continuous renal replacement therapy (crrt) workshop cyrus custodio, cnc king faisal specialist...
TRANSCRIPT
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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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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
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Outline for the Workshop
1430-1440 Introduction
1440-1500 Review of CRRT
1500-1530 Practical Hands On CRRT Machine CRRT Initiation Sharing of practical experiences in dealing with the CRRT
machine. Troubleshooting Practice
1530-1600 Break & Prayer
1600-1610 Modalities Review (Flash Animation)
1610-1640 Jeopardy
1640-1700 Workshop Summary
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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.
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History of CRRT
• 1950’s – CRRT concept originated
• 1960’s – Scribner proposed CAVHD in context of ARF
• 1977 – Kramer introduces CAVH
• 1980 – Paganini introduces SCUF
• 1984 – Geronemus and Schneider propose CAVHD
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History of CRRT
• 1987 – Uldall introduces CVVHD
• 1990’s – Transition to VV therapies from AV therapies
• 1996 – R. Mehta, UCSD, hosts the first international conference on CRRT in San Diego
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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
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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.
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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
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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
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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.
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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
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TRANSPORT MECHANISMSContinuous Renal Replacement Therapy
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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
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Transport mechanism: DIFFUSION
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Transport mechanism: ULTRAFILTRATION
Movement of fluid across a pressure gradient.
Positive pressure in blood compartment
Negative pressure in dialysate compartment
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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
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Transport mechanism: CONVECTION
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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.
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Transport mechanism: ADSORPTION
Adsorption: molecular adherence to the surface or interior of the membrane.
Molecules that can be effectively adsorbed include:- B2 Microglobulin- Cytokines- Coagulation factors- Anaphylatoxins
It must be noted that movement of fluid is required for adsorption to occur
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TREATMENT MODALITIESContinuous Renal Replacement Therapy
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Modality: SCUFSlow Continuous Ultrafiltration
PRINCIPLEUltrafiltration
PROCESSUsual blood circuit, synthetic membrane and anticoagulation.Fluid removal occurs due to volume.
APPLICATIONS Fluid overload, acute and chronic patients.
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Modality: CVVHContinuous Veno-Venous Hemofiltration
PRINCIPLEHemofiltrattiion Ultrafiltration & Convection.
PROCESSBlood circuit, filter & anticoagulation. Fluid removal and replacement solution.
APPLICATIONSARF/Critically ill patients.
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Modality: CVVHDContinuous Veno-Venous Hemodialysis
PRINCIPLEDiffusion and Ultrafiltration
PROCESSBlood circuit, filter and anticoagulation. Dialysate pathway provided by pumps using sterile fluid.
APPLICATIONSEfficient treatment for small molecule clearance (ARF /CRF, critically ill, sepsis.)
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Modality: CVVHDFContinuous Veno-Venous Hemodiafiltration
HEMODIAFILTRATION
Hemodialysis and Hemofiltration
PRINCIPLEDiffusion, Convection and Ultrafiltration.Best clearance of small, middle and large molecules.Pre-dilution can decrease clotting.Cost increase
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Summary of Modalities
PRINCIPLE SCUF HV & CVVH
CVVHD CVVHDF
Ultrafiltration YES YES YES YES
Convection NO YES NO YES
Diffusion NO NO YES YES
Dialysate NO NO YES YES
Replacement Fluid
NO YES NO YES
What is Removed
FluidFluid & some
Solutes
Fluid & Solutes
Fluid & Solutes
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Molecular 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 (113)• Phosphate (80)
• Urea (60)
• Phosphorus (31)• Sodium (23)
• Potassium (35)
100,000
50,000
10,000
5,000
1,000
500
100
50
10
50
molecular weight,in Daltons
}
}}
“small”
“middle”
“large”
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Program Issues: What is Needed at Your Hospital to Start a CRRRT Program
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Disposables/Machine/Equipments
CRRT Equipment: Separate and accurate pumps and scales for each
component of CRRTRange of blood flows with a minimum of
20ml/minThermoregulationMaximum safety features
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CRRT Machines: Current Generation
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Supplies
CRRT Circuit:• Pediatric :
• Minimum priming volume with low resistance Neonatal lines Pediatric lines
• Exchangeable components• Biocompatible membrane
• Adult• Exchangeable components• Biocompatible membrane
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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 proficiency5. 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 new—and existing—competencies, including those
for new equipment
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CRRT Training and Education
• Nurses Critical Care Nephrology
• Physicians: Ongoing
education Grand Rounds,
small groups BECOME AN
ACCEPTED PART OF THE TEAM
• Pharmacists• Nutritionists
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CRRT Education Plan Dialysis ICU
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
12th Annual International Conference on Continuous Renal Replacement Therapy, San Diego, CA, USA.
