Post on 03-Jun-2015
transcript
Pediatric CRRT Terminology
Helen Currier BSN, RN, CNNAssistant Director, Renal/Pheresis
Texas Children’s Hospital
Houston, Texas
History of Continuous Renal Replacement Therapy (CRRT)
1960 Continuous arteriovenous approach first described for treatment of renal failure
1974 Ultrafiltration isolated from hemodialysis circuit and the addition of a hemofilter
1975 Hemofiltration technique proposed
1979-82 SCUF and CAVH used by Paganini (MD) and Whitman (RN) at Cleveland Clinic
History of Continuous Renal Replacement Therapy (CRRT)
1980s CRRT used in pediatrics 1987 Pump-assisted CRRT
introduced 1990 CRRT considered state of the art therapy
for treatment of acute renal failure 1993 Standards of Clinical Practice for CRRT
published by the American Nephrology Nurses’ Association (ANNA) and endorsed by the American Association of Critical
Care Nurses (AACN)
History of Continuous Renal Replacement Therapy (CRRT)
2000 Continued development of integrated blood pump and
fluid balance equipment for CRRT
2002 Second pCRRT meeting in Orlando, FL
2004 Third pCRRT meeting in Orlando, FL
Test your knowledge
Pediatric CRRT therapies are approximately
A. 40 years old
B. 30 years old
C. 20 years old
D. 10 years old
Test your knowledge
Pediatric CRRT therapies are approximately
A. 40 years old
B. 30 years old
C. 20 years old
D. 10 years old
Indications for CRRT in the Critical Care Setting Fluid removal
Solute removal
Basic Concepts of CRRT: Concepts Related to Fluid Removal or Ultrafiltration Blood flow
– Arteriovenous– Venovenous
Hydrostatic pressure– Arteriovenous– Venovenous
Other factors– Hematocrit– Plasma proteins– Transmembrane pressure
Basic Concepts of CRRT: Concepts Related to Solute Removal or Clearance
Convection – solute drag; hemofiltration
Diffusion – concentration gradient; hemodiafiltration
Solute Mass Transfer in CRRT
Post-Dilution CVVH CVVHD
Pre-Dilution CVVH CVVHDF
Qb
Qb Qb
Qb
Qeff Qeff
QeffQeff Qd
Qd
Qr
Qr
Qr
Solute Molecular Weight and ClearanceSolute (MW) Sieving Coefficient Diffusion Coefficient
Urea (60) 1.01 ± 0.05 1.01 ± 0.07
Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06
Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04*
Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04**
*P<0.05 vs sieving coefficient**P<0.01 vs sieving coefficient
Comparison of Urea Clearance: CVVH vs CVVHD(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)
Study design– Fixed blood flow rate - 4 ml/kg/min– HF-400 (0.3 m2 polysulfone)– Cross over for 24 hrs each to
pre-filter replacement fluid (CVVH) or Dx (CVVHD) flow at 2000 ml/hr/1.73 m2
Comparison of Urea Clearance: CVVH vs CVVHD(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)
0
5
10
15
20
25
30
CVVH CVVHD
U
rea
Cle
aran
ce(m
ls/m
in/1
.73
m2)
BFR = 4 mls/kg/minFRF/Dx FR = 2 l/1.73 m2/hrSAM = 0.3 m2
p = NS
Methods of Continuous Renal Replacement Therapy
Definition of Acronyms and Terms
SCUF slow continuous ultrafiltration CAVHCAVH continuous arteriovenous continuous arteriovenous
hemofiltrationhemofiltration CAVHDCAVHD continuous arteriovenous continuous arteriovenous
hemodialysishemodialysis CVVH continuous venovenous
hemofiltration CVVHD continuous venovenous
hemodialysis CVVHDF continuous venovenous
hemodiafiltration
Continuous Renal Replacement Therapy
Advantages– Slower blood flows– Slower UF rates– Adjust UF rates with hourly patient intake– Increased cytokine (bad humors) removal?
Disadvantages– Prolonged anticoagulation– Increased cytokine (good humors) removal?
The Pediatric Ideal: CRRT Equipment
Separate and accurate pumps and scales for each component of CRRT
Range of blood flows with a minimum of 20ml/min
Thermoregulation Maximum safety features
The Pediatric Ideal: CRRT Circuit
Minimum priming volume with low resistance
Exchangeable components
Biocompatible membrane