1、Continuous Renal Replacement Therapy(CRRT)WorkshopCyrus Custodio,CNCKing Faisal Specialist Hospital&RCRiyadh,Saudi ArabiaObjectives Purpose of CRRT Advantages of CRRT Filter dynamics Transport mechanisms of CRRT Modes of therapy&indications Flow rate relationships Pressures&their meanings Buffer sel
2、ectionOutline for the Workshop1430-1440Introduction1440-1500Review of CRRT1500-1530Practical Hands On CRRT Machine CRRT Initiation Sharing of practical experiences in dealing with the CRRT machine.Troubleshooting Practice1530-1600 Break&Prayer1600-1610 Modalities Review(Flash Animation)1610-1640 Jeo
3、pardy1640-1700 Workshop SummaryCRRT: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.H
4、istory 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 CAVHDHistory of CRRT 1987 Uldall introduces CVVHD 1990s Transition to VV therapies from AV therapies 1996 R.Meht
5、a,UCSD,hosts the first international conference on CRRT in San Diego Continuous Renal Replacement TherapyDefined 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/
6、day.”*Bellomo R.,Ronco C.,Mehta R,Nomenclature for Continuous Renal Replacement Therapies,AJKD,Vol 28,No.5,Suppl 3,November 1996Why continuous therapies?Continuous therapies closely mimic the native kidney in treating ARF and fluid overloadSlow,gentle and well tolerated by hypotensive patientsRemove
7、 large amounts of fluid and waste products over timeTolerated well by the hemodynamically unstable patientSlower 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
8、 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 mort
9、ality(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 patientsTerminologyHemodialysistransport process by which a solute passively diffuse
10、s down itsconcentration gradient from one fluid compartment(either bloodor dialysate)into the other Hemofiltrattiionuse of a hydrostatic pressure gradient to induce the filtration(orconvection)of plasma water across the membrane of the hemofilter.Hemodiafiltrationdialysis+filtration.solute loss prim
11、arily occurs by diffusion dialysis but 25 percentor more may occur by hemofiltrationWho 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-acqu
12、ired 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.Dere
13、k 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 TRANSPORT MECHANISMSContinuous Renal Replacement TherapyTransport mechanism:DIFFUSIONMovement of solute from an area o
14、f 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 effectivelyTransport m
15、echanism:DIFFUSIONTransport mechanism:ULTRAFILTRATIONMovement of fluid across a pressure gradient.Positive pressure in blood compartmentNegative pressure in dialysate compartmentTransport mechanism:CONVECTION The movement of solutes with a water flow or “Solvent drag”Used to remove middle and large
16、molecules The greater the amount of fluid that moves,the greater the solute loss Transport mechanism:CONVECTIONTransport 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 th
17、e whole membrane when molecules can permeate it.Transport mechanism:ADSORPTIONAdsorption:molecular adherence to the surface or interior of the membrane.Molecules that can be effectively adsorbed include:-B2 Microglobulin-Cytokines-Coagulation factors-AnaphylatoxinsIt must be noted that movement of f
18、luid is required for adsorption to occur TREATMENT MODALITIESContinuous Renal Replacement Therapy Modality:SCUFSlow Continuous UltrafiltrationPRINCIPLEqUltrafiltrationPROCESSqUsual blood circuit,synthetic membrane and anticoagulation.qFluid removal occurs due to volume.APPLICATIONS qFluid overload,a
19、cute and chronic patients.Modality:CVVHContinuous Veno-Venous HemofiltrationPRINCIPLEqHemofiltrattiion Ultrafiltration&Convection.PROCESSqBlood circuit,filter&anticoagulation.qFluid removal and replacement solution.APPLICATIONSqARF/Critically ill patients.Modality:CVVHDContinuous Veno-Venous Hemodia
20、lysisPRINCIPLEqDiffusion and UltrafiltrationPROCESSqBlood circuit,filter and anticoagulation.Dialysate pathway provided by pumps using sterile fluid.APPLICATIONSqEfficient treatment for small molecule clearance(ARF/CRF,critically ill,sepsis.)Modality:CVVHDFContinuous Veno-Venous HemodiafiltrationHEM
21、ODIAFILTRATION qHemodialysis and HemofiltrationPRINCIPLEqDiffusion,Convection and Ultrafiltration.qBest clearance of small,middle and large molecules.qPre-dilution can decrease clotting.qCost increaseSummary of ModalitiesPRINCIPLESCUFHV&CVVHCVVHDCVVHDFUltrafiltrationYESYESYESYESConvectionNOYESNOYESD
22、iffusionNONOYESYESDialysateNONOYESYESReplacement FluidNOYESNOYESWhat is RemovedFluidFluid&some SolutesFluid&SolutesFluid&SolutesMolecular Weights Albumin(55,000-60,000)Beta 2 Microglobulin(11,800)Inulin(5,200)Vitamin B12(1,355)Aluminum/Desferoxamine Complex(700)Glucose(180)Uric Acid(168)Creatinine(1