CRRT Education Plan
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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
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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
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Time Zero
10 20 30 40 50 60 90 120... minutes
Nephrology MD: Contacts HD Nurse to start CRRT
ICU Nurse: Moves Patient to
Room with HD water Port
HD Nurse: Meet MD; discuss RRT Plan
HD Nurse: Arrives at HD Unit and Begins Set-up
ICU Nurse: Meet MD; discuss RRT
Plan
HD Nurse: Completes Prime; Ready for
Access; Meet the ICU Team and starts CRRT
ICU Nurse: Meet ICU Team and Nephrology commences CRRT
Intensivist MD: Arrive & begin insertion of HD Access Intensivist MD: Completes insertion of HD Access
Nephro.MD:
Enters Orders for RRT
Nephrology MD: Meets ICU MD’s and RN’s; Discuss RRT Plan
Nephrology MD: Present in ICU for
initiation; Meet ICU Team
Time Zero
10 20 30 40 50 60 90 120... minutes
Time Zero
10 20 30 40 50 60 90 120... minutes
Acute Initiation Timeline: Example
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The Nephrologist in-charge of CRRT must continuously interact and communicate with all the other practitioners involved.
Th e M u l t id isc ipl in a r y a ppr o a c h
Audit
Patient Care: CRRT
Policies & Documents
Standards
Physicians
Pharmacists
Suppliers
Educators
Nurses
Technicians
CRRT “Leader ”
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Practical information: Techniques and Methods to Perform CRRT
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Practical information: Techniques and Methods to Perform CRRT
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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
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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
2.5-10 6.5 Fr DLC (10cm)
10-20 8Fr DLC (15cm)
>20 10.8Fr 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
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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).
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CRRT in Pediatrics
Strazdins V, et al. RRT for ARF in Children: European GuidelinesArtificial Organs, 27(9):781-785 Overview of Pediatric RRT in ARFBaldwin, 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.Age Estimated Total Blood volume in
ml/kg
Preterm infants
90 -105 ml
Term newborns
78 -86 ml
1-12 months 73 -78 ml
1-3 years 74 -82 ml
4-6 years 80 -86 ml
7-18 years 83 -90 ml
Adults 66 -88 ml
Note: From Gunn, V. L. & Nechgyba, C. (2002)
• The ECBV (blood in the dialyzer and bloodlines) should not exceed 10% of the patient’s total blood volume.
• If the ECBV will exceed 10%, of the patient’s 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
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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)
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Potential Complications of CRRT
• Volume related problems• Biochemical and nutritional problems• Hemorrhage• Infections• Thermic loss • Technical problems• Logistical problems
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CRRT Flash Animation (Modes review)
multifiltrate_GB.exe
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CRRT WORKSHOPFourth Annual International Conference of Saudi Society of
Nephrology
26-29 April 2009
Riyadh, Saudi Arabia
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Summary
• CRRT is something we can do• Can be life-saving for critically ill patients (pediatric and
adult)• Careful planning of the institution’s 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.