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1 prismaflex crrt intro - seg 1 (2007) Presentation Transcript

  • 1. PrismaFlex STEPP Basic CRRT Principles ®
  • 2. Course Objectives
    • By 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.
  • 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. Why CRRT?
    • Removes large amounts of fluid and waste products over time
    • Tolerated well by hemodynamically unstable patients
    CRRT closely mimics the native kidney in treating ARF and fluid overload
  • 5. 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
  • 6. Determinants of Outcome
    • Initiation of Therapy
      • Ronco Study
      • Gettings Study
      • ADQI Consensus Initiative - Rifle Criteria
    • Dose
      • Ronco Study
      • Kellum Meta-Analysis
      • Saudan Study
  • 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. 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. 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.
  • 10. Anatomy of a Hemofilter
    • 4 External ports
      • blood and dialysis fluid
    • Potting material
      • support structure
    • Hollow fibers
      • Semi-permeable membrane
    • Outer casing
  • 11. CRRT Transport Mechanisms
  • 12. Molecular Transport Mechanisms
    • Ultrafiltration
    • Diffusion
    • Convection
    • Adsorption
    Fluid Transport Solute Transport }
  • 13. Ultrafiltration
    • Movement of fluid through a semi-permeable membrane caused by a pressure gradient
    • Positive, negative and osmotic pressure from non-permeable solutes
  • 14. Ultrafiltration Blood Out Blood In to waste (to patient) (From patient) HIGH PRESS LOW PRESS Fluid Volume Reduction
  • 15. Molecular Weights Daltons • Inflammatory Mediators (1,200-40,000) “ small” “ middle” “ large”
  • 16. 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.
  • 17. Hemodialysis: Diffusion Dialysate In Dialysate Out (to waste) Blood Out Blood In (to patient) (from patient) HIGH CONC LOW CONC
  • 18. 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
  • 19. Hemofiltration: Convection to waste HIGH PRESS LOW PRESS Repl. Solution Blood Out Blood In (to patient) (from patient)
  • 20. 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.
    K+ Ca++ Na+ NaCO3
  • 21. Adsorption
    • Molecular adherence to the surface or interior of the membrane.
  • 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. What is the transport mechanism associated with dialysate and replacement solutions?
  • 24. Flow Control Unit – Pumps Effluent Pre Blood Pump Replacement: Convection Blood Dialysate: Diffusion
  • 25. Effluent Flow Rate
    • Effluent = Total Fluid Volume:
      • Patient Fluid Removal
      • Dialysate Flow
      • Replacement Flow
      • Pre-Blood Pump Flow
  • 26. CRRT Modes of Therapy
    • SCUF - Slow Continuous Ultrafiltration
    • CVVH - Continuous Veno-Venous Hemofiltration
    • CVVHD - Continuous Veno-Venous HemoDialysis
    • CVVHDF - Continuous Veno-Venous HemoDiaFiltration
  • 27. SCUF Slow Continuous UltraFiltration
    • Primary therapeutic goal:
      • Safe and effective management of fluid removal from the patient
  • 28. SCUF Slow Continuous UltraFiltration Effluent Pump Infusion or Anticoagulant Blood Pump PBP Pump Effluent Access Return
  • 29. CVVHD Continuous 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 .
  • 30. CVVHD Continuous VV HemoDialysis Hemofilter Effluent Pump Effluent Access Return Dialysate Pump Dialysate Fluid Blood Pump Infusion or Anticoagulant PBP Pump
  • 31. 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
  • 32. 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 .
  • 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. Pre-Dilution Replacement Solution
    • Decreases risk of clotting
    • Higher UF capabilities
    • Decreases Hct. In filter
    Hemofilter Effluent Pump Blood Pump PBP Pump Effluent Access Return Replacement Pump Replacement Fluid Infusion or Anticoagulant
  • 35. Post-Dilution Replacement Solution
    • Consider lowering replacement rates (filtration %)
    • Higher BFR (filtration %)
    • Higher anticoagulation
    • More efficient clearance (>15%)
    Hemofilter Effluent Pump Blood Pump Effluent Access Return Replacement Pump Replacement Fluid Replacement Pump Replacement Fluid PBP Pump Infusion or Anticoagulant
  • 36. 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
  • 37. CVVHDF
    • Primary 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 Fl ow Rates .
  • 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