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Sled 2019
This document provides an overview of sustained low-efficiency extended dialysis (SLED). SLED uses a hemodialysis machine with slower blood and dialysate flow rates and a smaller filter over 8-12 hours, often overnight. This allows for less rapid fluid and electrolyte shifts compared to conventional hemodialysis. SLED has similar outcomes to continuous renal replacement therapy but is simpler, cheaper, and easier on nurses. It also allows more time for patient rehabilitation compared to other acute renal replacement therapies.
Sled 2019
- 1. Sustained Low-Efficiency Extended Dialysis TBDaka Swapnil Hiremath, @hswapnil University of Ottawa
- 2. Disclosures • No relevantfinancial conflicts • Research funding from CIHR, PSI, TOHAMO, KFoC
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- 4. Objectives • At theend 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
- 6. TL:DR; version • Usean 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? • SlowLow-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 Historyof 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 Softwaremodified 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: mainlyfrom 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 youorder? • 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 • 30mL = 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’
- 14. SLED: anticoagulation • Heparin •No Anticoagulation: needed for ~ 30 - 80 % • Saline flushes • Citrasate (use 1.5 Ca bath)
- 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
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- 17. SLED across theworld: Nursing model
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- 19. SLED: Ottawa • SLEDdone 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
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- 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
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- 31. Cost: Consumables • Machinesdifferent 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
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- 34. Details of SLED 1litre saline/hr
- 35. Source: Berbece, Richardson,Kidney Int 2006, PMID: 16850023 Cost: Summary Toronto model: Cost based on 1 HD RN dialyzing 2 patients simultaneously
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- 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
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- 40. Safety SLED • Can choosedialysate 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 nocturnalhome 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 • ICUsurvivors 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
- 43. SLED summary • Clinicaloutcomes: SLED = CRRT • Simpler • Cheaper • Easier on Nurses • ?better for rehab/recovery
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- 45. TL:DR; version • Usean 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)