Transcript Continuous Renal Replacement Therapy Workshop

Continuous Renal Replacement Therapy
(CRRT) Workshop
Cyrus Custodio, CNC
King Faisal Specialist Hospital & RC
Riyadh, Saudi Arabia
Objectives
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Purpose of CRRT
Advantages of CRRT
Filter dynamics
Transport mechanisms of CRRT
Modes of therapy & indications
Flow rate relationships
Pressures & their meanings
Buffer selection
Outline for the Workshop
1430-1440
1440-1500
1500-1530
Introduction
Review of CRRT
Practical Hands On CRRT Machine
 CRRT Initiation
 Sharing of practical experiences in dealing with the CRRT
machine.
 Troubleshooting
 Practice
1530-1600
1600-1610
1610-1640
1640-1700
Break & Prayer
Modalities Review (Flash Animation)
Jeopardy
Workshop Summary
CRRT: Important Points to
Remember During This Workshop
• Maintaining expertise with a rarely-performed
procedure can be difficult.
• Planning ahead (protocols, procedures, etc)
helps avoid confusion at the bedside.
• Communication and cooperation is essential.
• Do what you do best.
History of CRRT
• 1950’s – CRRT concept originated
• 1960’s – Scribner proposed CAVHD in context of ARF
• 1977 – Kramer introduces CAVH
• 1980 – Paganini introduces SCUF
• 1984 – Geronemus and Schneider propose CAVHD
History of CRRT
• 1987 – Uldall introduces CVVHD
• 1990’s – Transition to VV therapies from AV therapies
• 1996 – R. Mehta, UCSD, hosts the first international
conference on CRRT in San Diego
Continuous Renal
Replacement Therapy
Defined as
• “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, November 1996
Why continuous therapies?
• Continuous therapies closely mimic the native kidney
in treating ARF and fluid overload
 Slow, gentle and well tolerated by hypotensive patients
 Remove large amounts of fluid and waste products over time
 Tolerated well by the hemodynamically unstable patient
• Slower solute & fluid
removal - IHD removes
fluid & solutes more
rapidly than CRRT does.
• If the patient has a life-threatening
condition hemodialysis may be used
initially to correct and stabilize ……
then CRRT used to further correct the
condition.
• Overtime CRRT demonstrates a
superiority by longer periods of RRT.
Advantages
• Hemodynamic stability
• Management of fluid overload
• Control of Urea and creatinine
• Nutritional support
• Membrane absorption and removal of humoral mediators
of sepsis
• Effect on mortality ( CRRT vs IHD )
 Unclear whether either modality is superior in terms of survival
 Much larger prospective controlled studies are required
 Consensus that CRRT can be more safely performed in
hemodynamically unstable patients
Terminology
Hemodialysis
• transport process by which a solute passively diffuses down its
• concentration gradient from one fluid compartment (either blood
or dialysate) into the other
Hemofiltrattiion
• use of a hydrostatic pressure gradient to induce the filtration (or
convection) of plasma water across the membrane of the
hemofilter.
Hemodiafiltration
• dialysis + filtration.
• solute loss primarily occurs by diffusion dialysis but 25 percent
or more may occur by hemofiltration
Who is affected by Acute Renal
Failure (ARF)?
• ARF occurs most often in people who are already
hospitalized for other medical conditions.
• Patients with hospital-acquired ARF are more likely
than those with community-acquired ARF to be
admitted to the ICU.
• Up to ~ 70% of intensive or critical care patients
develop ARF.
Where is CRRT Performed?
• Practice patterns for CRRT are extremely variable.
• Broadly speaking, CRRT is almost exclusively applied to
ICU patients.
• However, beyond this, there are large variations in
practice.
Derek Angus, Rinaldo Bellomo & Robert Star, 2000 Selection of
patients for acute extracorporeal renal support in general and CRRT
in particular Acute Dialysis Quality Initiative Workgroup 2
Continuous Renal Replacement Therapy
TRANSPORT MECHANISMS
Transport mechanism:
DIFFUSION
Movement of solute from an area of high
concentration to an area of low concentration
• In the case of dialysis, via a semi permeable membrane
• Concentration gradient necessary
• Rate of diffusion is dependent on:
 surface area of filter
 ratio of dialysate flow to blood flow
 size of the solute
• Removes small molecules effectively
Transport mechanism:
DIFFUSION
Transport mechanism:
ULTRAFILTRATION
Movement of fluid across a pressure gradient.
