CRRT Terminology
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  • Concepts related to solute removal Convection Diffusion Formulas related to CRRT Sieving coefficient for a solute Ultrafiltrate concentration/plasma concentration Convective clearance (UFR x UF concentration)/arterial concentration Diffusive clearance (DFR x UF concentration)/arterial concentration Fluid replacement rate and net hourly fluid loss Components of a CRRT System Vascular accesses Blood lines Hemofilters Fluid-integrated CRRT systems Priming the CRRT system Anticoagulation of the CRRT system CRRT Procedures Procedures related to initiation of therapy Procedures related to monitoring therapy Procedures related to terminating therapy Potential problems encountered during CRRT Patient related concerns Dehydration Hypotension Electrolyte imbalance Acid/base imbalance Blood loss Air embolism Technical or procedure-related problems Small size of the patient Establishing vascular access Preventing heat loss Small size of pediatric hemofilters can prohibit the rate of replacement fluids in volumes used in adults Large size of extracorporeal priming volume Clotted hemofilter Poor ultrafiltration rate Blood leaks Malfunction of equipment Indications for CRRT in the critical care setting Fluid removal Patients w/acute renal failure (ARF) Patients w/cardiac instability and severe fluid overload Patients w/burns Patients w/rhabdomyolysis Solute removal Patients w/ARF or liver failure Patients w/inborn errors of metabolism (i.e. hyperammonemia) Patients w/toxic ingestions Patients w/pulmonary failure requiring extracorporeal membrane oxygenation (ECMO) CRRT outcomes research
  • 1960 – Belding Scribner first described a continuous arteriovenous approach for treatment of renal failure 1974 – Silversteins used a technique to perform ultrafiltration isolated from hemodialysis circuit and the addition of a hemofilter 1975 – Henderson proposed hemofiltration technique by collecting an ultrafiltrate of plasma and then reconstituting the blood volume with a fluid composition similar to normal plasma
  • Mid 1980s – CRRT used in pediatrics
  • Mid 1980s – CRRT used in pediatrics
  • Ultrafiltration or fluid removal – removal of plasma volume across membrane driven by hydrostatic pressure
  • Dialysis or clearance – removal of solute across a membrane driven by diffusion and convention
  • Separate and accurate pumps and scales for each component of CRRT (i.e., UF, replacement fluid, dialysate)

CRRT Terminology Presentation Transcript

  • 1. Pediatric CRRT Terminology Helen Currier BSN, RN, CNN Assistant Director, Renal/Pheresis Texas Children’s Hospital Houston, Texas
  • 2.  
  • 3. History of Continuous Renal Replacement Therapy (CRRT)
    • 1960 Continuous arteriovenous approach first described for treatment of renal failure
    • 1974 Ultrafiltration isolated from hemodialysis circuit and the addition of a hemofilter
    • 1975 Hemofiltration technique proposed
    • 1979-82 SCUF and CAVH used by Paganini (MD) and Whitman (RN) at Cleveland Clinic
  • 4. History of Continuous Renal Replacement Therapy (CRRT)
    • 1980s CRRT used in pediatrics
    • 1987 Pump-assisted CRRT introduced
    • 1990 CRRT considered state of the art therapy for treatment of acute renal failure
    • 1993 Standards of Clinical Practice for CRRT published by the American Nephrology Nurses’ Association (ANNA) and endorsed by the American Association of Critical Care Nurses (AACN)
  • 5. History of Continuous Renal Replacement Therapy (CRRT)
    • 2000 Continued development of integrated blood pump and fluid balance equipment for CRRT
    • 2002 Second pCRRT meeting in Orlando, FL
    • 2004 Third pCRRT meeting in Orlando, FL
  • 6. Test your knowledge
    • Pediatric CRRT therapies are approximately
      • A. 40 years old
      • B. 30 years old
      • C. 20 years old
      • D. 10 years old
  • 7. Test your knowledge
    • Pediatric CRRT therapies are approximately
      • A. 40 years old
      • B. 30 years old
      • C. 20 years old
      • D. 10 years old
  • 8. Indications for CRRT in the Critical Care Setting
    • Fluid removal
    • Solute removal
  • 9. Basic Concepts of CRRT: Concepts Related to Fluid Removal or Ultrafiltration
    • Blood flow
      • Arteriovenous
      • Venovenous
    • Hydrostatic pressure
      • Arteriovenous
      • Venovenous
    • Other factors
      • Hematocrit
      • Plasma proteins
      • Transmembrane pressure
  • 10. Basic Concepts of CRRT: Concepts Related to Solute Removal or Clearance
    • Convection – solute drag; hemofiltration
    • Diffusion – concentration gradient; hemodiafiltration
  • 11. Solute Mass Transfer in CRRT Post-Dilution CVVH CVVHD Pre-Dilution CVVH CVVHDF Q b Q b Q b Q b Q eff Q eff Q eff Q eff Q d Q d Q r Q r Q r
  • 12. Solute Molecular Weight and Clearance Solute (MW) Sieving Coefficient Diffusion Coefficient Urea (60) 1.01 ± 0.05 1.01 ± 0.07 Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06 Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04* Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04** *P<0.05 vs sieving coefficient **P<0.01 vs sieving coefficient
  • 13. Comparison of Urea Clearance: CVVH vs CVVHD (Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)
    • Study design
      • Fixed blood flow rate - 4 ml/kg/min
      • HF-400 (0.3 m2 polysulfone)
      • Cross over for 24 hrs each to pre-filter replacement fluid (CVVH) or Dx (CVVHD) flow at 2000 ml/hr/1.73 m 2
  • 14. Comparison of Urea Clearance: CVVH vs CVVHD (Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5) Urea Clearance (mls/min/1.73 m2) BFR = 4 mls/kg/min FRF/Dx FR = 2 l/1.73 m2/hr SAM = 0.3 m2 p = NS
  • 15. Methods of Continuous Renal Replacement Therapy
  • 16. Definition of Acronyms and Terms
    • SCUF slow continuous ultrafiltration
    • CAVH continuous arteriovenous hemofiltration
    • CAVHD continuous arteriovenous hemodialysis
    • CVVH continuous venovenous hemofiltration
    • CVVHD continuous venovenous hemodialysis
    • CVVHDF continuous venovenous hemodiafiltration
  • 17. Continuous Renal Replacement Therapy
    • Advantages
      • Slower blood flows
      • Slower UF rates
      • Adjust UF rates with hourly patient intake
      • Increased cytokine (bad humors) removal?
    • Disadvantages
      • Prolonged anticoagulation
      • Increased cytokine (good humors) removal?
  • 18. The Pediatric Ideal: CRRT Equipment
    • Separate and accurate pumps and scales for each component of CRRT
    • Range of blood flows with a minimum of 20ml/min
    • Thermoregulation
    • Maximum safety features
  • 19. The Pediatric Ideal: CRRT Circuit
    • Minimum priming volume with low resistance
    • Exchangeable components
    • Biocompatible membrane