1 prismaflex crrt intro - seg 1 (2007)

1. PrismaFlex
STEPP
Basic CRRT Principles
®

2. Course Objectives
By the end of the Gambro CRRT training course
the participant will be able to:
•Define CRRT and the associated therapies
•Discuss the basic CRRT principles
•Discuss the basic principles of the solute transport mechanisms
•Identify the clinical indications for administering CRRT, including
an overview of patient selection and therapy application
•Have a working knowledge of basic CRRT machine set up, run, end
treatment and troubleshooting skills.
•Describe the CRRT machine’s safety management features,
pressure monitoring and fluid balance principles.

3. Continuous Renal Replacement
Therapy (CRRT)
““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, Nov 1996

4. CRRT closely mimics the native kidney in
treating ARF and fluid overload
Why CRRT?
Removes large amounts of fluid and waste products
over time
Tolerated well by hemodynamically unstable patients

5. CRRT Treatment Goals
Maintain fluid, electrolyte, acid/base balance
Prevent further damage to kidney tissue
Promote healing and total renal recovery
Allow other supportive measures; nutritional
support

6. Determinants of Outcome
Initiation of Therapy
•Ronco Study
•Gettings Study
•ADQI Consensus Initiative - Rifle Criteria
Dose
•Ronco Study
•Kellum Meta-Analysis
•Saudan Study

7. Risk
Injury
Failure
Loss
ESRD
GFR Criteria Urine Output Criteria
Increased creatinine x 1.5
or GFR decrease >25%
UO <,0.5ml/kg/hr x 6 hours
Increased creatinine x 2 or
GFR decrease >50%
UO <0.5 ml/kg/hr x 12 hours
Increased creatinine x 3 or
GFR decrease >75% or
Serum Creatinine > 4mg/dl
UO <0.3 ml/kg/hr x 24 hours
or anuria x 12 hours
Persistent ARF= complete loss of
renal function >4 weeks
End-stage renal disease (>3
months)
Early
Initiation

8. 100
90
80
70
60
50
40
30
20
10
0
Group 1(n=146)
((Uf = = 20 ml/h/Kg)
Group 2 (n=139)
(Uf = 35 ml/h/Kg)
Group 3 (n=140)
(Uf = 45 ml/h/Kg)
41 %
57 % 58 %
p < 0.001 p n..s.
p < 0.001
Survival (%) Survival (%)
Cumulative Survival (%) vs Treatment Dose
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study.
Lancet . july 00

9. Summary
Evidenced Based Research reports that
patient survival is improved by:
•Early initiation:
•Utilization of RIFLE Criteria

•Minimum dose delivery of 35 ml/kg/hr
•eg. 70 kg patient = 2450 ml/h
Effects of different doses in CVVH on outcomes of ARF – C. Ronco M.D., R. Bellomo
M.D. Lancet 2000; 356:26-30.

10. Anatomy of a Hemofilter
• 4 External ports
•blood and dialysis fluid
• Potting material
•support structure
• Hollow fibers
•Semi-permeable
membrane
• Outer casing

11. CRRT
Transport Mechanisms

12. Molecular Transport Mechanisms
Ultrafiltration
Diffusion
Convection
Adsorption
Fluid Transport
Solute Transport}

13. Ultrafiltration
•Movement of fluid through a semi-
permeable membrane caused by a
pressure gradient
•Positive, negative and osmotic pressure
from non-permeable solutes

14. Blood Out
Blood Into waste
(to patient)
(From patient)
HIGH PRESSLOW PRESS
Fluid Volume
Reduction
Ultrafiltration

15. Molecular Weights
Daltons
• Inflammatory Mediators (1,200-40,000)
“small”
“middle”
“large”

16. Diffusion
•Movement of solutes from an area of
higher concentration to an area of
lower concentration.
•Dialysate is used to create a
concentration gradient across a semi-
permeable membrane.

17. Hemodialysis: Diffusion
Dialysate In
Dialysate Out
(to waste)
Blood Out
Blood In
(to patient)
(from patient)
HIGH CONCLOW CONC

18. Convection
•Movement of solutes with water flow,
“solvent drag”.
•The more fluid moved through a semi-
permeable membrane, the more solutes
that are removed.
•Replacement Fluid is used to create
convection

19. to waste
HIGH PRESSLOW PRESS
Repl.Repl.
SolutionSolution
Hemofiltration: Convection
Blood Out
Blood In
(to patient)
(from patient)

20. Electrolytes & pH Balance
Another primary goal for CRRT, specifically:
•Sodium
•Potassium
•Calcium
•Glucose
•Phosphate
•Bicarbonate or lactate buffer
Dialysate and replacement solutions are
used in CRRT to attain this goal.