Positive
pressure in
blood
compartment
Negative
pressure in
dialysate
compartment
Transport mechanism:
CONVECTION
• The movement of solutes with a
water flow or “Solvent drag”
• Used to remove middle and large
molecules
• The greater the amount of fluid that
moves, the greater the solute loss
Transport mechanism:
CONVECTION
Transport mechanism:
ADSORPTION
• Surface adsorption where the molecules are too
large to permeate and migrate through the
membrane; however can adhere to the
membrane.
• Bulk adsorption within the whole membrane
when molecules can permeate it.
Transport mechanism:
ADSORPTION
Adsorption: molecular adherence to the surface or interior of the membrane.
Molecules that can be effectively adsorbed include:
- B2 Microglobulin
- Cytokines
- Coagulation factors
- Anaphylatoxins
It must be noted that movement of fluid is required for adsorption to occur
Continuous Renal Replacement Therapy
TREATMENT MODALITIES
Modality: SCUF
Slow Continuous Ultrafiltration
PRINCIPLE
Ultrafiltration
PROCESS
Usual blood circuit,
synthetic membrane
and anticoagulation.
Fluid removal
occurs due to volume.
APPLICATIONS
Fluid overload,
acute and chronic
patients.
Modality: CVVH
Continuous Veno-Venous Hemofiltration
PRINCIPLE
Hemofiltrattiion
Ultrafiltration &
Convection.
PROCESS
Blood circuit,
filter &
anticoagulation.
Fluid removal
and replacement
solution.
APPLICATIONS
ARF/Critically ill
patients.
Modality: CVVHD
Continuous Veno-Venous Hemodialysis
PRINCIPLE
Diffusion and
Ultrafiltration
PROCESS
Blood circuit, filter
and anticoagulation.
Dialysate pathway
provided by pumps
using sterile fluid.
APPLICATIONS
Efficient treatment
for small molecule
clearance (ARF
/CRF, critically ill,
sepsis.)
Modality: CVVHDF
Continuous Veno-Venous Hemodiafiltration
HEMODIAFILTRATION
Hemodialysis and
Hemofiltration
PRINCIPLE
Diffusion,
Convection and
Ultrafiltration.
Best clearance of
small, middle and
large molecules.
Pre-dilution can
decrease clotting.
Cost increase
Summary of Modalities
PRINCIPLE
SCUF
HV &
CVVH
CVVHD
CVVHDF
Ultrafiltration
YES
YES
YES
YES
Convection
NO
YES
NO
YES
Diffusion
NO
NO
YES
YES
Dialysate
NO
NO
YES
YES
Replacement
Fluid
NO
YES
NO
YES
Fluid
Fluid &
some
Solutes
Fluid &
Solutes
Fluid &
Solutes
What is
Removed
Molecular Weights
100,000
• Albumin (55,000 - 60,000)
50,000
10,000
5,000
molecular weight,
in Daltons
1,000
500
10
0
50
10
5
0
• Beta 2 Microglobulin (11,800)
• Inulin (5,200)
}
• Vitamin B12 (1,355)
• Aluminum/Desferoxamine Complex (700)
(180)
• Glucose
Acid (168)
• Uric
(113)
• Creatinine
• Phosphate (80)
• Urea (60)
• Potassium (35)
(31)
• Phosphorus
• Sodium (23)
}
“large”
}
“small”
“middle”
Program Issues: What is Needed at Your
Hospital to Start a CRRRT Program
Disposables/Machine/Equipments
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
CRRT Machines:
Current Generation
Supplies
CRRT Circuit:
• Pediatric :
• Minimum priming volume with low resistance
 Neonatal lines
 Pediatric lines
• Exchangeable components
• Biocompatible membrane
• Adult
• Exchangeable components
• Biocompatible membrane
CRRT Competency Management
1.
