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Pediatric CRRT Terminology

Pediatric CRRT Terminology . Helen Currier BSN, RN, CNN Assistant 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

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Pediatric CRRT Terminology

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  1. Pediatric CRRT Terminology Helen Currier BSN, RN, CNN Assistant Director, Renal/Pheresis Texas Children’s Hospital Houston, Texas

  2. 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

  3. 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)

  4. 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

  5. Test your knowledge • Pediatric CRRT therapies are approximately A. 40 years old B. 30 years old C. 20 years old D. 10 years old

  6. Test your knowledge • Pediatric CRRT therapies are approximately A. 40 years old B. 30 years old C. 20 years old D. 10 years old

  7. Indications for CRRT in the Critical Care Setting • Fluid removal • Solute removal

  8. 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

  9. Basic Concepts of CRRT: Concepts Related to Solute Removal or Clearance • Convection – solute drag; hemofiltration • Diffusion – concentration gradient; hemodiafiltration

  10. Post-Dilution CVVH CVVHD Qr Qb Qb Qeff Qeff Qd Qr Qr Qb Qb Qeff Qeff Qd Pre-Dilution CVVH CVVHDF Solute Mass Transfer in CRRT

  11. Solute Molecular Weight and Clearance Solute (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

  12. 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

  13. Comparison of Urea Clearance: CVVH vs CVVHD(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5) p = NS Urea Clearance (mls/min/1.73 m2) BFR = 4 mls/kg/min FRF/Dx FR = 2 l/1.73 m2/hr SAM = 0.3 m2

  14. Methods of Continuous Renal Replacement Therapy

  15. Definition of Acronyms and Terms • SCUF slow continuous ultrafiltration • CAVHcontinuous arteriovenous hemofiltration • CAVHD continuous arteriovenous hemodialysis • CVVH continuous venovenous hemofiltration • CVVHD continuous venovenous hemodialysis • CVVHDF continuous venovenous hemodiafiltration

  16. 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?

  17. 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

  18. The Pediatric Ideal: CRRT Circuit • Minimum priming volume with low resistance • Exchangeable components • Biocompatible membrane

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