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Aquarius System Nikkiso Educational Framework
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Aquarius System Continuous Renal Replacement Therapy (CRRT)
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Agenda Morning
Theoretical perspectives
Kidney Anatomy & Physiology Acute Kidney Injury Acute Blood Purification Transport Mechanisms Treatment Modalities Treatment Dose
Practical Aquarius Overview Lining and Priming Recirculation
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3
Agenda Afternoon
Theoretical Filtration Fraction Filtration Ratio Vascular Access
Practical
Programming Connection Alarms Troubleshooting Disconnection Safe Disposal
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4
Aquarius System Renal Anatomy and Physiology
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Renal Anatomy and Physiology
The kidneys are two bean shaped organs, located just below the inferior boundary of the rib cage.
Each kidney can function independently of the other. Each adult kidney weighs approximately 110 – 170 grams and is about the size of a human fist.
The adult kidneys receive 1200 millilitres of blood (25% of cardiac output) every minute. That is 72 litres per hour or 1728 litres per day.
Normal kidney function is measured in terms of glomerular filtration rate (GFR). Normal GFR is typically 90-120 millilitres per minute. An estimation of Glomerular Filtration Rate (eGFR) can be calculated based on age and serum creatinine Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Component of the Kidney
Consists mainly of 3 parts: Medulla contains 20% of the nephrons that filter the blood and concentrate urine. An important diagnostic tool.
Cortex contains 80% of the nephrons to filter the blood continuously to maintain fluid balance.
Renal pelvis is the start of the collecting system, containing the collecting tubules and the ureter. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
7
Components of the Kidney
The kidney functions using three principles: • Ultrafiltration • Excretion • Re-absorption
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Components of the Kidney – The Nephron Nephron – Is the functional unit of the kidney. Each kidney has about one million nephrons
Each nephron contains a glomerulus, which functions as an individual filtering unit
The nephron also contains tubules for secretion and absorption of substances
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Components of the Kidney
The Glomerulus; The glomerulus consists of a group of cells with selective permeability. Selective permeability means that certain substances will cross the membrane and others will not be allowed to cross. Through selective permeability, the kidney regulates fluid and electrolyte balance. In an adult, the kidneys produce approximately 180 litres of filtrate per day. Only 1.5 - 2 litres are excreted as urine. The remaining 178 litres are reabsorbed by the kidney.
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The tea filter is a good example of a semi-permeable membrane
10
Functions of the Nephron
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Functions of the Kidney
Fluid balance Through ultrafiltration and reabsorption. Electrolyte balance Through reabsorption and excretion. Acid-base balance Through reabsorption and excretion. Excretion of drugs and by-products of metabolism Nitrogen, urea, creatinine. Synthesis of erythropoietin Stimulates bone marrow to produce mature red blood cells. Regulation of blood pressure Through the secretion of renin. Maintenance of calcium-phosphate balance Through the activation of vitamin D production. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
12
Aquarius System Acute Kidney Injury
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Acute Kidney Injury Acute Kidney Injury (AKI) results from the sudden loss of kidney function. AKI in the setting of critical care patients is defined as “..an abrupt decline in glomerular filtration rate.” Jefferson et al (2007) Waste products will start to accumulate in the blood.
AKI may be accompanied by metabolic, acid-base and electrolyte disturbances and fluid overload.
AKI may affect other organ systems. AKI may require immediate treatment. Jefferson JA, Schrier RW. Pathophysiology and Etiology of Acute Renal Failure. In: Comprehensive Clinical Nephrology. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2007:755-770.
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RIFLE Criteria
The Acute Dialysis Quality Improvement Initiative (ADQI) Recommends the Classification of AKI based on the RIFLE criteria.
2 Ricci et al - The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney International (2008) 73, 538– 546
Summary of Classifications of AKI
Kristensen et al (2014) ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). European Heart Journal 35 (35) 2383–2431
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Acute Kidney Injury Classification There are 3 types of Acute Kidney Injury Classification
Pre-Renal
Renal (Intra-Renal)
Post-Renal
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AKI Classification: Pre-Renal Pre-renal failure typically results from decreased blood flow to the kidneys. The reduction in glomerular filtration enables the solutes in the blood to accumulate but does not cause any structural damage to the kidney itself. Examples of situations leading to pre-renal failure may include: – dehydration – haemorrhage Pre renal 30-60% – congestive heart failure (think „p‟ for pressure) – sepsis – embolism/thrombosis • Volume depletion • Decreased circulating volume • Reduced cardiac output • Renal vascular disease
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AKI Classification: Renal (Intra-Renal) Renal (Intra-renal) failure typically involves direct injury to the kidney itself. The most common cause is Acute Tubular Necrosis (ATN). Some causes of ATN are: – Ischaemia – Hypertension – Nephrotoxins – Some systemic vascular diseases such as lupus. . Intra-Renal 20-40% (think “I” for infection) • Glomerular infection • Vascular • Nephritis
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AKI Classification: Post Renal In post-renal failure, the underlying cause is typically a bilateral obstruction below the level of the renal pelvis. Causes for this may be: – Tumour development – Thrombi – Urinary tract obstruction – Hypertrophic prostate. Post renal 1 – 10% (think „o‟ for obstruction) • • • •
Obstruction Ureters Bladder Urethra
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Nephrotoxic Drugs
Nephrotoxicity is the poisonous effect on the kidneys caused by toxic
chemicals and medication. Drug-induced AKI is common in critical illness and accounts for 15% to 25% of all cases of renal failure seen in this population. The medications implicated in causing drug-induced AKI can be classified based on their mechanism of renal injury; pre-renal, intra-renal and postrenal. The mechanisms of toxicity are complex and, in many cases, affect more than one aspect of kidney function. All NSAIDs have been associated with AKI, and consideration should be given to either avoid their use or, when indicated, use with extreme caution.
Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174 Ricci Z., Ronco C., (2008) The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney International 7 (5) 538-546
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Nephrotoxic Drugs - Nonsteroidal antiinflammatory drugs Volume contraction from any cause or other forms of pre-renal AKI (cirrhosis, congestive heart failure) will increase the incidence of and severity of nephrotoxicity due to nonsteroidal anti-inflammatory drugs (NSAIDs). Conditions such as a. b. c. d.
Congestive heart failure Hypotension Volume depletion 3rd spacing
These conditions all decrease effective arterial volume. These are conditions that predispose the patient to NSAID-induced nephrotoxicity.
Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174
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Nephrotoxic Drugs- ACE Inhibitors & others
ACE inhibitors ACE inhibitors are commonly prescribed drugs used for hypertension, congestive heart failure and chronic kidney disease. These drugs affect renal haemodynamics through an decrease in efferent arteriolar tone and intraglomerular capillary pressure. The use of these drugs under normal circumstances when renal perfusion is adequate poses very little problem. However when these drugs are used in states of prerenal azotemia, renal artery stenosis or concomitantly with other drugs such as NSAIDs, renal failure may occur. Other drugs that cause altered glomerular haemodynamic instability Drugs such as cyclosporine and tacrolimus, belong to a class of commonly used immunosuppressant's for organ transplantation referred to as calcineurin inhibitors. Calcineurin inhibitors are associated with early prerenal oliguria due to vasoconstriction Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174
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Begins when urine output begins to rise
Has variable time frames, sometimes occurring as little as 24 hours after the onset of renal failure Associated with potassium and sodium loss in the urine Enhanced urine output may not reflect restored kidney function but rather may be the result of accumulating serum urea and creatinine, which have an osmotic diuretic effect
Recovery phase
Low urine output (less than 400 mL/24 hrs) Possibly protein in the urine Electrolyte imbalances Metabolic acidosis
Polyuric phase
Oliguric phase
Phases of Acute Kidney Injury
May
last several months following the onset of the Acute Kidney Injury
During this period, kidney function gradually returns to normal and proper urine concentrations and volumes are achieved
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Management Goals for Acute Kidney Injury
Fluid balance. Correction of electrolyte abnormalities.
Restoration of acid-base balance. Removal of waste products. Haemodynamic stabilisation. Nutritional support.
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Treatment options for AKI
Information and support
Peritoneal dialysis
Pharmacological and fluid management
Acute Kidney Injury
Relieve urological obstruction
Intermittent haemodialysis (IHD) Continuous Renal Replacement Therapy (CRRT)
Monitoring
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Aquarius System Continuous Renal Replacement Therapy (CRRT)
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Indications for commencing CRRT
Renal Indications: Rapidly rising serum urea and creatinine or the development of uraemic complications. Hyperkalaemia unresponsive to medical management. Severe metabolic acidosis. Diuretic resistant pulmonary oedema. Oliguria or anuria.
Non Renal indications: Management of fluid balance e.g. in cardiac failure. Clearing of ingested toxins. Correction of electrolyte abnormalities. Temperature control. Removal of inflammatory mediators in sepsis.
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Some Indications for CRRT
Pre & Post Cardiac Surgery
Haemodynamic Instability
Fluid Overload
Shock
Sepsis – Lactate Acidosis
Acute Multi-Organ Failure
Drug Overdose
ARDS / / ARDS VAP VAP
Shock
Trauma Rhabdomylosis 29
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Continuous Renal Replacement Therapy Goals
Clean the blood Manage Intravascular volume Wastes are cleaned from the blood by diffusion and convection. Water is removed by ultrafiltration.
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Defining The Therapy Early application of Continuous Renal Replacement Therapy (CRRT) may prove to be beneficial to the patient. CRRT is a therapy indicated for continuous solute removal in the critically ill patient.
CRRT allows for continuous, slow and isotonic fluid removal that results in better haemodynamic tolerance even in unstable patients with shock and severe fluid overload. CRRT can be modified at any time of the day and night to allow adaptation to the rapidly changing haemodynamic situation of critically ill patients. CRRT therapy indications may be renal, non-renal, or a combination of both. It is the treatment of choice for the critically ill patient requiring renal support and/or fluid management. Kellum J, Ronco C, Joannidis M (2012) An emerging consensus for AKI ICU Management 12 (1) 38-40
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Aquarius System Treat ment M odal i t i es & Transport M echani sms
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Treatment Modalities
CRRT includes several treatment modalities. All of these modalities use veno-venous access. The choice will depend on the needs of the patient and the preferences of the physician.
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CRRT Treatment Modalities
.
SCUF
CVVH
Slow Continuous Diffusive & Ultrafiltration Convective
Therapy
Continuous Diffusive Veno-Venous Therapy Haemofiltration
CVVHDF
CVVHD
Continuous VenoContinuous VenoConvective Therapies Venous Venous HaemoDiaFiltration Haemodialysis Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
Slow Continuous Ultrafiltration (SCUF)
Primary therapeutic goal:
Safe management of fluid removal
Primary indications:
Fluid overload
Principle used:
Ultrafiltration (removal of water)
Therapy characteristics:
• No dialysate or substitution solutions. • Fluid removal only.
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Transport Mechanism: Ultrafiltration
Ultrafiltration is the movement of fluid through a semi-permeable membrane along a pressure gradient.
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Slow Continuous Ultrafiltration (SCUF)
Graphics will become visible in presenter mode.
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Continuous Veno-Venous Haemofiltration (CVVH)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Ultrafiltration (removal of water) Convection (clearance of solutes)
Therapy characteristics:
• Requires substitution solution with a buffer to drive convection. • No dialysate solution • Used to achieve solute removal (small, medium and large sized molecules) and fluid balance.
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Transport Mechanism: Convection
Convection is the one-way movement of solutes through a semi-permeable membrane with a water flow. Sometimes it is referred to as solvent drag.
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Continuous Veno-Venous Haemofiltration (CVVH)
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Continuous Veno-Venous Haemodialysis (CVVHD)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Diffusion
Therapy characteristics:
• Requires substitution solution with a buffer to aid the diffusive process. • No substitution solution. • Used to achieve solute removal (small and medium sized molecules) and fluid balance.
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Transport Mechanism: Diffusion
Diffusion is the movement of solutes through a semi-permeable membrane from an area of higher concentration to an area of lower concentration.
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Transport Mechanism: Diffusion Solutes move from a higher concentration to a lower concentration In CRRT, diffusion occurs when blood flows on one side of the membrane, and dialysate solution flows counter-current on the other side The dialysate does not mix with the blood Efficient for removing small and medium molecules but not large molecules Molecular size and membrane type can affect clearances Diffusion occurs during haemodialysis Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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No Counter Current Principle
3
3
3
3.5
3
3
3
4
3
3
3
3.5
3
4
2.5
4.5
5
6
3
4
2.5
2
6.5 2
Anaesthesia UK (2003) Acute renal failure and renal replacement therapy in the ICU http://www.frca.co.uk/article.aspx?articleid=100367# Accessed 10th August 2015 10:10
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Counter current principle (Diffusion)
2
2.5
3
3.5
2
2.5
3
4.0
2.5
3.5
4.5
3
3.5
4
5
4.5
6
4
4.5
5
5.5
5
5.5
6.5
Anaesthesia UK (2003) Acute renal failure and renal replacement therapy in the ICU http://www.frca.co.uk/article.aspx?articleid=100367# Accessed 10th August 2015 10:10
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Continuous Veno-Venous Haemodialysis (CVVHD)
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Continuous Veno-Venous Haemodiafiltration (CVVHDF)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Diffusion and Convection
Therapy characteristics:
• Requires dialysate solution and substitution solution, both contain a buffer that drives the convection and diffusion processes. • Used to achieve solute removal (small, medium and large sized molecules) and fluid balance.