Organize your CRRT competency assessment
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2.
Understand JCIA expectations
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3.
Validate clinical proficiency
Maintain a consistent CRRT validation system
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6.
Design a compliant, consistent and effective competency assessment
program
Validate CRRT competency
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5.
Patient Safety Goals
Develop your CRRT competency assessment program
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4.
Determine critical competencies to evaluate annually
Tie critical competencies to annual performance reviews
Ensure that clinical proficiency is assessed and validated in a consistent
manner with our easy to implement skill sheets
Keep up with new CRRT competencies
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Verify and document new—and existing—competencies, including those
for new equipment
CRRT Training and Education
• Nurses
 Critical Care
 Nephrology
• Physicians:
 Ongoing
education
 Grand Rounds,
small groups
 BECOME AN
ACCEPTED
PART OF THE
TEAM
• Pharmacists
• Nutritionists
CRRT Education Plan
Dialysis
ICU
History of CRRT
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Definition of Acronyms and Terms
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The Pediatric Ideal
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Concepts related to fluid removal
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Concepts related to solute removal
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Formulas related to CRRT
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Components of a CRRT System
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Procedures related to initiation of therapy
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Procedures related to monitoring therapy
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Procedures related to terminating therapy
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Potential problems encountered during CRRT
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Indications for CRRT in the critical care setting
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CRRT outcomes research
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
CRRT Education Plan
CRRT Procedures
12th Annual International Conference on Continuous Renal
Replacement Therapy, San Diego, CA, USA.
Competencies:
Bedside ICU Nurse
Verbalize
• How CRRT works (fluid and
solute balance, changes in
nutrition and medications)
• Reason for treatment
• When and how to terminate
treatment
• How to troubleshoot alarms
(AP, VP, blood leak, error
codes, air detector)
• When and how to recirculate
the system
• How to care for catheter and
catheter exit site
• When and how to contact
nephrologists or hemodialysis
nurse
• How to operate extracorporeal
circuit warmer
Demonstrate
• How to calculate fluid
balance
• How to assess clotting in
the system
• How to adjust AP and VP
limits, BFR, UFR
• How to verify dialysis and
replacement fluid solution
and rates
• Document continuing care
in nursing notes and CRRT
flow chart
• Highly skilled in
troubleshooting alarms
Competencies:
Nephrology Nurse
• Knows how CRRT
works
• Reason for treatment
• When and how to
terminate treatment
• Equipment operation
• Most common alarms
conditions
• When and how to
reach the nephrology
team
• Fluid balance
calculations
• Assessment of clotting
• How to adjust AP/VP
limits, BFR or UFR
• How to verify dialysis
fluid or replacement
fluid and/or rate
changes
Acute Initiation Timeline: Example
Time
Zero
10
20
minutes
Nephrology
MD: Contacts
HD Nurse to
start CRRT
Nephro.
MD:
Enters
Orders
for RRT
30
40
50
60
Nephrology MD: Meets ICU MD’s and
RN’s; Discuss RRT Plan
90
120...
Nephrology MD:
Present in ICU for
initiation; Meet ICU
Team
Intensivist MD: Arrive & begin
Intensivist MD: Completes insertion of HD Access
insertion of HD Access
Time
10
20
30
40
50
60
90
120...
Zero
minutes
HD Nurse: Completes
HD Nurse: Arrives at HD Unit and Begins Set-up
Prime; Ready for
HD Nurse: Meet MD;
Access; Meet the ICU
discuss RRT Plan
Team and starts CRRT
ICU Nurse:
ICU Nurse: Meet
Moves Patient to
ICU Nurse: Meet ICU Team and Nephrology
MD; discuss RRT
Room with HD water
commences CRRT
Plan
Port
Time
10
20
30
40
50
60
90
120...
Zero
minutes
The Multidisciplinary approach
Nurses
Standards
Policies &
Documents
Technicians
Physicians
CRRT “Leader”
Pharmacists
Patient Care: CRRT
Suppliers
Educators
Audit
The Nephrologist in-charge of CRRT must continuously interact and communicate with all the
other practitioners involved.
