Cnus Renal

1 —CRRT Explained—
Replacement Therapy
RENAL SYSTEM REVIEW
To understand what we are
trying to accomplish with CRRT. . .

2 Kidneys
Right Lower than the
Left due to Liver 3 Layers of the Kidney
• Located in retroperitoneal cavity
• One on each side of the spine
• Between T-12 and L-3
• Each kidney = > 1 million NEPHRONS
LA
Renal Artery

Renal Pelvis L

• Urine collected and sent to ureter

Renal Vein
Watch the Lessons!

Cortex & Medulla

• Contain various parts of the NEPHRON
20-25% of
cardia.c output
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goes to kidneys!
 Cnus Renal
2 —CRRT Explained—
Replacement Therapy
RENAL SYSTEM REVIEW
The Nephron: The functional unit of the kidney
• Maintain water, electrolyte, waste & acid-base balance
Distal Convoluted Tubule
Proximal Tubule • Regulate BP
• Reabsorb water, solutes, electrolytes • Absorb/excrete solutes
Efferent Arteriole • H+ passive secretion • ADH aids reabsorption of water
• Blood exiting the glomerulus • Bicarb reabsorption

I
• Remaining large molecules create • Active H+ secretion
oncotic pressure (aids reabsorption)
• Oxygenated blood perfuses kidney Waste Products
• BUN
• Uric acid
• Creatinine
Glomerulus · LA
• Surrounded by Bowman’s capsule
• High pressure capillary bed
• Semi-permeable membrane
Water filters across
Diffusion • Higher concentration to lower membrane d/t hydrostatic Collecting
+ pressure
Convection • High flow drags solutes Tubule

Collecting
Afferent Arteriole Renal Duct
• Enters Bowman’s capsule Renal
• Forms the glomerulus Arteriole Venuole Loop of Henle
• Larger diameter than efferent • Part of the proximal tubule
• This allows more flow in than out 1. Thin Descending Loop
• Creates hydrostatic pressure 2. Thin Ascending Loop
Peritubular 3. Thick Ascending Loop
Capillaries
• Interface with various tubules Cortical (short) Juxtomedullary (long)
• Help perform function of nephron • excretion • dilute/concentrate urine
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• regulatory function
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 Cnus Renal

3 —CRRT Explained—
Replacement Therapy
WHAT IS CRRT?
Why is it used? Critically ill, unstable
GOAL: Remove toxins, AKI/ARF and ESRD
Patients often unable to tolerate rapid, short Form of Dialysis
excess fluid & balance iterations & accompanying fluid/electrolyte shifts. • Like IHD, SLED & PD
electrolytes. • Elevated toxins (BUN/creatinine) • Fluid volume overload
• Slow run 24/7
*Mimic failing kidney! • Severe electrolyte imbalances • Acid/base imbalances

Insertion Sites Dialysis Catheter

• Temporary (may be tunneled)
Internal Jugular Return • Typically 14g or 16g
(IJ)

Subclavian Access
(SC)
Pressure
LA Measurements

Femoral
Access (-) Return (+)
Pre Filter (+) Effluent (+/-)

Deaeration Chamber
• Removes air in line
• Measures return pressure

Co
Fluid & Effluent Pumps
• Controls speed of fluids Filter
• Acts as nephron
• 1000s of tubes
Blood Pump

Anticoagulation

Effluent Pre Blood Pump Dialysate Replacement Fluid

• Dialysate waste (Pre replacement) • Flows top to bottom • Can be pre or post filter
(C) Eddie Watson & ICU Advantage LLC • Outside hollow fiber tubes
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 Cnus Renal

4 —CRRT Explained—
Replacement Therapy
PRINCIPLES OF CRRT
Diffusion Semi-permiable
(Hemodialysis) Membrane

The movement of particles (solutes) from

concentration to concentration across a
--

semi-permiable membrane.
• Semi-permiable membrane allows for selective diffusion

Dialysate
Blood

• Effective for small molecules, not large.