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Continuous Veno-Venous Haemodiafiltration (CVVHDF)
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Treatment Modality Summary Continuous Renal Replacement Therapy : A Summary Modes
Principles
SCUF Slow Continuous UltraFiltration
UltraFiltration Movement of fluid through a semi-permeable membrane along a pressure gradient.
CVVH Continuous Veno-Venous Haemofiltration (can be pre or post dilution)
Convection (active) One-way movement of solutes through a semi permeable membrane with a water flow – sometimes referred to as „solvent drag‟.
CVVHD Continuous Veno-Venous HaemoDialysis
Diffusion (passive) Movement of solutes through a semi-permeable membrane from an area of high concentration to low concentration.
CVVHDF Continuous Veno-Venous HaemoDiaFiltration
Combined Mode: Convection • Haemofiltration • Active – convection Diffusion • Haemodialysis • Passive - diffusion
Fluids
Molecules Cleared
Pumps In Use No Fluid (for fluid removal only)
Nil
Pre-dilution pump Post-dilution pump Filtrate Pump Substitution fluid (pre/post)
Small Medium Large
Pre-dilution pump Post-dilution pump Filtrate Pump Dialysate fluid
Small Medium
Dialysate pump Filtrate pump
Substitution / Replacement Fluid Dialysate Small Medium Large
Post dilution pump Dialysate pump Filtrate pump
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Molecular Weights
Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 1857758730
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Adsorption
Adsorption is the adherence of solutes and biological matter to the surface of a membrane
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Transport Mechanism: Adsorption
High levels of adsorption can cause some filters to clog and become ineffective
Membrane type affects adsorption tendencies/effectiveness Adsorption may also limited removal of some solutes (eg. β2 microglobulins) from the blood
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Replacement Fluid
Accusol 35 is a bicarbonate based solution primarily intended for use in patients with hyperkalaemia.
Accusol 35 solution gives health care providers a convenient and easy-touse solution for the patient‟s CRRT needs. It is completely lactate-free, with a 100% bicarbonate buffer that provides all the necessary electrolytes. Accusol solution comes in ready-to-mix formulations with varying potassium levels
Substitution fluid in haemofiltration and haemodiafiltration and a diaylsis solution in haemodialysis and haemodiafiltration. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Accusol 35
Accusol 35 purifies blood of waste products; it corrects acidity or alkalinity the level of salts in the blood.
Accuosl 35 solutions are supplied in a non PVC bag with two chambers containing bicarbonate and calcium. The chambers need to be spilt and mixed before use. Once mixed the solution lasts for 24 hours.
Accusol 35 works closely with the body‟s natural chemistry to maintain electrolyte balance during therapy and restore haemodynamic stability
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Aquarius System Tr e a t m e n t D o s e
6.02.08 Software Education Module
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Measurement of therapy dose
Therapy dose is a measure of the quantity of blood purification achieved. The concept of clearance represents the volume of blood cleared of a given solute over time.
Commonly used solute markers to quantify clearance are serum Urea and Creatinine.
Best clinical practices combine clearance and dosing effectiveness using a weight-related dosage of therapy
On Aquarius, therapy dose is defined by the total ultrafiltration rate and is expressed as millilitres (therapy amount) per kilogramme (patient weight) per hour (time) or ml/kg/hr Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Prescribed vs Delivered Dose Prescription should exceed that calculated to be adequate because of the known gap. 8ml/kg/hr less
Prescribed dose of therapy should be assessed daily to account for any measured shortfalls in delivered dose.
Delivered dose of therapy should be assessed to ensure the adequacy of the prescription. According to Vesconi et al (2009) in practice the delivered therapy dose was on average 8ml/kg/hr less.
Vesconi et al (2009) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Critical Care 13 (2);r57
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Where does that 8mls/kg/hr go?
Why might we „lose‟ significant amounts of therapy dose? • • • • • •
Recirculation in vascular access High filtration fractions Filter clogging and clotting Troubleshooting skills Changing of circuits Filter down time
Vesconi et al (2009) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Critical Care 13 (2);r57
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Clinical Evidence for Therapy Dose
Landmark studies suggest that increasing therapy dose improved survival1 Recent studies find no difference in survival between 25 and 40 ml/kg/hr therapy dose2,3
Higher therapy doses (40 ml/kg/hr) did not alter mortality in the subgroup of sepsis patients.
How may clinicians use the evolving evidence base to choose an appropriate therapy dose?
1. Ronco et al Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial Lancet 2000; 355: 26–30 2. Bellomo et al Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients n engl j med 2009 361;17 3. Palevsky et al Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury n engl j med 2008 359;1
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Study Comparison AUTHORS
STUDY
POPULATION
NUMBERS
CRRT
UFR
TECHNIQUE
(ML/HR) 1000
Sander et al
26
SIRS
CVVH
John et al
30
SEPSIS
CVVH
De Vriese
15
SEPSIS/ ARF
CVVH
2700
Wakabayashi
6
SIRS/ MOF
CVVH
VARIABLE
Matamis
20
SEPSIS MOF
CVVH
1500
26
SEPSIS/ MOF
CVVH
4500
Grootendorst
Honore
20
EFFECTS
PATIENT
No effects
WEIGHT 70 kg
VARIABLE Increase in MAP Increase in SVR
Increase in MAP and Oxygenation Increase in MAP and Oxygenation Improved Haemodynamics and Survival
Improved Haemodynamics and survival Copyright © 2015 NIKKISO Co., LTD. All rights reserved. SEPTIC SHOCK
CVVH
9000
70 kg 70 kg
N/A
70 kg
70 kg
74 kg
Pedrini et al (2000) The comparison of mixed pre and postdilution compared to traditional infusion modes.
300 250 200
PostDilution Mixed Pre-Dilution
150 100
50 0
Urea
Creatinine
Phosphate
Pedrini LA1, De Cristofaro V, Pagliari B, Samà F. (2000) Mixed predilution and postdilution online hemodiafiltration compared with the traditional infusion modes. Kidney Int Nov; 58 (5):2155-56.
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Predilution and middle molecule clearances.
Bellomo et al (2001)
Clearance (ml/min)
100 80
60 40 20 0
0
1
2
4
5
6
preliminary experience with high volume haemofiltration in human septic shock. 6 litre exchange. Effects of predilution on clearance of Vancomycin (middle sized molecule).
Amount of Predilution (Litres)
Bellomo R, Tipping P, Boyce N (1993) Continuous veno-venous hemofiltration with dialysis removes cytokines from the circulation of septic patients. Crit Care Med 21:522–526
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Aquarius- Renal Dose display
Renal Dose display on Aquarius 6.02- during treatment, patient weight can be entered and modified at any time.
At the start of treatment or after a programmed value change, the programmed renal dose is displayed for the first 2 minutes.
