5Conventional Dialysis on ECMO Conventional Dialysis on ECMO is performed by accessing the circuit by stopcocks, taking blood from the arterial side of the circuit and returning it to the venous side or into a venous access line in the patient.Dialysis Service controls solute and fluid removal rates.Dialysis blood flow rates vary with size of patient and access.
6Hemofiltration Rate Blood Flow TMP = (P in + P out)/2 + vacuum on HF side, ex ( )/2 =110+(-75) = 185 mmHgHematocritProtein concentrationResists fluid removalBlood ViscosityTemperature
11Molecular Cut Off Device acts as a sieve Solutes (molecules) dissolved in plasma are either retained or removed according to their size (molecular Wt. MW)MW cut off 50,000 daltonsElectrolytes daltonsTherapeutic drugs 6,000-20,0000 daltonsNote - Dalton is unit of atomic Wt. 1Da = 1.66X10-24
12Solute ClearanceSolutes in hemofiltrate are in the same concentration as the pts. Blood (if below the MW cut off)The amount removed is equal to the hemofiltration rate time the concentration of solute in question in the filtrateAmount removed = (Concentration in filtrate) X (HR)
13Solute ClearanceIf large amounts of volume are removed with Hemofiltration, the actual amount of a given solute removed from a baby may be substantial
14Solute ClearanceWhile the concentration of a solute in the HF may not be known, its concentration in the blood is routinely measured.Ex. Sodium. 134 mEq/lIf the MW is below the cut off of the fiber the concentration in the HF is essentially the same as the blood. Then: amount removed = (Conc.in blood) X (HF Rate)
15Sieving CoefficientSC - The ratio of the amount of a given solute in the UF to that amount in the Blood.Ex 1. Sodium - amount in UF is 135 mEq/L and amount in the blood is 135 mEq/L the Sieving Coef. is 1.0.Ex 2. Albumin Serum = 5 gm/dl Blood Albumin UF = 0 gm/dl SC = ?Other large molecules:Total Bilirubin , erythromycin- 0.37, calcium
17Sieving Coefficient & Protein Binding Calculation of Solute clearance is complicated if molecule is protein bound. Monitoring of medication blood level is advised when aggressive HF is used.Protein binding data is available for many medication used during ECMO.
18Calculating Solute Clearance It turns out to be easier to calculate the amount of a substance being removed if you know its Sieving Coefficient using:Amount lost =(Conc. In blood) X (SC) X (HR)
19Dialysis With Hemofiltration Dialysate solution may be used on the Hemofiltrate side of the cartridge to the remove solutes by osmotic gradients (conduction) and filtration(convection). Concentration of molecules in Dialysate control removal of various solutes from the blood.Ex. If Potassium is high in blood Dialysate will be low in Potassium the rest of the molecules will be balanced.