4. Objectives
• At the end of this talk, the participant will be able:
• obtain an overview of the principles of SLED
• Discuss some logistic considerations
• Understand why SLED makes sense
5.
6. TL:DR; version
• Use an HD machine
• Slow Qb, Qd
• Use smaller filter
• 4K bath; Add PO4 to dialysate
• 8 - 12 hours, overnight, daily
• (Persuade ICU RNs to do SLED)
7. What is
SLEDD/SLED/SLEDD-f?
• Slow Low-Efficiency Daily Dialysis
• Sustained Low-Efficiency Dialysis
• Slow Extended Dialysis
• Slow Low-efficiency Daily Dia-Filtration
• Mainly New Zealand using Fresenius 4008S
• PIRRT: prolonged intermittent renal replacement therapy
8. A Brief History of Dialysis for
AKI
1950-70
Conventional HD
1970-85
Acute PD or conventional HD
1985-2005
CRRT
2005-
Conventional HD, CRRT, SLED
9. Fresenius 2008H machine
Software modified to do Qd 100 mL/min
Used Qb 100-200 mL/min
F40 dialyzer (surface area 0.7 sq metres)
Continuous
SLED is not really new: First Report from 1999
10. Issues
Hemodynamic instability: mainly from
Need to remove large volumes in 4 hours
Large amounts of fluids administered between
treatments
Rapid osmotic shifts
Multiple Investigations
EXTEND TIME TO 8
HOURS OR MORE
LOWER QB AND QD (SLOW)
DAILY
TREATMENTS
DO DIALYSIS AT NIGHT
11. How do you order?
• Filter: pediatric filter (F40s); order larger if you have
concerns about adequacy
• Duration: 8 - 12 hours (shorter if concerns of dialysis
dysequilibrium) Longer if more volume to come off*
• Qb, Qd: 200, 300* default (Can go higher if required)
• Fluid Removal: Total UF - unlike CRRT, like HD
12. Orders Contd.
• Dialysate:
• K - suggest 4 as default; 3 if hyperkalemia. Rarely if
ever 2 or lower
• Ca: 1.25 or 1.5 mmol/L
• HCO3: range 28-38 - perhaps 32 should be default
13. Orders: PO4
• 30 mL = 0.2 mmol/L
• 1 full fleet = 133 mL =
0.94 mmol/L
• Suggest starting with 90
- 120 ml for first run and
going to 150 ml (1
mmol/L) second run on
• Or just ‘full fleet’
15. SLED: Logistics elsewhere
• Fresenius 2008H
• CRRT option
• Qb ~200; Qd ~ 100mL/min (1 canister = complete Rx); small
dialyzer (F80)
• Usually nocturnal, started between 1600 – 2400 hours
• Usually HD RN starts and terminates; ICU RN does most of the
hourly charting/alarms
19. SLED: Ottawa
• SLED done by ICU RNs
• Have dedicated SLED machines (Artis: same as our HD
machines*)
• Any time
• 3 - 7 times a week
• Upto 8 hours, but can do more
• Qb 200, Qd 300; F40 dialyser
23. RRT in AKI: What Matters?
Patient survival and renal recovery
Cost
Complexity and nursing workload
Safety – correction of electrolyte disorders,
anticoagulation, risk of errors
Flexibility
Patient rehabilitation
31. Cost: Consumables
• Machines different but same cost
• PRISMAFLEX vs any conventional HD machine
• Dialysate:
• $5-7/L purchased in bags for CRRT
• $0.10/L purified city water for IHD, SLED
• Filter sets
• Prisma: $200
• IHD/SLED: $20
32. Cost: Labour
• Labour
• If No HD nurse involvement then ICU RN only (no labour cost???)
• IHD: 1 HD nurse for 4 hours
• SLED: 1 HD nurse for 8 hours, but usually does 2 patients
simultaneously
• SLED: precedents for HD nurse doing set up and ICU nurses
doing monitoring
• i.e. 1 hour HD nurse involvement/treatment
35. Source: Berbece, Richardson, Kidney Int 2006, PMID: 16850023
Cost: Summary
Toronto model: Cost based on 1 HD RN dialyzing 2 patients simultaneously
37. Complexity/Nursing
Workload: CRRT
• CRRT - heparin
• Manage bags of dialysate (5L) q.2-3.h
• Empty drain bag (5L) q.2-3.h
• RN or pharmacy must add KCl to each bag
• Hourly recording of machine data and flows
• CRRT – citrate: all of the above +
• Manage citrate infusion
• Manage calcium infusion
• Manage saline infusion (to correct high HCO3)
• Monitor ionized calcium to regulate citrate and calcium infusions
38. Complexity/Nursing
Workload: SLED
• SLED
• Connect machine to patient after priming
• Heparin or alternately, saline flushes using bags of
saline
• Hourly monitoring of machine functions
• Wait for an alarm ( 1 per treatment for SLED)
(One HD RN may monitor 1-3 machines)
Simplicity/Nursing Workload:
SLED
40. Safety
SLED
• Can choose dialysate with 0, 1, 2 ,3 , 4 mmol/L KCl,
appropriate calcium, magnesium, HCO3
• Can add sodium PO4 to correct low phosphate
• Most often done without anticoagulant- saline
flushes
41. Safety: compare with
nocturnal home HD
• Follow exactly the same protocol as SLED
• 8 hours, 4-6 nights/week
• Qb 200, Qd 350 ml/min, heparin
• Central line or fistula
• Sleep through the treatment with very few alarms
42. Patient Rehabilitation
• ICU survivors have grossly impaired muscle strength,
mobility, QOL
• Early mobilization thought to be key to prevent this
• CRRT precludes mobilization
• IHD or SLED (especially overnight) frees patients for many
hours/day
45. TL:DR; version
• Use an HD machine
• Slow Qb, Qd
• Use smaller filter
• 4K bath; Add PO4 to dialysate
• 8 - 12 hours, overnight, daily
• (Persuade ICU RNs to do SLED)
