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PrismaFlex  STEPP Basic CRRT Principles ®
Course Objectives <ul><li>By the end of the Gambro CRRT training course  </li></ul><ul><li>the participant will be able to...
Continuous Renal Replacement Therapy (CRRT) “ “ Any extracorporeal blood purification therapy intended to substitute for i...
Why CRRT? <ul><li>Removes large amounts of fluid and waste products over time </li></ul><ul><li>Tolerated well by hemodyna...
CRRT Treatment Goals <ul><li>Maintain fluid, electrolyte, acid/base balance </li></ul><ul><li>Prevent further damage to ki...
Determinants of Outcome <ul><li>Initiation of Therapy </li></ul><ul><ul><li>Ronco Study </li></ul></ul><ul><ul><li>Getting...
R isk I njury F ailure L oss E SRD GFR Criteria Urine Output Criteria Increased creatinine x 1.5  or GFR decrease >25% UO ...
Cumulative Survival (%) vs Treatment Dose Effects of different doses in CVVH on outcome of ARF -  Ronco & Bellomo study. L...
Summary <ul><li>Evidenced Based Research reports that </li></ul><ul><li>patient survival is improved by: </li></ul><ul><li...
Anatomy of a Hemofilter <ul><li>4 External ports  </li></ul><ul><ul><li>blood and dialysis fluid  </li></ul></ul><ul><li>P...
CRRT  Transport Mechanisms
Molecular Transport Mechanisms <ul><li>Ultrafiltration </li></ul><ul><li>Diffusion </li></ul><ul><li>Convection </li></ul>...
Ultrafiltration <ul><li>Movement of  fluid  through a semi-permeable membrane caused by a pressure gradient </li></ul><ul>...
Ultrafiltration Blood Out Blood In to waste (to patient) (From patient) HIGH PRESS LOW  PRESS Fluid Volume Reduction
Molecular Weights Daltons •   Inflammatory Mediators (1,200-40,000) “ small” “ middle” “ large”
Diffusion <ul><li>Movement of  solutes  from an area of  higher  concentration to an area of  lower  concentration. </li><...
Hemodialysis: Diffusion Dialysate  In Dialysate  Out (to waste) Blood Out Blood In (to patient) (from patient) HIGH CONC L...
Convection <ul><li>Movement of  solutes  with water flow, “solvent drag”. </li></ul><ul><li>The more fluid moved through a...
Hemofiltration: Convection to waste HIGH PRESS LOW  PRESS Repl. Solution Blood Out Blood In (to patient) (from patient)
Electrolytes & pH Balance <ul><li>Another primary goal for CRRT, specifically: </li></ul><ul><ul><li>Sodium </li></ul></ul...
Adsorption <ul><li>Molecular adherence to the surface or interior of the membrane. </li></ul>
Small vs. Large Molecules Clearance 0 20 40 60 80 100 Clearance in % 35.000 55.000 20.000 5.000 2.500 Urea (60) Albumin (6...
What is the transport mechanism associated with dialysate and replacement solutions?
Flow Control Unit – Pumps Effluent Pre Blood Pump Replacement: Convection Blood Dialysate: Diffusion
Effluent Flow Rate <ul><li>Effluent = Total Fluid Volume: </li></ul><ul><ul><li>Patient Fluid Removal </li></ul></ul><ul><...
CRRT Modes of Therapy <ul><li>SCUF  -  Slow Continuous Ultrafiltration </li></ul><ul><li>CVVH   -  Continuous Veno-Venous ...
SCUF Slow Continuous UltraFiltration <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Safe and effective management...
SCUF Slow Continuous UltraFiltration Effluent Pump Infusion or Anticoagulant Blood Pump PBP Pump Effluent Access Return
CVVHD Continuous VV HemoDialysis   <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Small solute removal by diffusi...
CVVHD Continuous VV HemoDialysis Hemofilter Effluent Pump Effluent Access Return Dialysate Pump Dialysate Fluid Blood Pump...
Dialysate Solutions <ul><li>Flows counter-current to blood flow  </li></ul><ul><li>Remains separated by a semi-permeable m...