23、13)Phosphate(80)Urea(60)Phosphorus(31)Sodium(23)Potassium(35)100,00050,00010,0005,0001,000500100501050molecular weight,in Daltons“small”“middle”“large”Program Issues:What is Needed at Your Hospital to Start a CRRRT ProgramDisposables/Machine/EquipmentsCRRT Equipment:Separate and accurate pumps and s
24、cales for each component of CRRTRange of blood flows with a minimum of 20ml/minThermoregulationMaximum safety featuresCRRT Machines:Current GenerationSuppliesCRRT Circuit:Pediatric:Minimum priming volume with low resistance Neonatal lines Pediatric lines Exchangeable components Biocompatible membran
25、e Adult Exchangeable components Biocompatible membraneCRRT Competency Management1.Organize your CRRT competency assessmentDetermine critical competencies to evaluate annually Tie critical competencies to annual performance reviews 2.Understand JCIA expectationsPatient Safety Goals 3.Develop your CRR
26、T competency assessment programDesign a compliant,consistent and effective competency assessment program 4.Validate CRRT competencyValidate clinical proficiency5.Maintain a consistent CRRT validation systemEnsure that clinical proficiency is assessed and validated in a consistent manner with our eas
27、y to implement skill sheets 6.Keep up with new CRRT competencies Verify and document newand existingcompetencies,including those for new equipment CRRT Training and EducationNursesq Critical Careq NephrologyPhysicians:q Ongoing educationq Grand Rounds,small groupsq BECOME AN ACCEPTED PART OF THE TEA
28、MPharmacistsNutritionistsCRRT Education PlanDialysisICUHistory of CRRTDefinition of Acronyms and TermsThe Pediatric IdealConcepts related to fluid removalConcepts related to solute removalFormulas related to CRRTComponents of a CRRT SystemCRRT ProceduresProcedures related to initiation of therapyPro
29、cedures related to monitoring therapyProcedures related to terminating therapyPotential problems encountered during CRRTIndications for CRRT in the critical care settingCRRT outcomes research12th Annual International Conference on Continuous Renal Replacement Therapy,San Diego,CA,USA.CRRT Education
30、PlanCompetencies:Bedside ICU NurseVerbalizeHow CRRT works(fluid and solute balance,changes in nutrition and medications)Reason for treatmentWhen and how to terminate treatmentHow to troubleshoot alarms(AP,VP,blood leak,error codes,air detector)When and how to recirculate the systemHow to care for ca
31、theter and catheter exit siteWhen and how to contact nephrologists or hemodialysis nurseHow to operate extracorporeal circuit warmerDemonstrate 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 solu
32、tion and rates Document continuing care in nursing notes and CRRT flow chart Highly skilled in troubleshooting alarmsCompetencies: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
33、 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 changesAcute Initiation Timeline:ExamplePractical information:Techniques and Methods to Perform CRRTPractical information:Techniques
34、and Methods to Perform CRRTPractical 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.A
35、larms 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 returnCRRT Access:What Works?PediatricsPERMAMENT CATHETER36 CM 1.3 cc 1.4 cc40 CM 1.4 cc 1
36、.5 cc45 CM 1.6 cc 1.7 ccTEMPORARY CATHETER24 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)AdultsPatient Size(kg)Vascular Access2.5-106.5 Fr DLC(10cm)10-208Fr DLC(15cm)2010.8Fr or larger DLC(20cm)Pediatric Perma Cath 28 Cm 0.8 cc 0.85 ccStrazdins V,etal.RRT for A
37、RF in Children:European GuidelinesCorrect 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 PediatricsStrazdins V,et al.RRT for ARF in Children:European
38、GuidelinesArtificial Organs,27(9):781-785 Overview of Pediatric RRT in ARFBaldwin,I.et al,Adequacy Dialysis Quality Initiative,4th International Consensus ConferenceAfter access insertion,staffing in place,CRRT circuit is blood primed for patients 15kgExtracorporeal circuit volume greater than 10%of
39、 patients circulating blood volume.AgeEstimated Total Blood volume in ml/kgPreterm infants90-105 mlTerm newborns78-86 ml1-12 months73-78 ml1-3 years74-82 ml4-6 years80-86 ml7-18 years83-90 mlAdults66-88 mlNote:From Gunn,V.L.&Nechgyba,C.(2002)The ECBV(blood in the dialyzer and bloodlines)should not e
40、xceed 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
41、)=78 ml 100 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 s
42、lowly 10ml/minute Advance BFR slowly(15-20 minutes)Potential Complications of CRRT Volume related problems Biochemical and nutritional problems Hemorrhage Infections Thermic loss Technical problems Logistical problemsCRRT Flash Animation(Modes review)CRRT WORKSHOPFourth Annual International Conferen
43、ce of Saudi Society of Nephrology26-29 April 2009Riyadh,Saudi ArabiaSummary 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!12th Annual International Conference on Continuous Renal Replacement Therapy,San Diego,CA,USA.
