PRISMAFLEX

CRRT
Oleh :
Yeni Nur Azizah
PT.Tawada
Healthcare
© 2008, Gambro 1
Introduction to CRRT
What is CRRT?
Transport Principles
Therapies of CRRT

© 2008, Gambro 2
 Renal failure
Neurological condition

ICU Respiratory failure

Clotting or bleeding
infection

sepsis shock

Multi organ failure

© 2008, Gambro 3
Indication For CRRT
Congesif heart failure Hepatic failure
. Low cardiac out put . Ascites
. Pulmonari edema . Elevated biliru

. Circulation fluid overload bin

SIRS AKI
(Systemc inflamantory response syndrom)
. Trauma
. Burns
. Pancreastistis
. Sepsis / infection
ICP/ Celebral edema
© 2008, Gambro 4
Classification of RRT

Renal
Replacement
Therapy

Intermittent Continuous

Slow Low Continuous Renal

Intermittent Peritoneal
Efficiency Replacement
hemodialysis Dialysis Therapy
Dialysis

© 2008, Gambro 5
 Continuous Renal Replacement Therapy

Defination:

“Any extracorporeal blood purification therapy intended

to substitute for impaired renal function over an
extended period of time and applied for or aimed at
being applied for 24 hours/day.”

R. Bellomo, C Ronco and R. Mehta, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, November 1996

© 2008, Gambro 6
Kidney

 The kidneys are bean shaped

organs

 Located at the back of the

abdominal cavity.

 Approximately 0.5% of total body wt

 Receive approximately 25% of

cardiac output in a minute

© 2008, Gambro 7
Secretory & Excretory function of kidney

SECRETORY EXCRETORY

Renin: Regulate blood pressure

Remove excess fluid

Remove waste products

EPO: Regulate red blood cell
production
Regulate acid/base balance

Vitamin D: Regulate calcium Regulate electrolyte levels

uptake

© 2008, Gambro 8
Hemofilter – the artificial kidney

 Blood filtering device used mainly to replace the

excretory functions of the kidney

 Also known as an “artificial kidney” or dialyzer

 Hemofilter is composed of multiple hollow fibers

© 2008, Gambro 9
The hemofilter is the main functional unit of the CRRT
circuit, where blood is processed for solute and/or fluid
removal

© 2008, Gambro 10
 GRF Urine Output

Definition of ARF
according to the
RIFLE criteria

RIFLE defines three grades of

severity of ARF on the basis of either:
• acute increase in serum creatinine
• decrease in GFR
• decreased urine output.

© 2008, Gambro 11
 Ultra filtration

Movement of fluid through a semi-permeable membrane driven by a

pressure gradient.

Positive Pressure Negative Pressure

© 2008, Gambro 12
 Difussion
 Solutes move from an area of higher concentration to lower
concentration.
 Small molecules will diffuse across the semi permeable membrane to
the fluid side of the filter (lower concentration area).
 Dialysate is used to create a lower concentration gradient across a semi
permeable membrane.

Diffusion will continue happen until both side of concentration gradient reach
equilibrium

© 2008, Gambro 13
 Convection
 Movement of the solute across a membrane caused by a passage
of fluid or solvent known as “ solvent drag”

 removal of solutes, especially middle and large molecules, by

convection or relatively large volumes of fluid and simultaneous

High pressure to low pressure

© 2008, Gambro 14
 Additional Transport Mechanism:
- Adsorption
 Molecular adhere to the surface of the semi permeable membrane.
 AN 69 filters used in CRRT have strong adsorptive properties.

© 2008, Gambro 15
 Molecular Weights
3 category of solutes for removal in CRRT.

“Large”

Convection
Septic Mediators
Interleukins “Middle”
TNF
Adsorption

Diffusion
“Small”

© 2008, Gambro 16
 CRRT modalities
•SCUF – Ultra filtration ( water )
•CVVH – Ultra filtration + Convection
( water, sepsis )
•CVVHD – Ultra filtration + Diffusion
( water, urea, kreatinin, kalium )
•CVVHDF - Ultra filtration + Diffusion + Convection
( water, urea, kreatinin, kalium, sepsis )

© 2008, Gambro 17
SCUF- Slow Continuous Ultra Filtration

 Require a Blood and Effluent pump

 NO dialysate or replacement solution needed
 fluid removal up to 2L/Hr can be achieved

GOAL Safe management of fluid removal

Fluid removal by ultra filtration

© 2008, Gambro 18
Prismaflex Set Configuration - Flowpath

prismafleX SCUF

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Access pressure
Filter pressure

BLD

Effluent Anticoagulant

Effluent

© 2008, Gambro 19
CVVH –Continuous Veno-Venous Hemofiltration

 Require blood, effluent and replacement pumps.

 Require a replacement solution.