Practical information: Techniques
and Methods to Perform CRRT
Practical information: Techniques
and Methods to Perform CRRT
Practical Hands On CRRT
Machine
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Lines volume and tracing
Pre/post dilution
Set and check orders
Opaque/non-opaque
alarm
What mode are we in?
Transducer maintenance
Help key, Graphs, scales,
Bag/syringe Change
Dialysate/substituate bags
preparation
Change post-dilution to
pre.
• Alarms settings
(automatic)
• Venous bubble catcher:
↑or ↓ level
• Arterial chamber: ↑or ↓
level
• De-aeration
• Blood sampling
• Hand bolus Vs Sub bolus
• Flushing filters
• Temporary Disconnect
• Terminate treatment with
& without blood return
CRRT Access : What Works?
Pediatrics
Adults
Patient Size (kg) Vascular Access
2.5-10
6.5 Fr DLC (10cm)
10-20
8Fr DLC (15cm)
>20
10.8Fr or larger DLC
(20cm)
Pediatric Perma Cath 28 Cm 0.8 cc 0.85 cc
Strazdins V, etal. RRT for ARF in Children: European Guidelines
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PERMAMENT CATHETER
36 CM 1.3 cc 1.4 cc
40 CM 1.4 cc 1.5 cc
45 CM 1.6 cc 1.7 cc
TEMPORARY CATHETER
24 cm 1.4 ml 1.5 ml (Fr 11.5)
19.5 cm 1.2 ml 1.3 ml (Fr 11.5)
19.5 cm 1.0 ml 1.1 ml (Fr 10)
Correct Double Lumen Catheter
(DLC) Connection
Re-circulation is particularly high (20-40%) whenever the
roles of the different catheter lumens are exchanged (the
venous become arterial and vice versa).
CRRT in Pediatrics
After access insertion, staffing in place, CRRT circuit is blood primed
for patients < 15kg
Extracorporeal circuit volume greater than 10% of patients circulating
Age
Total Blood volume in
bloodEstimated
volume.
ml/kg
•The ECBV (blood in the dialyzer and
Preterm
90 -105 ml
infants
bloodlines) should not exceed 10% of the
Term
78 -86 ml
patient’s total blood volume.
newborns
•If the ECBV will exceed 10%, of the
1-12 months
73 -78 ml
patient’s total blood volume it must be
1-3 years
74 -82 ml
primed with blood/human albumin.
4-6 years
80 -86 ml
Formula : Estimated total blood volume by
7-18 years
83 -90 ml
age X body weight X 10%.
Adults
66 -88 ml
Note: From Gunn, V. L. & Nechgyba, C. (2002)
Example: Patient is 12 months old with body weight
10kg.: Calculation = (78 ml x 10 x 10 ) = 78 ml
100
Strazdins V, et al. RRT for ARF in Children: European Guidelines
Artificial Organs, 27(9):781-785 Overview of Pediatric RRT in ARF
Baldwin, I. et al, Adequacy Dialysis Quality Initiative, 4th International Consensus Conference
CRRT in Pediatrics
• Use a Tru-Flo or PALL blood filter
• Blood “chases” the NS out into the priming collection bag.
• When blood bag is near empty, stop pump and clamp the arterial
and venous lines.
• Disconnect blood and collection bags and quickly proceed to
patient connection.
• Enter therapy very slowly ~ 10ml/minute
 Advance BFR slowly (15-20 minutes)
Potential Complications of CRRT
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Volume related problems
Biochemical and nutritional problems
Hemorrhage
Infections
Thermic loss
Technical problems
Logistical problems
CRRT Flash Animation
(Modes review)
CRRT WORKSHOP
Fourth Annual International Conference of Saudi Society of
Nephrology
26-29 April 2009
Riyadh, Saudi Arabia
Summary
• CRRT is something we can do
• Can be life-saving for critically ill patients (pediatric and
adult)
• Careful planning of the institution’s program, standardized
protocols and orders and continuous education of Health
Care Providers improves care.
• Technical challenges can be met.
• Cooperation, Communication (KEY) and Collaboration
will increase our success!
12th Annual International Conference on Continuous Renal
Replacement Therapy, San Diego, CA, USA.