CVVH : Continuous VV Hemofiltration   <ul><li>Primary Therapeutic Goal:  </li></ul><ul><ul><li>Removal of small, middle an...
CVVH Continuous VV Hemofiltration Effluent Pump Blood Pump Effluent Access Return Replacement Pump 1 Replacement Pump 2 Re...
Pre-Dilution   Replacement Solution <ul><li>Decreases risk of clotting </li></ul><ul><li>Higher UF capabilities </li></ul>...
Post-Dilution Replacement Solution <ul><li>Consider  lowering replacement rates  (filtration %) </li></ul><ul><li>Higher B...
Replacement Solutions <ul><li>Infused directly into the blood at points along the blood pathway </li></ul><ul><li>Drives c...
CVVHDF <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Solute removal by diffusion and convection </li></ul></ul><...
CVVHDF Continuous VV  H emo D ia F iltration Effluent Pump Effluent Access Return Dialysate Pump Dialysate Fluid Blood Pum...
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1 prismaflex crrt intro - seg 1 (2007)

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Transcript of "1 prismaflex crrt intro - seg 1 (2007)"

  1. 1. PrismaFlex STEPP Basic CRRT Principles ®
  2. 2. Course Objectives <ul><li>By the end of the Gambro CRRT training course </li></ul><ul><li>the participant will be able to: </li></ul><ul><li>Define CRRT and the associated therapies </li></ul><ul><li>Discuss the basic CRRT principles </li></ul><ul><li>Discuss the basic principles of the solute transport mechanisms </li></ul><ul><li>Identify the clinical indications for administering CRRT, including an overview of patient selection and therapy application </li></ul><ul><li>Have a working knowledge of basic CRRT machine set up, run, end treatment and troubleshooting skills. </li></ul><ul><li>Describe the CRRT machine’s safety management features, pressure monitoring and fluid balance principles. </li></ul>
  3. 3. 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
  4. 4. Why CRRT? <ul><li>Removes large amounts of fluid and waste products over time </li></ul><ul><li>Tolerated well by hemodynamically unstable patients </li></ul>CRRT closely mimics the native kidney in treating ARF and fluid overload
  5. 5. CRRT Treatment Goals <ul><li>Maintain fluid, electrolyte, acid/base balance </li></ul><ul><li>Prevent further damage to kidney tissue </li></ul><ul><li>Promote healing and total renal recovery </li></ul><ul><li>Allow other supportive measures; nutritional support </li></ul>
  6. 6. Determinants of Outcome <ul><li>Initiation of Therapy </li></ul><ul><ul><li>Ronco Study </li></ul></ul><ul><ul><li>Gettings Study </li></ul></ul><ul><ul><li>ADQI Consensus Initiative - Rifle Criteria </li></ul></ul><ul><li>Dose </li></ul><ul><ul><li>Ronco Study </li></ul></ul><ul><ul><li>Kellum Meta-Analysis </li></ul></ul><ul><ul><li>Saudan Study </li></ul></ul>
  7. 7. R isk I njury F ailure L oss E SRD 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/dl UO <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) Early Initiation
  8. 8. Cumulative Survival (%) vs Treatment Dose Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00 100 90 80 70 60 50 40 30 20 10 0 Group 1(n=146) ( Uf = 20 ml/h/Kg) Group 2 (n=139) ( Uf = 35 ml/h/Kg) Group 3 (n=140) ( Uf = 45 ml/h/Kg) 41 % 57 % 58 % p < 0.001 p n..s. p < 0.001 Survival (%)
  9. 9. Summary <ul><li>Evidenced Based Research reports that </li></ul><ul><li>patient survival is improved by: </li></ul><ul><li>Early initiation: </li></ul><ul><ul><li>Utilization of RIFLE Criteria </li></ul></ul><ul><li>Minimum dose delivery of 35 ml/kg/hr </li></ul><ul><ul><li>eg. 70 kg patient = 2450 ml/h </li></ul></ul>Effects of different doses in CVVH on outcomes of ARF – C. Ronco M.D., R. Bellomo M.D. Lancet 2000; 356:26-30.
