Basics on CRRT : practical

Content

o Defining the right treatment

o Preparing the treatment

o Running the treatment

o Ending the treatment

 Basics on CRRT : Defining the treatment

Questions are :

o When to start ?
o Which modality ?
o Which blood access ?
o Which flows ?
 CRRT
Treatments possible with Infomed’s devices :

CVVHF
CVVHDF
SCUF

CRRT

Fluid Acute Congestive Crush Lactic Pulmonary Lung

overload Renal Heart syndrome acidosois oedema failure
Failure Failure
(ARF)
 Defining CRRT : When to start ?

CRRT should be started according to RIFLE criteria or AKIN definition.

If RIFLE is used, starting treatment should be in Injury or Failure.

o Risk : Increase in serum creatinine x 1.5 or GFR decrease > 38%

o Injury : Increase in serum creatinine x 2 or GFR decrease > 50%
o Failure : Increase in serum creatinine x 2 or GFR decrease > 74%

Global recommendation is to start as early as possible when Injury is

detected because :

o CRRT protects the kidneys from further injury

o The sooner the less treatment duration
o The sooner the higher the renal recovery
o The sooner the less overall costs
 Defining CRRT : Which modality ?

Choices are :
CVVH, CVVHDF, SLEDD …

None of these technic has proven superior patient outcome or renal recovery
compared to the others.

The first key point is probably to ultrafiltrate or dialyse at least 30 ml/kg/h

while the patient is unstable. Higher flows did not demonstrate better results,
including in presence of sepsis.
The second key point is to perform the modality for which local staff is trained
and has necessary devices.

…. and related anticoagulation mode

None ?
Heparin ?
Citrate ?
 Defining CRRT : Which anticoagulation ?
None ? If :
o Platelet count < 50,000/mm3
o INR > 2.0
o APTT > 60 seconds
o Active bleeding or with an active bleeding episode in the last 24 hours
o Severe hepatic dysfunction or recent liver transplantation
o Within 24 hours post cardiopulmonary bypass or (ECMO)

Heparin ?
o For intermittent RRT and in case of contraindication to citrate (KDIGO)

Citrate ?
o In CRRT if patient do not have contraindication to citrate.
o In case of Heparin-induced thrombocytopenia and thrombosis (HITT)
which should be suspected if the platelet count drops by more than
50% from the patient’s baseline after heparin is begun.
o In case of absence of antithrombin III because heparin would be useless.
 Defining CRRT : Blood access ?

CRRT blood access is always a catheter

3 possible locations
Subclavian vein
Jugular vein
Femoral vein
 Defining CRRT : Blood access ?
Which catheter ?
The difference in catheters are :
o Length : 10-40 cm
o Diameter : 6-15 French
o Channel type : double D, coaxial …

o External shape

o The inlet-outlet
 Defining CRRT : Blood access ?
Which catheter ?
o Length should be adapted to the patient and long enough to bring
the catheter ends in the expected zone
o Diameter should be adapted to requested blood flow.

0 ml/min 100 ml/min 200 ml/min 400 ml/min

6FR 8 FR 12 FR 15 FR

o Channel type : double D is preferred as it offers the minimum

resistance compared to the external diameter
o External shape should allow convenient connection and comfort
for the patient.
o For inlet-outlet, 1 hole is preferred to multiple holes which would
clot.
 Defining CRRT : Blood access ?
Which is our concern?
Our concern is that the blood access allows to perform the
requested treatment with A/V pressures being stable between -
10 and -120 for the inlet and 10-120 for the return.

If the blood access is not sufficient the problem may come from
:
- The catheter position
- The catheter type
Don’t hesitate to request the right access !
 Defining CRRT : Which flows ?

Ultrafiltration + dialysate = 30 ml/kg/h

Blood flow shall be at least :

o 5 x greater than UF flow (hemoconcentration increases clogging and
clotting) and
o 2 x greater than dialysate flow to saturate this one

Weight loss shall be adapted to patient status

Substitution flows are the result of the above
Anticoagulation : see dedicated presentation
 Defining CRRT : Which flows ?