After 2 minutes of uninterrupted therapy, the delivered renal dose is displayed based on the actual pump rates.
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Aquarius System Vascul ar Access
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Overview Vascular access is required to perform all CRRT therapies.
Central venous catheters provide rapid and easy vascular access permitting immediate use
The most common catheter now in use is the large-bore, doublelumen catheter.
A practical understanding of vascular access contributes to optimal delivery of CRRT therapies Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Insertion Sites - Choices
Internal Jugular
Femoral
Subclavian
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Considerations Diameter, length and types of catheters (II) Type: Material features Silicone elastomer catheters have lower thrombogenicity and better flexibility. Biocompatible and kink resistance Conform to vessel anatomy, therefore reduce risk of trauma Diameter and blood flow: 11 French : 250-300 ml/min Blood Flow 13.5 French : 450-500 ml/min Blood Flow Recirculation- up to 20% Especially if femoral access is less than 20 cm Avoid reverse AV connection
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Patient Preparation
Patient body status Coagulation and Intravascular filling Mobility influences Presence of other central lines Influences on catheter choice Clinician choice Availability of ultrasound guidance
Assessment of catheter patency Connection techniques Special circumstances
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Catheter Characteristics Ease of insertion: to avoid vessel trauma
Good flow characteristics: to optimise blood flow
Kink resistant: to avoid access pressure problems
Biocompatible: to reduce complication risks
Amenability to guide wire change: to optimise therapy Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Side-by-Side Polyurethane Catheters
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Coaxial Polyurethane Catheters
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Triple lumen Catheters
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Silicone Catheters
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Reversing the Lines
1 Lewington A, Kanagasundaram S. Acute Kidney Injury. Renal Association guidelines: Guideline 8.1 – AKI: Vascular access for RRT. Guideline 8.2, Page 45 of 59, Para 3 ‘Rationale for 8.1-8.9’ lines 7-9 http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx
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Vascular Access
Vascular Access is continuously tested during CRRT treatment Practical understanding about vascular access is necessary for optimal treatment
Catheter site, size, type and patient preparation may be considered Inadequacies in vascular access may limit delivered therapy
Troubleshooting choices
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Vascular Access Troubleshooting
Starting blood flow Gradual increase Optimising blood flow rates Starting treatment
Using Aquarius History Using Recirculation Troubleshooting choices
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Access Is KING Vascular Access is continuously tested during CRRT treatment. Catheter site, size, type and patient preparation should be considered. Practical understanding about vascular access is necessary for optimal treatment.
Inadequacies in vascular access may limit delivered therapy.
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Aquarius System Other Considerations
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Choices of Anticoagulation
Low Molecular Weight Heparin (LMWH)
Unfractioned Heparin Regional Heparinisation Regional Citrate Adjunctive anticoagulation methods
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Introduction to Anticoagulation In CRRT, the anticoagulation is a challenge for physicians. The target is to limit the risk of circuit coagulation and at the same time to limit the Hemorrhage risk for the patient . The coagulation activation is due to: Exogenous causes: extracorporeal circuit i.e. lines and the filter that is in contact with the blood. If no anticoagulation is used the thrombosis is ineluctable with the following consequences: Renal dose reduction Blood loss and loss of the coagulation factors Increase of the workload and the cost of the therapy
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Anticoagulation
Systemic
Regional
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How does Heparin work? Heparin inhibits reactions that lead to the clotting of blood and the formation of fibrin clots.
Heparin acts at multiple sites in the normal coagulation system. Small amounts of heparin in combination with antithrombin III (heparin cofactor) can inhibit thrombosis by inactivating activated Factor X and inhibiting the conversion of prothrombin to thrombin.
Heparin prevents the formation of a stable fibrin clot by inhibiting the activation of the fibrin stabilizing factor.
Bleeding time is usually unaffected by heparin.
Clotting time is prolonged by full therapeutic doses of heparin. Heparin does not have fibrinolytic activity; therefore, it will not lyse existing clots. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Advantages & Disadvantages related to the use of Heparin Advantages: Easy to administer and monitor. Low cost of drug 2 Short half life, Heparin can be antagonized. Disadvantages:
Results in systemic anticoagulation and potential risk of bleeding3 Heparin induced thrombocytopenia (HIT) around 1% to 5% in patients given heparin for 5 days leading to increased risk of central venous thrombosis within the catheter4 2 Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials Mei-Yi Wu, MD Am J Kidney Dis. 2012;59 810-818. 3 Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding Runolfur Palsson and John L Niles Kidney International (1999) 55, 1991–1997; doi:10.1046/j.1523-1755.1999.00444. 4Heparin-induced thrombocytopenia during renal replacement therapy Andrew DAVENPORT Center for Nephrology, The Royal Free Hospital, Pond Street, London, United Kingdom Hemodialysis International 2004; 8: 295--303
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How does Regional Citrate Anticoagulatin (RCA) work? Citrate is added to the extracorporeal circuit pre-filter. It chelates or combines with ionized Calcium (free Calcium) in the filter by forming Ca-Citrate complexes, thus removing Ca needed in coagulation cascade, anticoagulant effect.
Majority of these complexes are removed in the filter, some pass on to the systemic circulation.
Ca gets infused post-filter to restore iCa. Ca-Citrate complexes get metabolized in liver, muscle & kidney (Krebs cycle; aerobic) releasing Ca & forming Bicarbonate (1:3), buffer effect.
Anticoagulant effect is limited to the filter. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Advantages related to Citrate
Citrate is safer than nadroparin anticoagulation in CRRT. Citrate is recommended in patients who require CRRT but are at high risk of bleeding (Only the extracorporeal circuit is anticoagulated).
Monitoring can be performed to tightly control infusion rates. Can be performed in combination with standard CRRT equipment.
5 Citrate anticoagulation for continuous venovenous hemofiltration: Heleen M. Oudemans-van Straaten Crit Care Med 2009 Vol. 37, No. 2 6 Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials Mei-Yi Wu, MD Am J Kidney Dis. 2012;59 810-818.
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Aquarius System
Questions and Discussion
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T h a n k Yo u
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AQUAMAX hemofilter Bellco Società unipersonale a r.l. Via Camurana, 1 41037 Mirandola Italy
AQUARIUS system NIKKISO Europe GmbH Desbrocksriede 1 30855 Langenhagen Germany
AQUALINE tubing Haemotronic Via Carreri, 16 41037 Mirandola Italy
CITRASETRCA Assembled by Haemotronic Via Carreri, 16 41037 Mirandola Italy
AQUALINE and AQUARIUS are trademarks of Nikkiso international Inc. Copyright 2015. All rights reserved. EJFT copy UK CS team 01052014
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Aquarius System Continuous Renal Replacement Therapy (CRRT)
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Agenda Morning
Theoretical perspectives
Kidney Anatomy & Physiology Acute Kidney Injury Acute Blood Purification Transport Mechanisms Treatment Modalities Treatment Dose
Practical Aquarius Overview Lining and Priming Recirculation
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3
Agenda Afternoon
Theoretical Filtration Fraction Filtration Ratio Vascular Access
Practical
Programming Connection Alarms Troubleshooting Disconnection Safe Disposal
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4
Aquarius System Renal Anatomy and Physiology
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Renal Anatomy and Physiology
The kidneys are two bean shaped organs, located just below the inferior boundary of the rib cage.
