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Continuous Renal Replacement Therapy (CRRT) Workshop Cyrus Custodio, CNC King Faisal Specialist Hospital & RC Riyadh, Saudi Arabia.

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Presentation on theme: "Continuous Renal Replacement Therapy (CRRT) Workshop Cyrus Custodio, CNC King Faisal Specialist Hospital & RC Riyadh, Saudi Arabia."— Presentation transcript:

1 Continuous Renal Replacement Therapy (CRRT) Workshop Cyrus Custodio, CNC King Faisal Specialist Hospital & RC Riyadh, Saudi Arabia

2 Objectives Purpose of CRRT Advantages of CRRT Filter dynamics Transport mechanisms of CRRT Modes of therapy & indications Flow rate relationships Pressures & their meanings Buffer selection

3 Outline for the Workshop Introduction Review of CRRT Practical Hands On CRRT Machine CRRT Initiation Sharing of practical experiences in dealing with the CRRT machine. Troubleshooting Practice Break & Prayer Modalities Review (Flash Animation) Jeopardy Workshop Summary

4 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.

5 History of CRRT 1950s – CRRT concept originated 1960s – Scribner proposed CAVHD in context of ARF 1977 – Kramer introduces CAVH 1980 – Paganini introduces SCUF 1984 – Geronemus and Schneider propose CAVHD

6 History of CRRT 1987 – Uldall introduces CVVHD 1990s – Transition to VV therapies from AV therapies 1996 – R. Mehta, UCSD, hosts the first international conference on CRRT in San Diego

7 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

8 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.

9 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

10 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

11 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.

12 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

13 TRANSPORT MECHANISMS Continuous Renal Replacement Therapy

14 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

15 Transport mechanism: DIFFUSION

16 Transport mechanism: ULTRAFILTRATION Movement of fluid across a pressure gradient. Positive pressure in blood compartment Negative pressure in dialysate compartment

17 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

18 Transport mechanism: CONVECTION

19 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.

20 Transport mechanism: ADSORPTION Adsorption: molecular adherence to the surface or interior of the membrane. Molecules that can be effectively adsorbed include: - B 2 Microglobulin - Cytokines - Coagulation factors - Anaphylatoxins It must be noted that movement of fluid is required for adsorption to occur

21 TREATMENT MODALITIES Continuous Renal Replacement Therapy

22 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.

23 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.

24 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.)

25 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

26 Summary of Modalities PRINCIPLESCUF HV & CVVH CVVHDCVVHDF UltrafiltrationYES ConvectionNOYESNOYES DiffusionNO YES DialysateNO YES Replacement Fluid NOYESNOYES What is Removed Fluid Fluid & some Solutes Fluid & Solutes

27 Molecular Weights Albumin (55, ,000) Beta 2 Microglobulin (11,800) Inulin (5,200) Vitamin B 12 (1,355) Aluminum/Desferoxamine Complex (700) Glucose (180) Uric Acid (168) Creatinine (113) Phosphate (80) Urea (60) Phosphorus (31) Sodium (23) Potassium (35) 100,000 50,000 10,000 5,000 1, molecular weight, in Daltons } } } small middle large

28 Program Issues: What is Needed at Your Hospital to Start a CRRRT Program

29 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

30 CRRT Machines: Current Generation

31 Supplies CRRT Circuit: Pediatric : Minimum priming volume with low resistance Neonatal lines Pediatric lines Exchangeable components Biocompatible membrane Adult Exchangeable components Biocompatible membrane

32 CRRT Competency Management 1.Organize your CRRT competency assessment –Determine critical competencies to evaluate annually –Tie critical competencies to annual performance reviews 2.Understand JCIA expectations –Patient Safety Goals 3.Develop your CRRT competency assessment program –Design a compliant, consistent and effective competency assessment program 4.Validate CRRT competency –Validate clinical proficiency 5.Maintain a consistent CRRT validation system –Ensure that clinical proficiency is assessed and validated in a consistent manner with our easy to implement skill sheets 6.Keep up with new CRRT competencies –Verify and document newand existingcompetencies, including those for new equipment

33 CRRT Training and Education Nurses Critical Care Nephrology Physicians: Ongoing education Grand Rounds, small groups BECOME AN ACCEPTED PART OF THE TEAM Pharmacists Nutritionists

34 CRRT Education Plan DialysisICU History of CRRT Definition of Acronyms and Terms The Pediatric Ideal Concepts related to fluid removal Concepts related to solute removal Formulas related to CRRT Components of a 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 Indications for CRRT in the critical care setting CRRT outcomes research 12 th Annual International Conference on Continuous Renal Replacement Therapy, San Diego, CA, USA. CRRT Education Plan

35 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

36 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

37 Acute Initiation Timeline: Example


39 Practical information: Techniques and Methods to Perform CRRT


41 Practical Hands On CRRT Machine 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

42 CRRT Access : What Works? Pediatrics 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) Adults Patient Size (kg)Vascular Access Fr DLC (10cm) Fr DLC (15cm) >2010.8Fr 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

43 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).

44 CRRT in Pediatrics Strazdins V, et al. RRT for ARF in Children: European Guidelines Artificial Organs, 27(9): Overview of Pediatric RRT in ARF Baldwin, I. et al, Adequacy Dialysis Quality Initiative, 4 th International Consensus Conference After access insertion, staffing in place, CRRT circuit is blood primed for patients < 15kg Extracorporeal circuit volume greater than 10% of patients circulating blood volume. AgeEstimated Total Blood volume in ml/kg Preterm infants ml Term newborns ml 1-12 months ml 1-3 years ml 4-6 years ml 7-18 years ml Adults ml Note: From Gunn, V. L. & Nechgyba, C. (2002) The ECBV (blood in the dialyzer and bloodlines) should not exceed 10% of the patients total blood volume. If the ECBV will exceed 10%, of the patients total blood volume it must be primed with blood/human albumin. Formula : Estimated total blood volume by age X body weight X 10%. Example: Patient is 12 months old with body weight 10kg.: Calculation = (78 ml x 10 x 10 ) = 78 ml 100

45 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)

46 Potential Complications of CRRT Volume related problems Biochemical and nutritional problems Hemorrhage Infections Thermic loss Technical problems Logistical problems

47 CRRT Flash Animation (Modes review)

48 CRRT WORKSHOP Fourth Annual International Conference of Saudi Society of Nephrology April 2009 Riyadh, Saudi Arabia

49 Summary CRRT is something we can do Can be life-saving for critically ill patients (pediatric and adult) Careful planning of the institutions 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! 12 th Annual International Conference on Continuous Renal Replacement Therapy, San Diego, CA, USA.

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