  10. 10. Anatomy of a Hemofilter <ul><li>4 External ports </li></ul><ul><ul><li>blood and dialysis fluid </li></ul></ul><ul><li>Potting material </li></ul><ul><ul><li>support structure </li></ul></ul><ul><li>Hollow fibers </li></ul><ul><ul><li>Semi-permeable membrane </li></ul></ul><ul><li>Outer casing </li></ul>
  11. 11. CRRT Transport Mechanisms
  12. 12. Molecular Transport Mechanisms <ul><li>Ultrafiltration </li></ul><ul><li>Diffusion </li></ul><ul><li>Convection </li></ul><ul><li>Adsorption </li></ul>Fluid Transport Solute Transport }
  13. 13. Ultrafiltration <ul><li>Movement of fluid through a semi-permeable membrane caused by a pressure gradient </li></ul><ul><li>Positive, negative and osmotic pressure from non-permeable solutes </li></ul>
  14. 14. Ultrafiltration Blood Out Blood In to waste (to patient) (From patient) HIGH PRESS LOW PRESS Fluid Volume Reduction
  15. 15. Molecular Weights Daltons • Inflammatory Mediators (1,200-40,000) “ small” “ middle” “ large”
  16. 16. Diffusion <ul><li>Movement of solutes from an area of higher concentration to an area of lower concentration. </li></ul><ul><li>Dialysate is used to create a concentration gradient across a semi-permeable membrane. </li></ul>
  17. 17. Hemodialysis: Diffusion Dialysate In Dialysate Out (to waste) Blood Out Blood In (to patient) (from patient) HIGH CONC LOW CONC
  18. 18. Convection <ul><li>Movement of solutes with water flow, “solvent drag”. </li></ul><ul><li>The more fluid moved through a semi-permeable membrane, the more solutes that are removed. </li></ul><ul><li>Replacement Fluid is used to create convection </li></ul>
  19. 19. Hemofiltration: Convection to waste HIGH PRESS LOW PRESS Repl. Solution Blood Out Blood In (to patient) (from patient)
  20. 20. Electrolytes & pH Balance <ul><li>Another primary goal for CRRT, specifically: </li></ul><ul><ul><li>Sodium </li></ul></ul><ul><ul><li>Potassium </li></ul></ul><ul><ul><li>Calcium </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Phosphate </li></ul></ul><ul><ul><li>Bicarbonate or lactate buffer </li></ul></ul><ul><li>Dialysate and replacement solutions are used in CRRT to attain this goal. </li></ul>K+ Ca++ Na+ NaCO3
  21. 21. Adsorption <ul><li>Molecular adherence to the surface or interior of the membrane. </li></ul>
  22. 22. Small vs. Large Molecules Clearance 0 20 40 60 80 100 Clearance in % 35.000 55.000 20.000 5.000 2.500 Urea (60) Albumin (66.000) Myoglobin (17.000) 65.000 Creatinine (113) Kidney Convection Diffusion
  23. 23. What is the transport mechanism associated with dialysate and replacement solutions?
  24. 24. Flow Control Unit – Pumps Effluent Pre Blood Pump Replacement: Convection Blood Dialysate: Diffusion
  25. 25. Effluent Flow Rate <ul><li>Effluent = Total Fluid Volume: </li></ul><ul><ul><li>Patient Fluid Removal </li></ul></ul><ul><ul><li>Dialysate Flow </li></ul></ul><ul><ul><li>Replacement Flow </li></ul></ul><ul><ul><li>Pre-Blood Pump Flow </li></ul></ul>
  26. 26. CRRT Modes of Therapy <ul><li>SCUF - Slow Continuous Ultrafiltration </li></ul><ul><li>CVVH - Continuous Veno-Venous Hemofiltration </li></ul><ul><li>CVVHD - Continuous Veno-Venous HemoDialysis </li></ul><ul><li>CVVHDF - Continuous Veno-Venous HemoDiaFiltration </li></ul>
  27. 27. SCUF Slow Continuous UltraFiltration <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Safe and effective management of fluid removal from the patient </li></ul></ul>
  28. 28. SCUF Slow Continuous UltraFiltration Effluent Pump Infusion or Anticoagulant Blood Pump PBP Pump Effluent Access Return
  29. 29. CVVHD Continuous VV HemoDialysis <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Small solute removal by diffusion </li></ul></ul><ul><ul><li>Safe fluid volume management </li></ul></ul><ul><li>Dialysate volume automatically removed through the Effluent pump </li></ul>Solute removal determined by Dialysate Flow Rate .