Each kidney can function independently of the other. Each adult kidney weighs approximately 110 – 170 grams and is about the size of a human fist.
The adult kidneys receive 1200 millilitres of blood (25% of cardiac output) every minute. That is 72 litres per hour or 1728 litres per day.
Normal kidney function is measured in terms of glomerular filtration rate (GFR). Normal GFR is typically 90-120 millilitres per minute. An estimation of Glomerular Filtration Rate (eGFR) can be calculated based on age and serum creatinine Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Component of the Kidney
Consists mainly of 3 parts: Medulla contains 20% of the nephrons that filter the blood and concentrate urine. An important diagnostic tool.
Cortex contains 80% of the nephrons to filter the blood continuously to maintain fluid balance.
Renal pelvis is the start of the collecting system, containing the collecting tubules and the ureter. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Components of the Kidney
The kidney functions using three principles: • Ultrafiltration • Excretion • Re-absorption
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Components of the Kidney – The Nephron Nephron – Is the functional unit of the kidney. Each kidney has about one million nephrons
Each nephron contains a glomerulus, which functions as an individual filtering unit
The nephron also contains tubules for secretion and absorption of substances
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Components of the Kidney
The Glomerulus; The glomerulus consists of a group of cells with selective permeability. Selective permeability means that certain substances will cross the membrane and others will not be allowed to cross. Through selective permeability, the kidney regulates fluid and electrolyte balance. In an adult, the kidneys produce approximately 180 litres of filtrate per day. Only 1.5 - 2 litres are excreted as urine. The remaining 178 litres are reabsorbed by the kidney.
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The tea filter is a good example of a semi-permeable membrane
10
Functions of the Nephron
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Functions of the Kidney
Fluid balance Through ultrafiltration and reabsorption. Electrolyte balance Through reabsorption and excretion. Acid-base balance Through reabsorption and excretion. Excretion of drugs and by-products of metabolism Nitrogen, urea, creatinine. Synthesis of erythropoietin Stimulates bone marrow to produce mature red blood cells. Regulation of blood pressure Through the secretion of renin. Maintenance of calcium-phosphate balance Through the activation of vitamin D production. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Aquarius System Acute Kidney Injury
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Acute Kidney Injury Acute Kidney Injury (AKI) results from the sudden loss of kidney function. AKI in the setting of critical care patients is defined as “..an abrupt decline in glomerular filtration rate.” Jefferson et al (2007) Waste products will start to accumulate in the blood.
AKI may be accompanied by metabolic, acid-base and electrolyte disturbances and fluid overload.
AKI may affect other organ systems. AKI may require immediate treatment. Jefferson JA, Schrier RW. Pathophysiology and Etiology of Acute Renal Failure. In: Comprehensive Clinical Nephrology. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2007:755-770.
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RIFLE Criteria
The Acute Dialysis Quality Improvement Initiative (ADQI) Recommends the Classification of AKI based on the RIFLE criteria.
2 Ricci et al - The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney International (2008) 73, 538– 546
Summary of Classifications of AKI
Kristensen et al (2014) ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). European Heart Journal 35 (35) 2383–2431
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Acute Kidney Injury Classification There are 3 types of Acute Kidney Injury Classification
Pre-Renal
Renal (Intra-Renal)
Post-Renal
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AKI Classification: Pre-Renal Pre-renal failure typically results from decreased blood flow to the kidneys. The reduction in glomerular filtration enables the solutes in the blood to accumulate but does not cause any structural damage to the kidney itself. Examples of situations leading to pre-renal failure may include: – dehydration – haemorrhage Pre renal 30-60% – congestive heart failure (think „p‟ for pressure) – sepsis – embolism/thrombosis • Volume depletion • Decreased circulating volume • Reduced cardiac output • Renal vascular disease
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AKI Classification: Renal (Intra-Renal) Renal (Intra-renal) failure typically involves direct injury to the kidney itself. The most common cause is Acute Tubular Necrosis (ATN). Some causes of ATN are: – Ischaemia – Hypertension – Nephrotoxins – Some systemic vascular diseases such as lupus. . Intra-Renal 20-40% (think “I” for infection) • Glomerular infection • Vascular • Nephritis
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AKI Classification: Post Renal In post-renal failure, the underlying cause is typically a bilateral obstruction below the level of the renal pelvis. Causes for this may be: – Tumour development – Thrombi – Urinary tract obstruction – Hypertrophic prostate. Post renal 1 – 10% (think „o‟ for obstruction) • • • •
Obstruction Ureters Bladder Urethra
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Nephrotoxic Drugs
Nephrotoxicity is the poisonous effect on the kidneys caused by toxic
chemicals and medication. Drug-induced AKI is common in critical illness and accounts for 15% to 25% of all cases of renal failure seen in this population. The medications implicated in causing drug-induced AKI can be classified based on their mechanism of renal injury; pre-renal, intra-renal and postrenal. The mechanisms of toxicity are complex and, in many cases, affect more than one aspect of kidney function. All NSAIDs have been associated with AKI, and consideration should be given to either avoid their use or, when indicated, use with extreme caution.
Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174 Ricci Z., Ronco C., (2008) The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney International 7 (5) 538-546
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Nephrotoxic Drugs - Nonsteroidal antiinflammatory drugs Volume contraction from any cause or other forms of pre-renal AKI (cirrhosis, congestive heart failure) will increase the incidence of and severity of nephrotoxicity due to nonsteroidal anti-inflammatory drugs (NSAIDs). Conditions such as a. b. c. d.
Congestive heart failure Hypotension Volume depletion 3rd spacing
These conditions all decrease effective arterial volume. These are conditions that predispose the patient to NSAID-induced nephrotoxicity.
Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174
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Nephrotoxic Drugs- ACE Inhibitors & others
ACE inhibitors ACE inhibitors are commonly prescribed drugs used for hypertension, congestive heart failure and chronic kidney disease. These drugs affect renal haemodynamics through an decrease in efferent arteriolar tone and intraglomerular capillary pressure. The use of these drugs under normal circumstances when renal perfusion is adequate poses very little problem. However when these drugs are used in states of prerenal azotemia, renal artery stenosis or concomitantly with other drugs such as NSAIDs, renal failure may occur. Other drugs that cause altered glomerular haemodynamic instability Drugs such as cyclosporine and tacrolimus, belong to a class of commonly used immunosuppressant's for organ transplantation referred to as calcineurin inhibitors. Calcineurin inhibitors are associated with early prerenal oliguria due to vasoconstriction Bentley, M.L., Corwin H.L., Dasta J. (2010) Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. (Supplement in) Critical Care 38 S169-174
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Begins when urine output begins to rise
Has variable time frames, sometimes occurring as little as 24 hours after the onset of renal failure Associated with potassium and sodium loss in the urine Enhanced urine output may not reflect restored kidney function but rather may be the result of accumulating serum urea and creatinine, which have an osmotic diuretic effect
Recovery phase
Low urine output (less than 400 mL/24 hrs) Possibly protein in the urine Electrolyte imbalances Metabolic acidosis
Polyuric phase
Oliguric phase
Phases of Acute Kidney Injury
May
last several months following the onset of the Acute Kidney Injury
During this period, kidney function gradually returns to normal and proper urine concentrations and volumes are achieved
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Management Goals for Acute Kidney Injury
Fluid balance. Correction of electrolyte abnormalities.
Restoration of acid-base balance. Removal of waste products. Haemodynamic stabilisation. Nutritional support.
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Treatment options for AKI
Information and support
Peritoneal dialysis
Pharmacological and fluid management
Acute Kidney Injury
Relieve urological obstruction
Intermittent haemodialysis (IHD) Continuous Renal Replacement Therapy (CRRT)
Monitoring
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Aquarius System Continuous Renal Replacement Therapy (CRRT)
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Indications for commencing CRRT
Renal Indications: Rapidly rising serum urea and creatinine or the development of uraemic complications. Hyperkalaemia unresponsive to medical management. Severe metabolic acidosis. Diuretic resistant pulmonary oedema. Oliguria or anuria.
Non Renal indications: Management of fluid balance e.g. in cardiac failure. Clearing of ingested toxins. Correction of electrolyte abnormalities. Temperature control. Removal of inflammatory mediators in sepsis.
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Some Indications for CRRT
Pre & Post Cardiac Surgery
Haemodynamic Instability
Fluid Overload
Shock
Sepsis – Lactate Acidosis
Acute Multi-Organ Failure
Drug Overdose
ARDS / / ARDS VAP VAP
Shock
Trauma Rhabdomylosis 29
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Continuous Renal Replacement Therapy Goals
Clean the blood Manage Intravascular volume Wastes are cleaned from the blood by diffusion and convection. Water is removed by ultrafiltration.
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Defining The Therapy Early application of Continuous Renal Replacement Therapy (CRRT) may prove to be beneficial to the patient. CRRT is a therapy indicated for continuous solute removal in the critically ill patient.
CRRT allows for continuous, slow and isotonic fluid removal that results in better haemodynamic tolerance even in unstable patients with shock and severe fluid overload. CRRT can be modified at any time of the day and night to allow adaptation to the rapidly changing haemodynamic situation of critically ill patients. CRRT therapy indications may be renal, non-renal, or a combination of both. It is the treatment of choice for the critically ill patient requiring renal support and/or fluid management. Kellum J, Ronco C, Joannidis M (2012) An emerging consensus for AKI ICU Management 12 (1) 38-40
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Aquarius System Treat ment M odal i t i es & Transport M echani sms
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Treatment Modalities
CRRT includes several treatment modalities. All of these modalities use veno-venous access. The choice will depend on the needs of the patient and the preferences of the physician.
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CRRT Treatment Modalities
.
SCUF
CVVH
Slow Continuous Diffusive & Ultrafiltration Convective
Therapy
Continuous Diffusive Veno-Venous Therapy Haemofiltration
CVVHDF
CVVHD
Continuous VenoContinuous VenoConvective Therapies Venous Venous HaemoDiaFiltration Haemodialysis Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
Slow Continuous Ultrafiltration (SCUF)
Primary therapeutic goal:
Safe management of fluid removal
Primary indications:
Fluid overload
Principle used:
Ultrafiltration (removal of water)
Therapy characteristics:
• No dialysate or substitution solutions. • Fluid removal only.
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Transport Mechanism: Ultrafiltration
Ultrafiltration is the movement of fluid through a semi-permeable membrane along a pressure gradient.
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Slow Continuous Ultrafiltration (SCUF)
Graphics will become visible in presenter mode.
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Continuous Veno-Venous Haemofiltration (CVVH)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Ultrafiltration (removal of water) Convection (clearance of solutes)
Therapy characteristics:
• Requires substitution solution with a buffer to drive convection. • No dialysate solution • Used to achieve solute removal (small, medium and large sized molecules) and fluid balance.
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Transport Mechanism: Convection
Convection is the one-way movement of solutes through a semi-permeable membrane with a water flow. Sometimes it is referred to as solvent drag.
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Continuous Veno-Venous Haemofiltration (CVVH)
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Continuous Veno-Venous Haemodialysis (CVVHD)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Diffusion
Therapy characteristics:
• Requires substitution solution with a buffer to aid the diffusive process. • No substitution solution. • Used to achieve solute removal (small and medium sized molecules) and fluid balance.
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Transport Mechanism: Diffusion
Diffusion is the movement of solutes through a semi-permeable membrane from an area of higher concentration to an area of lower concentration.
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Transport Mechanism: Diffusion Solutes move from a higher concentration to a lower concentration In CRRT, diffusion occurs when blood flows on one side of the membrane, and dialysate solution flows counter-current on the other side The dialysate does not mix with the blood Efficient for removing small and medium molecules but not large molecules Molecular size and membrane type can affect clearances Diffusion occurs during haemodialysis Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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No Counter Current Principle
3
3
3
3.5
3
3
3
4
3
3
3
3.5
3
4
2.5
4.5
5
6
3
4
2.5
2
6.5 2
Anaesthesia UK (2003) Acute renal failure and renal replacement therapy in the ICU http://www.frca.co.uk/article.aspx?articleid=100367# Accessed 10th August 2015 10:10
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Counter current principle (Diffusion)
2
2.5
3
3.5
2
2.5
3
4.0
2.5
3.5
4.5
3
3.5
4
5
4.5
6
4
4.5
5
5.5
5
5.5
6.5
Anaesthesia UK (2003) Acute renal failure and renal replacement therapy in the ICU http://www.frca.co.uk/article.aspx?articleid=100367# Accessed 10th August 2015 10:10
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Continuous Veno-Venous Haemodialysis (CVVHD)
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Continuous Veno-Venous Haemodiafiltration (CVVHDF)
Primary therapeutic goal:
Solute removal and safe management of fluid volume.
Primary indications:
Uremia, acid/base and/or electrolyte imbalances, fluid overload.
Principle used:
Diffusion and Convection
Therapy characteristics:
• Requires dialysate solution and substitution solution, both contain a buffer that drives the convection and diffusion processes. • Used to achieve solute removal (small, medium and large sized molecules) and fluid balance.