Dialysate typically contains:

• Normal serum levels of: Na+, Cl-, Mg++ LA
• Potassium (K+) - pts levels normally high to start ↑

-
• Bicarb • Urea & Creatinine NOT present

Ultrafiltration Semi-permiable
(Hemofiltration) Membrane

Fluid is able to cross a semi-permiable membrane

in response to a pressure gradient.
• Pressure from: osmotic, oncotic or hydrostatic.
Dialysate

• Hydrostatic pressure gradient created with CRRT

Blood

circuit to mimic the function of the afferent and

efferent arterioles.
• Positive pressure on the blood side or negative
pressure on the effluent side = pressure gradient
• Controls the amount of fluid removed from blood

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It’s illegal to copy or distribute without permission.!
+ or
Transmembrane Pressure (TMP)
-
 Cnus Renal
5 —CRRT Explained—
Replacement Therapy
PRINCIPLES OF CRRT
* Convection is a principle
of ultrafiltration! Convection Semi-permiable
Membrane
One way flow of solutes across a semi-permiable
membrane with the flow of water.
• "Solute Drag" - solutes being dragged by flow of water
• Effective for small, medium and large molecules.
• More flow = more clearance.
• Molecule size and membrane type will effect clearance.

Dialysate
Requires large volume of fluid removed
Blood

• Must give fluid back as replacement solution!

• Typically replacement solution will have same level of
electrolytes and bicarb found in normal serum. LA I

Pre-filter vs. Post-filter

• Dilute blood = clearance • concentration = clearance
• ↓Clotting = ↑ filter life • Iconcentration = Iclotting -

*Typically run BOTH!

All this fluid is removed via hemofiltration.

* Adsorption is a unique Adsorption Semi-permiable

Membrane
property of CRRT vs IHD!
Adherance of solutes and other biological
matter to the surface of the membrane.. - O
• Builds up as time goes on.
• Eventually can lead to a "clogged" filter (less effective)
Dialysate
Blood

• Membrane type will effect this.

• Adsorption has a small effect on additional clearance

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It’s illegal to copy or distribute without permission.!
 Cnus Renal

6 —CRRT Explained—
Replacement Therapy
MODES OF THERAPY
Slow Continuous Ultra Filtration
(SCUF)
The process of removing fluid at slow * This basic setup below is
rates without replacement fluid. present in ALL modes!

PRINCIPLE: Ultrafiltration
• Slow rate of fluid removal

J
• Little to no solute clearance (convection) Return

GOAL: The safe removal of fluid

from patients with fluid overload. Access

No dialysate or replacement used!

Effluent

Continuous Veno-Veno Hemofiltration

(CVVH)
The process of fluid removal and
solute clearance.
PRINCIPLES: Ultrafiltration
Convection ↓
Return
• D/t fluid removal volume, must use replacement

s
• Replacement can be pre, post or both.
• Small, medium & large molecules removed
• pH will be impacted by buffer in solution Access

No dialysate but replacement is used!

Effluent

(C) Eddie Watson & ICU Advantage LLC Pre Blood Pump
It’s illegal to copy or distribute without permission.! Replacement (pre replacement)
 Cnus Renal
7 —CRRT Explained—
Replacement Therapy
MODES OF THERAPY
Continuous Veno-Veno Hemodialysis
(CVVHD)
The process of the removal of solutes
and waste products.
PRINCIPLE: Diffusion
• Small and medium molecules removed

J
• pH will be impacted by buffer in solution Dialysate Return
• Can still use to safely remove fluid

Access
Dialysate is used but no replacement!

Effluent

Continuous Veno-Veno Hemodiafiltration

The process of using all the principles (CVVHDF)
discussed to remove solutes, waste * Most patients are just
products and fluid. run in this mode!
PRINCIPLES: Ultrafiltration
Convection
Diffusion

·
Dialysate Return
• Small, medium and large molecules removed
• pH will be impacted by buffer in solution
• Can safely remove fluid
Access
Dialysate and replacement both used!