  30. 30. CVVHD Continuous VV HemoDialysis Hemofilter Effluent Pump Effluent Access Return Dialysate Pump Dialysate Fluid Blood Pump Infusion or Anticoagulant PBP Pump
  31. 31. Dialysate Solutions <ul><li>Flows counter-current to blood flow </li></ul><ul><li>Remains separated by a semi-permeable membrane </li></ul><ul><li>Drives diffusive transport </li></ul><ul><ul><li>dependent on concentration gradient and flow rate </li></ul></ul><ul><li>Facilitates removal of small solutes </li></ul><ul><li>Physician prescribed </li></ul><ul><li>Contains physiologic electrolyte levels </li></ul><ul><li>Components adjusted to meet patient needs </li></ul>
  32. 32. CVVH : Continuous VV Hemofiltration <ul><li>Primary Therapeutic Goal: </li></ul><ul><ul><li>Removal of small, middle and large sized solutes </li></ul></ul><ul><ul><li>Safe fluid volume management </li></ul></ul><ul><li>Replacement solution is infused into blood compartment pre or post filter </li></ul><ul><li>Drives convective transport </li></ul><ul><li>Replacement fluid volume automatically removed by effluent pump </li></ul>Solute removal determined by Replacement Flow Rate .
  33. 33. CVVH Continuous VV Hemofiltration Effluent Pump Blood Pump Effluent Access Return Replacement Pump 1 Replacement Pump 2 Replacement 1 Replacement 2 Infusion or Anticoagulant PBP Pump
  34. 34. Pre-Dilution Replacement Solution <ul><li>Decreases risk of clotting </li></ul><ul><li>Higher UF capabilities </li></ul><ul><li>Decreases Hct. In filter </li></ul>Hemofilter Effluent Pump Blood Pump PBP Pump Effluent Access Return Replacement Pump Replacement Fluid Infusion or Anticoagulant
  35. 35. Post-Dilution Replacement Solution <ul><li>Consider lowering replacement rates (filtration %) </li></ul><ul><li>Higher BFR (filtration %) </li></ul><ul><li>Higher anticoagulation </li></ul><ul><li>More efficient clearance (>15%) </li></ul>Hemofilter Effluent Pump Blood Pump Effluent Access Return Replacement Pump Replacement Fluid Replacement Pump Replacement Fluid PBP Pump Infusion or Anticoagulant
  36. 36. Replacement Solutions <ul><li>Infused directly into the blood at points along the blood pathway </li></ul><ul><li>Drives convective transport </li></ul><ul><li>Facilitates the removal of small middle and large solutes </li></ul><ul><li>Physician Prescribed </li></ul><ul><li>Contains electrolytes at physiological levels </li></ul><ul><li>Components adjusted to meet patient needs </li></ul>
  37. 37. CVVHDF <ul><li>Primary therapeutic goal: </li></ul><ul><ul><li>Solute removal by diffusion and convection </li></ul></ul><ul><ul><li>Safe fluid volume management </li></ul></ul><ul><ul><li>Efficient removal of small, middle and large molecules </li></ul></ul><ul><li>Replacement and dialysate fluid volume automatically removed by effluent pump </li></ul><ul><ul><li>Solute removal determined by </li></ul></ul><ul><ul><li>Replacement + Dialysate Fl ow Rates . </li></ul></ul>
  38. 38. CVVHDF Continuous VV H emo D ia F iltration Effluent Pump Effluent Access Return Dialysate Pump Dialysate Fluid Blood Pump Replacement Pump Replacement Fluid PBP Pump Infusion or Anticoagulant
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