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Continuous Veno-Venous Haemodiafiltration (CVVHDF)
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Treatment Modality Summary Continuous Renal Replacement Therapy : A Summary Modes
Principles
SCUF Slow Continuous UltraFiltration
UltraFiltration Movement of fluid through a semi-permeable membrane along a pressure gradient.
CVVH Continuous Veno-Venous Haemofiltration (can be pre or post dilution)
Convection (active) One-way movement of solutes through a semi permeable membrane with a water flow – sometimes referred to as „solvent drag‟.
CVVHD Continuous Veno-Venous HaemoDialysis
Diffusion (passive) Movement of solutes through a semi-permeable membrane from an area of high concentration to low concentration.
CVVHDF Continuous Veno-Venous HaemoDiaFiltration
Combined Mode: Convection • Haemofiltration • Active – convection Diffusion • Haemodialysis • Passive - diffusion
Fluids
Molecules Cleared
Pumps In Use No Fluid (for fluid removal only)
Nil
Pre-dilution pump Post-dilution pump Filtrate Pump Substitution fluid (pre/post)
Small Medium Large
Pre-dilution pump Post-dilution pump Filtrate Pump Dialysate fluid
Small Medium
Dialysate pump Filtrate pump
Substitution / Replacement Fluid Dialysate Small Medium Large
Post dilution pump Dialysate pump Filtrate pump
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Molecular Weights
Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 1857758730
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Adsorption
Adsorption is the adherence of solutes and biological matter to the surface of a membrane
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Transport Mechanism: Adsorption
High levels of adsorption can cause some filters to clog and become ineffective
Membrane type affects adsorption tendencies/effectiveness Adsorption may also limited removal of some solutes (eg. β2 microglobulins) from the blood
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Replacement Fluid
Accusol 35 is a bicarbonate based solution primarily intended for use in patients with hyperkalaemia.
Accusol 35 solution gives health care providers a convenient and easy-touse solution for the patient‟s CRRT needs. It is completely lactate-free, with a 100% bicarbonate buffer that provides all the necessary electrolytes. Accusol solution comes in ready-to-mix formulations with varying potassium levels
Substitution fluid in haemofiltration and haemodiafiltration and a diaylsis solution in haemodialysis and haemodiafiltration. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Accusol 35
Accusol 35 purifies blood of waste products; it corrects acidity or alkalinity the level of salts in the blood.
Accuosl 35 solutions are supplied in a non PVC bag with two chambers containing bicarbonate and calcium. The chambers need to be spilt and mixed before use. Once mixed the solution lasts for 24 hours.
Accusol 35 works closely with the body‟s natural chemistry to maintain electrolyte balance during therapy and restore haemodynamic stability
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Aquarius System Tr e a t m e n t D o s e
6.02.08 Software Education Module
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Measurement of therapy dose
Therapy dose is a measure of the quantity of blood purification achieved. The concept of clearance represents the volume of blood cleared of a given solute over time.
Commonly used solute markers to quantify clearance are serum Urea and Creatinine.
Best clinical practices combine clearance and dosing effectiveness using a weight-related dosage of therapy
On Aquarius, therapy dose is defined by the total ultrafiltration rate and is expressed as millilitres (therapy amount) per kilogramme (patient weight) per hour (time) or ml/kg/hr Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Prescribed vs Delivered Dose Prescription should exceed that calculated to be adequate because of the known gap. 8ml/kg/hr less
Prescribed dose of therapy should be assessed daily to account for any measured shortfalls in delivered dose.
Delivered dose of therapy should be assessed to ensure the adequacy of the prescription. According to Vesconi et al (2009) in practice the delivered therapy dose was on average 8ml/kg/hr less.
Vesconi et al (2009) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Critical Care 13 (2);r57
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62
Where does that 8mls/kg/hr go?
Why might we „lose‟ significant amounts of therapy dose? • • • • • •
Recirculation in vascular access High filtration fractions Filter clogging and clotting Troubleshooting skills Changing of circuits Filter down time
Vesconi et al (2009) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Critical Care 13 (2);r57
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63
Clinical Evidence for Therapy Dose
Landmark studies suggest that increasing therapy dose improved survival1 Recent studies find no difference in survival between 25 and 40 ml/kg/hr therapy dose2,3
Higher therapy doses (40 ml/kg/hr) did not alter mortality in the subgroup of sepsis patients.
How may clinicians use the evolving evidence base to choose an appropriate therapy dose?
1. Ronco et al Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial Lancet 2000; 355: 26–30 2. Bellomo et al Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients n engl j med 2009 361;17 3. Palevsky et al Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury n engl j med 2008 359;1
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Study Comparison AUTHORS
STUDY
POPULATION
NUMBERS
CRRT
UFR
TECHNIQUE
(ML/HR) 1000
Sander et al
26
SIRS
CVVH
John et al
30
SEPSIS
CVVH
De Vriese
15
SEPSIS/ ARF
CVVH
2700
Wakabayashi
6
SIRS/ MOF
CVVH
VARIABLE
Matamis
20
SEPSIS MOF
CVVH
1500
26
SEPSIS/ MOF
CVVH
4500
Grootendorst
Honore
20
EFFECTS
PATIENT
No effects
WEIGHT 70 kg
VARIABLE Increase in MAP Increase in SVR
Increase in MAP and Oxygenation Increase in MAP and Oxygenation Improved Haemodynamics and Survival
Improved Haemodynamics and survival Copyright © 2015 NIKKISO Co., LTD. All rights reserved. SEPTIC SHOCK
CVVH
9000
70 kg 70 kg
N/A
70 kg
70 kg
74 kg
Pedrini et al (2000) The comparison of mixed pre and postdilution compared to traditional infusion modes.
300 250 200
PostDilution Mixed Pre-Dilution
150 100
50 0
Urea
Creatinine
Phosphate
Pedrini LA1, De Cristofaro V, Pagliari B, Samà F. (2000) Mixed predilution and postdilution online hemodiafiltration compared with the traditional infusion modes. Kidney Int Nov; 58 (5):2155-56.
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Predilution and middle molecule clearances.
Bellomo et al (2001)
Clearance (ml/min)
100 80
60 40 20 0
0
1
2
4
5
6
preliminary experience with high volume haemofiltration in human septic shock. 6 litre exchange. Effects of predilution on clearance of Vancomycin (middle sized molecule).
Amount of Predilution (Litres)
Bellomo R, Tipping P, Boyce N (1993) Continuous veno-venous hemofiltration with dialysis removes cytokines from the circulation of septic patients. Crit Care Med 21:522–526
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Aquarius- Renal Dose display
Renal Dose display on Aquarius 6.02- during treatment, patient weight can be entered and modified at any time.
