Sled 2019

1. Sustained Low-Efficiency Extended Dialysis TBD aka Swapnil Hiremath, @hswapnil University of Ottawa

2. Disclosures No relevant financial conflicts Research funding from CIHR, PSI, TOHAMO, KFoC

3. Disclosures

4. Objectives At the end of this talk, the participant will be able: obtain an overview of the principles of SLED Discuss some logistic considerations Understand why SLED makes sense

5. TL:DR; version Use an HD machine Slow Qb, Qd Use smaller filter 4K bath; Add PO4 to dialysate 8 - 12 hours, overnight, daily (Persuade ICU RNs to do SLED)

6. What is SLEDD/SLED/SLEDD-f? Slow Low-Efficiency Daily Dialysis Sustained Low-Efficiency Dialysis Slow Extended Dialysis Slow Low-efficiency Daily Dia-Filtration Mainly New Zealand using Fresenius 4008S PIRRT: prolonged intermittent renal replacement therapy

7. A Brief History of Dialysis for AKI 1950-70 Conventional HD 1970-85 Acute PD or conventional HD 1985-2005 CRRT 2005- Conventional HD, CRRT, SLED

8. Fresenius 2008H machine Software modified to do Qd 100 mL/min Used Qb 100-200 mL/min F40 dialyzer (surface area 0.7 sq metres) Continuous SLED is not really new: First Report from 1999

9. Issues Hemodynamic instability: mainly from Need to remove large volumes in 4 hours Large amounts of fluids administered between treatments Rapid osmotic shifts Multiple Investigations Extend time to 8 hours or more Lower Qb and Qd (slow) Daily treatments Do dialysis at night

10. How do you order? Filter: pediatric filter (F40s); order larger if you have concerns about adequacy Duration: 8 - 12 hours (shorter if concerns of dialysis dysequilibrium) Longer if more volume to come off* Qb, Qd: 200, 300* default (Can go higher if required) Fluid Removal: Total UF - unlike CRRT, like HD

11. Orders Contd. Dialysate: K - suggest 4 as default; 3 if hyperkalemia. Rarely if ever 2 or lower Ca: 1.25 or 1.5 mmol/L HCO3: range 28-38 - perhaps 32 should be default

12. Orders: PO4 30 mL = 0.2 mmol/L 1 full fleet = 133 mL = 0.94 mmol/L Suggest starting with 90 - 120 ml for first run and going to 150 ml (1 mmol/L) second run on Or just ‘full fleet’

13. SLED: anticoagulation Heparin No Anticoagulation: needed for ~ 30 - 80 % Saline flushes Citrasate (use 1.5 Ca bath)

14. SLED: Logistics elsewhere Fresenius 2008H CRRT option Qb ~200; Qd ~ 100mL/min (1 canister = complete Rx); small dialyzer (F80) Usually nocturnal, started between 1600 – 2400 hours Usually HD RN starts and terminates; ICU RN does most of the hourly charting/alarms

15. Ottawa Gambro Artis F40 Polysulfone 0.6m2 High 8 Nocturnal 3-7/week 200 300 bicarb SLED across the world

16. SLED across the world: Nursing model

17. SLED at Ottawa

18. SLED: Ottawa SLED done by ICU RNs Have dedicated SLED machines (Artis: same as our HD machines*) Any time 3 - 7 times a week Upto 8 hours, but can do more Qb 200, Qd 300; F40 dialyser

19. Transition

20. Antibiotics

21. RRT in AKI: What Matters? Patient survival and renal recovery Cost Complexity and nursing workload Safety – correction of electrolyte disorders, anticoagulation, risk of errors Flexibility Patient rehabilitation

22. Mortality

23. Mortality: RCTs only

24. More analyses

25. Mortality

26. Renal Recovery

27. Cost

28. Cost: Consumables Machines different but same cost PRISMAFLEX vs any conventional HD machine Dialysate: $5-7/L purchased in bags for CRRT $0.10/L purified city water for IHD, SLED Filter sets Prisma: $200 IHD/SLED: $20

29. Cost: Labour Labour If No HD nurse involvement then ICU RN only (no labour cost???) IHD: 1 HD nurse for 4 hours SLED: 1 HD nurse for 8 hours, but usually does 2 patients simultaneously SLED: precedents for HD nurse doing set up and ICU nurses doing monitoring i.e. 1 hour HD nurse involvement/treatment

30. Canadian Experience

31. Details of SLED 1 litre saline/hr

32. Source: Berbece, Richardson, Kidney Int 2006, PMID: 16850023 Cost: Summary Toronto model: Cost based on 1 HD RN dialyzing 2 patients simultaneously Microcosting performed in Ottawa: $450/day saving with SLED compared to CRRT

33. Complexity

34. Complexity/Nursing Workload: CRRT CRRT - heparin Manage bags of dialysate (5L) q.2-3.h Empty drain bag (5L) q.2-3.h RN or pharmacy must add KCl to each bag Hourly recording of machine data and flows CRRT – citrate: all of the above + Manage citrate infusion Manage calcium infusion Manage saline infusion (to correct high HCO3) Monitor ionized calcium to regulate citrate and calcium infusions

35. Complexity /Nursing Workload: SLED SLED Connect machine to patient after priming Heparin or alternately, saline flushes using bags of saline Hourly monitoring of machine functions Wait for an alarm ( 1 per treatment for SLED) (One HD RN may monitor 1-3 machines) Simplicity /Nursing Workload: SLED

36. Safety

37. Safety SLED Can choose dialysate with 0, 1, 2 ,3 , 4 mmol/L KCl, appropriate calcium, magnesium, HCO3 Can add sodium PO4 to correct low phosphate Most often done without anticoagulant- saline flushes

38. Safety: compare with nocturnal home HD Follow exactly the same protocol as SLED 8 hours, 4-6 nights/week Qb 200, Qd 350 ml/min, heparin Central line or fistula Sleep through the treatment with very few alarms

39. Patient Rehabilitation ICU survivors have grossly impaired muscle strength, mobility, QOL Early mobilization thought to be key to prevent this CRRT precludes mobilization IHD or SLED (especially overnight) frees patients for many hours/day

40. SLED summary Clinical outcomes: SLED = CRRT Simpler Cheaper Easier on Nurses ?better for rehab/recovery

41. Thanks

42. TL:DR; version Use an HD machine Slow Qb, Qd Use smaller filter 4K bath; Add PO4 to dialysate 8 - 12 hours, overnight, daily (Persuade ICU RNs to do SLED)