21. Adsorption
Molecular adherence to the surface or
interior of the membrane.

22. 0
20
40
60
80
100
Clearance in %
35.00055.00020.0005.0002.500
Urea
(60)
Albumin
(66.000)
Myoglobin
(17.000)
65.000
Creatinine
(113)
Kidney
Convection
Diffusion
Small vs. Large Molecules Clearance

23. What is the transport
mechanism associated
with dialysate and
replacement solutions?

24. Effluent
Pre Blood Pump
Replacement:
Convection
Blood
Flow Control Unit – Pumps
Dialysate: Diffusion

25. Effluent Flow Rate
Effluent = Total Fluid Volume:
•Patient Fluid Removal
•Dialysate Flow
•Replacement Flow
•Pre-Blood Pump Flow

26. CRRT Modes of Therapy
SCUF - Slow Continuous Ultrafiltration
CVVH - Continuous Veno-Venous Hemofiltration
CVVHD - Continuous Veno-Venous HemoDialysis
CVVHDF - Continuous Veno-Venous HemoDiaFiltration

27. SCUF
Slow Continuous UltraFiltration
Primary therapeutic goal:
•Safe and effective management of
fluid removal from the patient

28. SCUF
Slow Continuous UltraFiltration
Effluent
Pump
Infusion or
Anticoagulant
Blood Pump
PBP
Pump
Effluent
Access
Return

29. CVVHD
Continuous VV HemoDialysis
Primary therapeutic goal:
•Small solute removal by diffusion
•Safe fluid volume management
Dialysate volume automatically removed
through the Effluent pump
Solute removal determined by Dialysate Flow Rate.

30. CVVHD
Continuous VV HemoDialysis
Hemofilter
Effluent
Pump
Effluent
Access
Return
Dialysate
Pump
Dialysate
Fluid
Blood
Pump
Infusion or
Anticoagulant
PBP
Pump

31. Dialysate Solutions
•Flows counter-current to blood flow
•Remains separated by a semi-permeable membrane
•Drives diffusive transport
•dependent on concentration gradient and flow rate
•Facilitates removal of small solutes
•Physician prescribed
•Contains physiologic electrolyte levels
•Components adjusted to meet patient needs

32. CVVH: Continuous VV Hemofiltration
Primary Therapeutic Goal:
• Removal of small, middle and large sized solutes
• Safe fluid volume management
•Replacement solution is infused into blood
compartment pre or post filter
•Drives convective transport
•Replacement fluid volume automatically removed
by effluent pump
Solute removal determined by Replacement Flow Rate.

33. CVVH
Continuous VV Hemofiltration
Effluent
Pump
Blood
Pump
Effluent
Access
Return
Replacement
Pump 1
Replacement
Pump 2
Replacement 1Replacement 2 Infusion or
Anticoagulant
PBP
Pump

34. Pre-Dilution Replacement Solution
•Decreases risk
of clotting
•Higher UF
capabilities
•Decreases Hct.
In filter
Hemofilter
Effluent
Pump
Blood
Pump
PBP
Pump
Effluent
Access
Return
Replacement
Pump
Replacement
Fluid
Infusion or
Anticoagulant

35. Post-Dilution Replacement Solution
•Consider
lowering
replacement rates
(filtration %)
•Higher BFR
(filtration %)
•Higher
anticoagulation
•More efficient
clearance (>15%)
Hemofilter
Effluent
Pump
Blood
Pump
Effluent
Access
Return
Replacement
Pump
Replacement
Fluid
Replacement
Pump
Replacement
Fluid
PBP
Pump
Infusion or
Anticoagulant

36. Replacement Solutions
•Infused directly into the blood at points along
the blood pathway
•Drives convective transport
•Facilitates the removal of small middle and
large solutes
•Physician Prescribed
•Contains electrolytes at physiological levels
•Components adjusted to meet patient needs

37. CVVHDF
Primary therapeutic goal:
•Solute removal by diffusion and convection
•Safe fluid volume management
•Efficient removal of small, middle and large
molecules
Replacement and dialysate fluid volume automatically
removed by effluent pump
Solute removal determined by
Replacement + Dialysate Flow Rates.

38. CVVHDF
Continuous VV HemoDiaFiltration
Effluent
Pump
Effluent
Access
Return
Dialysate
Pump
Dialysate
Fluid
Blood
Pump
Replacement
Pump
Replacement
Fluid
PBP
Pump
Infusion or
Anticoagulant