At the start of treatment or after a programmed value change, the programmed renal dose is displayed for the first 2 minutes.
After 2 minutes of uninterrupted therapy, the delivered renal dose is displayed based on the actual pump rates.
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Aquarius System Vascul ar Access
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Overview Vascular access is required to perform all CRRT therapies.
Central venous catheters provide rapid and easy vascular access permitting immediate use
The most common catheter now in use is the large-bore, doublelumen catheter.
A practical understanding of vascular access contributes to optimal delivery of CRRT therapies Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
78
Insertion Sites - Choices
Internal Jugular
Femoral
Subclavian
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Considerations Diameter, length and types of catheters (II) Type: Material features Silicone elastomer catheters have lower thrombogenicity and better flexibility. Biocompatible and kink resistance Conform to vessel anatomy, therefore reduce risk of trauma Diameter and blood flow: 11 French : 250-300 ml/min Blood Flow 13.5 French : 450-500 ml/min Blood Flow Recirculation- up to 20% Especially if femoral access is less than 20 cm Avoid reverse AV connection
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Patient Preparation
Patient body status Coagulation and Intravascular filling Mobility influences Presence of other central lines Influences on catheter choice Clinician choice Availability of ultrasound guidance
Assessment of catheter patency Connection techniques Special circumstances
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Catheter Characteristics Ease of insertion: to avoid vessel trauma
Good flow characteristics: to optimise blood flow
Kink resistant: to avoid access pressure problems
Biocompatible: to reduce complication risks
Amenability to guide wire change: to optimise therapy Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Side-by-Side Polyurethane Catheters
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Coaxial Polyurethane Catheters
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Triple lumen Catheters
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Silicone Catheters
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Reversing the Lines
1 Lewington A, Kanagasundaram S. Acute Kidney Injury. Renal Association guidelines: Guideline 8.1 – AKI: Vascular access for RRT. Guideline 8.2, Page 45 of 59, Para 3 ‘Rationale for 8.1-8.9’ lines 7-9 http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx
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Vascular Access
Vascular Access is continuously tested during CRRT treatment Practical understanding about vascular access is necessary for optimal treatment
Catheter site, size, type and patient preparation may be considered Inadequacies in vascular access may limit delivered therapy
Troubleshooting choices
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Vascular Access Troubleshooting
Starting blood flow Gradual increase Optimising blood flow rates Starting treatment
Using Aquarius History Using Recirculation Troubleshooting choices
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Access Is KING Vascular Access is continuously tested during CRRT treatment. Catheter site, size, type and patient preparation should be considered. Practical understanding about vascular access is necessary for optimal treatment.
Inadequacies in vascular access may limit delivered therapy.
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Aquarius System Other Considerations
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Choices of Anticoagulation
Low Molecular Weight Heparin (LMWH)
Unfractioned Heparin Regional Heparinisation Regional Citrate Adjunctive anticoagulation methods
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Introduction to Anticoagulation In CRRT, the anticoagulation is a challenge for physicians. The target is to limit the risk of circuit coagulation and at the same time to limit the Hemorrhage risk for the patient . The coagulation activation is due to: Exogenous causes: extracorporeal circuit i.e. lines and the filter that is in contact with the blood. If no anticoagulation is used the thrombosis is ineluctable with the following consequences: Renal dose reduction Blood loss and loss of the coagulation factors Increase of the workload and the cost of the therapy
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Anticoagulation
Systemic
Regional
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How does Heparin work? Heparin inhibits reactions that lead to the clotting of blood and the formation of fibrin clots.
Heparin acts at multiple sites in the normal coagulation system. Small amounts of heparin in combination with antithrombin III (heparin cofactor) can inhibit thrombosis by inactivating activated Factor X and inhibiting the conversion of prothrombin to thrombin.
Heparin prevents the formation of a stable fibrin clot by inhibiting the activation of the fibrin stabilizing factor.
Bleeding time is usually unaffected by heparin.
Clotting time is prolonged by full therapeutic doses of heparin. Heparin does not have fibrinolytic activity; therefore, it will not lyse existing clots. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Advantages & Disadvantages related to the use of Heparin Advantages: Easy to administer and monitor. Low cost of drug 2 Short half life, Heparin can be antagonized. Disadvantages:
Results in systemic anticoagulation and potential risk of bleeding3 Heparin induced thrombocytopenia (HIT) around 1% to 5% in patients given heparin for 5 days leading to increased risk of central venous thrombosis within the catheter4 2 Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials Mei-Yi Wu, MD Am J Kidney Dis. 2012;59 810-818. 3 Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding Runolfur Palsson and John L Niles Kidney International (1999) 55, 1991–1997; doi:10.1046/j.1523-1755.1999.00444. 4Heparin-induced thrombocytopenia during renal replacement therapy Andrew DAVENPORT Center for Nephrology, The Royal Free Hospital, Pond Street, London, United Kingdom Hemodialysis International 2004; 8: 295--303
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How does Regional Citrate Anticoagulatin (RCA) work? Citrate is added to the extracorporeal circuit pre-filter. It chelates or combines with ionized Calcium (free Calcium) in the filter by forming Ca-Citrate complexes, thus removing Ca needed in coagulation cascade, anticoagulant effect.
Majority of these complexes are removed in the filter, some pass on to the systemic circulation.
Ca gets infused post-filter to restore iCa. Ca-Citrate complexes get metabolized in liver, muscle & kidney (Krebs cycle; aerobic) releasing Ca & forming Bicarbonate (1:3), buffer effect.
Anticoagulant effect is limited to the filter. Copyright © 2015 NIKKISO Co., LTD. All rights reserved.
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Advantages related to Citrate
Citrate is safer than nadroparin anticoagulation in CRRT. Citrate is recommended in patients who require CRRT but are at high risk of bleeding (Only the extracorporeal circuit is anticoagulated).
Monitoring can be performed to tightly control infusion rates. Can be performed in combination with standard CRRT equipment.
5 Citrate anticoagulation for continuous venovenous hemofiltration: Heleen M. Oudemans-van Straaten Crit Care Med 2009 Vol. 37, No. 2 6 Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials Mei-Yi Wu, MD Am J Kidney Dis. 2012;59 810-818.
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Aquarius System
Questions and Discussion
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T h a n k Yo u
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AQUAMAX hemofilter Bellco Società unipersonale a r.l. Via Camurana, 1 41037 Mirandola Italy
AQUARIUS system NIKKISO Europe GmbH Desbrocksriede 1 30855 Langenhagen Germany
AQUALINE tubing Haemotronic Via Carreri, 16 41037 Mirandola Italy
CITRASETRCA Assembled by Haemotronic Via Carreri, 16 41037 Mirandola Italy
AQUALINE and AQUARIUS are trademarks of Nikkiso international Inc. Copyright 2015. All rights reserved. EJFT copy UK CS team 01052014
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