Effluent

(C) Eddie Watson & ICU Advantage LLC Pre Blood Pump
It’s illegal to copy or distribute without permission.!
Replacement (pre replacement)
 Cnus Renal
8 —CRRT Explained—
Replacement Therapy
ANTICOAGULATION
* The purpose of anticoagulation with CRRT is to maintain longer filter run times!
• If the filter is clotting, we are losing efficiency
• If the filter clots off, therapy is not running while being changed
• Providers often account for this with a “buffer” but the less down time the better
Clotting: Typically the result of platelet activation, activation of the clotting
cascade, and ultimately obstruction of the hollow membrane fibers.
• Anticoagulation strategies aimed at interfering
with the clotting cascade
• Risks of anticoagulation must be weighed against
benefits and patients closely monitored!

Anticoagulation Strategies Systemic Anticoagulation

Anticoagulation with Heparin syringe pump or systemically
No Anticoagulation Useful when systemic anticoagulation * Highest risk for bleeding!
Useful when anticoagulation is contraindicated needed (mechanical valve, DVT/PE)
• Trauma/post-surgical Heparin Bivalrudin/Argatroban
• Head bleeds • Commonly used
• Known bleeding (maybe?) Downside: poor filter life & • Easy monitoring/dosing
• Direct thrombin inhibitor
• Liver failure frequent filter changes • No reversal (FFP can help)
• Sepsis coagulopathy • Easy reversal • No risk of HIT
• Monitor for HIT

Regional Anticoagulation
• Studies show safe and effective
Heparin-Protamine Prostacyclines
• Less risk for bleeding • Heparin given pre-filter • Anti-platelet & anti-thrombotic
• Filter life preserved with less risk • Protamine given post filter to reverse heparin • Short 30min half-life
• Requires closer monitoring • 1mg of protamine for every 100u heparin • Potent vasodilator
• Risk for thrombocytopenia
* Becoming more popular! Citrate-Calcium
• Citrate binds calcium (Ca+) • Ca+ key player throughout clotting cascade • Once Ca+ bound, citrate is inactive
• Metabolized into sodium bicarbonate (can benefit in metabolic acidosis). • Equal efficacy to heparin w/less risk!
• Citrate given pre-filter • Most unbound citrate removed via filter. • Ca+ given post-filter or to patient systemicall y
Evaluate post-filter & patient ionized ca+
(C) Eddie Watson & ICU Advantage LLC • Post-filter should be critically low. If then citrate rate, and vice versa
- 1

It’s illegal to copy or distribute without permission.! • Pt target is normal. If - then Ca+ rate, and vice versa.
 Cnus Renal
9 —CRRT Explained—
Replacement Therapy
PEARLS OF CRRT
* Probably the biggest and most common issue encountered!
Access/Return Line Issues
Patient positioning is often the leading cause
• Access will be too negative (-)
• IJ Line: check upper body position (limb, head, neck)
• Return will be too positive (+)
• Femoral Line: check lower body position (leg bent,
• If too high/low, RED alarms will stop therapy AND blood flow! anything pressing on line?)
• If positioning fails, a good couple strong flushes can help
• Avoid flipping lines (red to blue, blue to red) • Flush line good when disconnectiong or filter change
• Can lead to recirculation of treated blood and thus • Does your facility pack the line? KNOW THIS!
decreased effectiveness of treatment.
At the end of the day, if all else fails, getting treatment is vital.
Advocate for a new line if persistent issues!

