monitorBalancing monitor– Substitution pump / filtrate pumpSubstitution pump / filtrate pump

– Integrated scales: claimed accuracy Integrated scales: claimed accuracy 1% (20mls in 2000mls)1% (20mls in 2000mls)

– Replacement fluid heaterReplacement fluid heater

– TMP monitorTMP monitor

– Operational rangesOperational ranges• Replacement fluid 100- 9000mls / Replacement fluid 100- 9000mls /

hr (100ml increments)hr (100ml increments)

• Filtrate pump 100 - 11,000mls / hrFiltrate pump 100 - 11,000mls / hr

• Net UFR 0.1 - 2000mls / hrNet UFR 0.1 - 2000mls / hr

CRRT TechnologyCRRT Technology

Edwards BM 25: AdvantagesEdwards BM 25: Advantages

• Relatively lower costRelatively lower cost

• SimplicitySimplicity– Easy primingEasy priming

• FlexibilityFlexibility– Separate arterial / venous tubingSeparate arterial / venous tubing

– Use any filterUse any filter

– Neonate to adultNeonate to adult

– Any treatment option Any treatment option

• with modificationwith modification

• With loss of simplicityWith loss of simplicity

• Replacement fluid warmerReplacement fluid warmer

CRRT TechnologyCRRT Technology

EdwardsEdwards BM 25: Disadvantages BM 25: Disadvantages

• Only 3 pumpsOnly 3 pumps– For CVVHDF, extra pump creates For CVVHDF, extra pump creates

problemsproblems

• Does not calculate FFDoes not calculate FF

• No screenNo screen

• Troubleshooting requires training!Troubleshooting requires training!

• Blood / air interface with bubble trap?Blood / air interface with bubble trap?

PRISMA CRRT MachinePRISMA CRRT Machine

• Touch screenTouch screen

• Complete range of therapiesComplete range of therapies

• 3 weighing scales 3 weighing scales

– accuracy < +/- 0.5%accuracy < +/- 0.5%

• Custom filter / circuitryCustom filter / circuitry

PRISMA CRRT Machine: Basic LayoutPRISMA CRRT Machine: Basic Layout

ReplacementReplacement

DialysateDialysate

EffluentEffluent

BloodBlood

Heparin Heparin Syringe PumpSyringe Pump

Pressure Pods

Scales x 3Scales x 3

PRISMA ScreenPRISMA Screen

PRISMA ScreenPRISMA Screen

CRRT TechnologyCRRT Technology

• User friendly interfaceUser friendly interface

• Step by step instructionsStep by step instructions

• Continuous display of treatment Continuous display of treatment conditionsconditions

• Easy / rapid institution of Easy / rapid institution of therapies (self prime)therapies (self prime)

• Continuous 24 hour recording of Continuous 24 hour recording of treatment historytreatment history

• Alarm explanationsAlarm explanations

PRISMA Machine: AdvantagesPRISMA Machine: Advantages

CRRT TechnologyCRRT Technology

• Need for company specific filterNeed for company specific filter

• Relatively high costRelatively high cost

• Limited blood flow rangesLimited blood flow ranges

• Can’t change therapies mid-courseCan’t change therapies mid-course

• Scales sensitive to knockingScales sensitive to knocking

• Learning curve - don’t they all?Learning curve - don’t they all?

PRISMA Machine: Dis-advantagesPRISMA Machine: Dis-advantages

CRRT TechnologyCRRT Technology

• Compact, self contained, flexibleCompact, self contained, flexible

• High resolution screenHigh resolution screen

• 3 pumps3 pumps– Blood flow 10-500mls/minBlood flow 10-500mls/min

– Dialysate - substitution flow 0-250 mls/minDialysate - substitution flow 0-250 mls/min

– UFR 0-300mls/minUFR 0-300mls/min

• Automatic priming procedureAutomatic priming procedure

• Substitution fluid warmerSubstitution fluid warmer

• Full range of therapiesFull range of therapies

• Battery powerBattery power

Diapact CRRTDiapact CRRT

CRRT TechnologyCRRT Technology

Clinical IssuesClinical Issues

• BiocompatabilityBiocompatability

• Hemodynamic stabilityHemodynamic stability

CRRT TechnologyCRRT Technology

ConclusionsConclusions

• Improving technologyImproving technology

• Ideal machines / circuits?Ideal machines / circuits?

• Issues to be resolvedIssues to be resolved

– Biocompatability / ThrombogenicityBiocompatability / Thrombogenicity

– FlexibilityFlexibility

– VersatilityVersatility

– CostCost