GOAL Plasma and solutes are removed by

convection and ultra filtration

© 2008, Gambro 20
Prismaflex Set Configuration - Flowpath

prismafleX CVVH

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Access pressure
Filter pressure

Post or Pre
Post
BLD

Replacement Effluent Replacement Infusion or Anticoagulant

POST DILUTION PRE DILUTION

© 2008, Gambro 21
 Convection
Pre Dilution

Replacement Solution

Post Dilution

© 2008, Gambro 22
Replacement Fluid : Pre vs. Post Filter
Dilution

Replacement Fluid
(Pre-dilution only)
Pre Dilution

It reduces risk of filter clotting

May prolonged haemofilter life

It reduces effective clearance up to

15%

More replacement solution is

required

© 2008, Gambro
© 2008,
Lundia
Gambro
AB 23
Replacement Fluid: Pre vs. Post Filter
Dilution
Post Dilution

No reduction of effective
clearance

Less replacement solution

required

Increases risk of filter clotting.

Increased need of anticoagulant

Replacement fluid
(Post-dilution only)

© 2008, Gambro
© 2008,
Lundia
Gambro
AB 24
CVVHD-Continuous Veno-Venous HaemoDialylisis

 Require the use of blood, effluent and dialysate pump

 Require a Dialysate solution

GOAL Plasma water & solutes are removed

by diffusion and ultrafiltration

© 2008, Gambro 25
Prismaflex Set Configuration - Flowpath

prismafleX CVVHD

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Access pressure
Filter pressure

Dialysate
BLD

Dialysate Effluent Infusion or Anticoagulant

Dialysate Effluent

© 2008, Gambro 26
 Diffusion

Dialysate Solution

Diffusion is the movement of waste (solutes) from

higher to lower concentration

© 2008, Gambro 27
CVVHDF- Continuous Veno-Venous HaemoDiaFiltration

 Require to use of blood, effluent, dialysate & replacement pumps

 Both dialysate and replacement solution are used

GOAL Plasma water and solutes are remove by

difussion, convection and ultrafiltration

© 2008, Gambro 28
Prismaflex Set Configuration - Flowpath

prismafleX CVVHDF

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Access pressure
Filter pressure
Dialysate Post or Pre

BLD

Dialysate Effluent Replacement Infusion or Anticoagulant

Dialysate Effluent Pre or Post dilution

© 2008, Gambro 29
 Dialysate
solution

Combination of Convection & Diffusion

© 2008, Gambro 30
Technical Summary CRRT
SCUF CVVH CVVHD CVVHDF

Blood Pump yes yes yes yes

Effluent (UF) Pump yes yes yes yes

Dialysate no no yes yes

Replacement
no yes no yes
Solution

Ultrafiltration
Principal Transport Ultrafiltration Ultrafiltration Convection
Ultrafiltration
Mechanism Convection Diffusion Diffusion

© 2008, Gambro 31
Component of CRRT
Hemofilter
Solutions
Vascular Access
Anticoagulation

© 2008, Gambro 32
Prismaflex M100 sets

PRIMSMAFLEX M100

Characteristics:
 Membrane: AN 69
 Priming volume: 152 ml
 QB Range: 50 - 400 ml/ min
 Application: ≥ 30 kg
 Validated to use for: 72 hours

© 2008, Gambro 33
Solutions

© 2008, Gambro 34
 Bicarbonate solution
Electrolyte solution: 250ml

Contains/1000 ml:
Two-compartment bag
•CaCl2, 2H2O 5,145g
• Latex free
• Separated by a frangible pin •MgCl2, 6H2O 2.033g
• Prevents carbonate formation/precipitation
• Promotes stability of solution
•Lactic acid 5.400g
Over-wrap Buffer solution: 4750ml
• Prevents CO2 evaporation
• Stable pH during storage • NaCl 6.45g

Shelf Life • KCl 0.157g

• Unopened - one year • Sodium hydrogen
• Mixed – use immediately within 24 hours carbonate 3.090g

Mixed solution: 5000ml

•Osmolarity 297 mOsm/l

•pH 7.0 –
8.5

© 2008, Gambro 35
Vascular Access

© 2008, Gambro 36
 Vascular Access - CRRT

Jugular Subclavian
 Long term access  Easy to insert
 Patient comformt  Risk of stenosis & kinking

Femoral
 Easy to insert
 Good blood flow condition
 Risk of stenosis & infectious

© 2008, Gambro 37
Anticoagulation

© 2008, Gambro 38
Prismaflex Hands-on
System overview
Basic troubleshooting

© 2008, Gambro 39
System Overview

Communication
Unit

Flow Control Unit

Fluid Control Unit

© 2008, Gambro 40
Status Light

All parameters are running good

Caution

Advisory

Warning

Malfunction

© 2008, Gambro 41
Flow Control Unit
Control patient output
Effluent pump
Max flow 10L/hr

Dialysate pump Pump dialysate fluid to the filter

Max flow 8L/hr

Pump the solution into the bld

Replacement
Circuit can be pre or post.
pump
Max flow 8L/hr

Pump replacement solution into

PBP pump The access line prior to the
bld pump
Max 8L/hr

© 2008, Gambro 42
Cont…

Blood pump

Pump blood through the blood

Flow path of the set.
Max flow 450mls/min

© 2008, Gambro 43
Five pressure pods

Extra pressure pod

Return pressure pod

Effluent pressure pod

Access pressure pod

Filter pressure pod

© 2008, Gambro 44
Discussion

© 2008, Gambro 51
THANK
YOU…

© 2008, Gambro 52