Clotting vs. Clogging

Transmembrane Pressure (TMP) Pressure Drop
• Pressure across the membrane • Pressure going through the hollow membrane fibers
• Pressure difference between blood & dialysate • +200 alarm
• +350 alert, +400 alarm • Filter is "clogging"
• Filter is "clotting"

Prescribed vs. Delivered Therapy Dose

We have a big impact on how much therapy is delivered compared to what is prescribed.
Delivered dose GOAL: 20-25 ml/kg/hr (surrogate for this measurement is effluent rate)
Stoppages in therapy happen frequently, and are often unavoidable.
• Simple bag changes stop therapy until changed Don't sit on bag
• The quicker we detect and do these, the less down time! changes or clearing
• Many alerts/alarms either stop therapy or even blood flow
• Important to listen for and correct these quickly! alarms!
• Access/return line issues can have significant impact to stoppage
* Goal to minimize interruptions in therapy. If delivered dose is <20-25 ml./kg/hr notify provider
for possible adjustmnets to prescribed therapy rates.
(C) Eddie Watson & ICU Advantage LLC
It’s illegal to copy or distribute without permission.!
 Cnus Renal
10 —CRRT Explained—
Replacement Therapy
PEARLS OF CRRT
* Precise managment of
Blood Return Fluid Balance I&O's is crucial!
• 150-165 ml of blood in filter set • Every hour we meticulously add & subtract all I's & O's
• Important to return blood before filter clots off • Make sure you don't miss anything (flushes, drains, etc)
• If not returned, this is almost 1/2 unit of blood! • We are usually chasing the hour that just happened
• Could lead to pt requiring transfusion • Most accurate: pull exact infused volume from IV pumps
To change filter: • Fluid/Blood/Albumin for hypotension? DON'T REMOVE THIS!
• Stop therapy • Regular transfusion for Hgb drift is ok to remove
• Disconnect and flush the access line of catheter • Maintenance fluids are usually pointless (pulled right off)
• Attach access line to bag of fluids • If therapy was down an extended time, don't try and
• Flush filter set with fluid to return most of the blood make all of it up in one hour. Spread it out!
• Every hour figure out if +/- from set fluid removal rate
* Don't pre-prime your new set and leave it sitting! • Add/subtract to next hour. 10-20 ml x 24 hrs adds up!
• After sitting too long, can lead to reaction & hypotension • Before a filter change, get patient fluid removed volume
• Best practice is to prime when ready to hook up • You'll lose that information once changed.!

Crashing Patients Coding Patients

• If your pt is going down, stop pulling additional fluid • Turn your blood flow down as low as it goes
• Ensure 0 balance • As soon as you can, return the blood and stop CRRT
• If your pt is nearing coding, stop ALL fluid removal • Compressions and CRRT running well don't mix!
• See which way its going.. • Last thing you want is CRRT alarms while coding your pt
• These pts often very sick with large volumes of fluids
• We don't want to do this long. * Always make sure you have a hand crank available!
• But, this could prevent a code in the moment.
Temperature Management Blood Leak Detector (BLD)
• Extracorporial blood means hypothermia is common • Finicky when not cleaned. Alcohol swab this between runs
• Blood and fluid warmers often used • Effluent should be clear or yellow/straw
• Sometimes warming blankets will also be needed • BLD alarm + pink effluent.. Ruptured membrane?
• CRRT likes to mask fevers • Sample to lab to check for blood
• If pt is normothermic with no warming, suspect fever! • Change set if detected

Citrate Anticoagulation Other

• Ensure dialysate with no Ca+ • Don't forget to clamp syringe line if not used
• Monitor sodium (Na+) levels while using citrate! • Check ALL connectors on new set (may be loose)
• May need to reduce Na+ in fluids (dialysate/replace) • Never use old effluent bag for a new prime!
• Replacement protocol? NS 0.45NS D5W - 1 • Don't need new bags of fluids when setting up new set
• Citrate and Ca+ must be start/stopped together! • Machine weighs these, can determine how much fluid
• Save waste and keep using it all!
(C) Eddie Watson & ICU Advantage LLC
It’s illegal to copy or distribute without permission.!