Example 1 : 90 kg patient in HDF, 50% UF / 50% dialysate

Total theoretical : flow = 30 ml/h * 90 kg = 2700 ml/h, thus 1350 UF and
1350 dialysate
Blood flow min = 5 x 1350 = 6750 ml/h = 112.5 ml/min
Choice : UF and dialysate = 1500 ml/h. Blood flow = 150 ml/min

Example 2 : 60 kg patient in HF,

Total theoretical : flow = 30 ml/h * 60 kg = 1800 ml/h UF
Blood flow min = 5 x 1800 = 9000 ml/h = 150ml/min
Choice : UF = 1800 ml/h,. Blood flow = 170 ml/min
 Preparing CRRT : Which devices ?
Machine
CRRT machine as HF440 from Infomed

Kits
Customers do appreciate to have complete kits which include at least
tubing sets, filters and all accessories such as 4-way octopus or waste
bags.
Infomed provides such kits with key features such as :
- Tubing set adapted to the patient size (baby, child, adult)
- Filter adapted to the need (4 hemofilters, 2 TPE)
- Accessories such as waste bags, 2, 3 or 4 ways octopus, expansion
chamber for single needle, vented spikes ...
- Standard kits exist however customised kits may be requested
whenever needed.
 Preparing CRRT
Filters
For the choice of the filter, the blood flow ranges must be considered. Values
are as follows :
Hemofilters
Plasmafilters
DF030 : 10-60 ml/min
LF030 : 10-120 ml/min
DF080 : 50-150 ml/min
LF060 : 50-200 ml/min
DF140 : 100-250 ml/min
DF190 : 150-400 ml/min

Above the maximum values provided above, hemolysis may occur as the red
cells are strongly pushed against the membrane.
Below the minimum value the clotting risk does increase.

In the choice of the filter, the blood volume may also be taken into account.
 Preparing CRRT : Which fluids ?
Fluids must be sterile and apyrogene and contain :
1) target values of electrolytes
2) a buffer such as lactate, bicarbonate or citrate (acetate
should not be used anymore)

All fluids are medications which must in all cases be prescribed

by the doctors.

Substitution fluids are drugs as they are injected directly in the

blood. Dialysate can be a CE marked device. Besides this both
fluids may be totally identical.
 Running CRRT : practical
Defining a protocol : key points :
- Clearance flow(UF + Dialysate) = 30 ml/kg/h
- Hemoconcentration (UF/Qb + Qpre) < 25%
- Weight loss flow : Must not induce hemodynamic instabilities. Better
too high than too low.
- Anticoagulation : Preferably based on a protocol considering clotting
and/or platelets and/or body weight
- Fluids : In general, their content in terms of salts must correspond to
a target value for the patients. In case of hyperkalemia it is useful to
have a low potassium fluid (K+ = 2-3 mmol/L).
In current practice, the optimal protocol, as defined above cannot be
reached. In such case the best compromise will be the new protocol !
 Running CRRT : practical
Setup, priming and rinsing : key points :
- Preparation of the disposable MUST be done using aseptic
techniques.
- After opening the sterile bags, first make sure that all pre-
connections are tight.
- Place the disposable on the machine.
- Make sure all connections are tight and that there is no kinking.
- Start priming/rinsing. In case of alarm or unusual sound check
carefully to find the origin of the problem.
- Avoid “special” connections with stopcocks, spikes and other
perfusion lines which are source of problems.
A good preparation of the circuit prevents alarms during
priming/rinsing and allows a smooth start of treatment.
 Running CRRT : practical
Running CRRT : key points :
- Make sure that the blood flow can be reached steadily. If not
consider to reduce it and compensate with predilution to maintain
the hemoconcentration. If the blood flow can’t reach 2/3 of the
planned value, a change in the catheter (position, model, A/V
exchange) must be considered.
- Check the pressures which must be constant and within reasonable
values :
Pressure (mmHg) Min Max
Arterial -120 -10
Venous 10 120
TMP 0 50
 Running CRRT : practical
Arterial or venous pressure out of range ?
- Reminder : the term “arterial” belongs to the historical arterio-
venous technic which uses the vessels pressure difference rather
than a pump to drive the blood. Today the “arterial” site is in the
vein.
- Reminder : to test the access with a syringe, the actual targeted
flow must be simulated. The fact the blood flows is not enough. To
simulate 150 ml/min with a 60 ml syringe, this one shall be filled in
24 seconds maximum.

A stable blood flow is the first condition for a smooth CRRT !

Each stop of the blood pump increases clotting risks !
 Running CRRT : practical

The following table gives an overview of the potential access

problems and their solutions.

Site Possible problem (s) Correction(s)

Vessel Not enough blood available Low intra-vascular blood flow Change catheter site or position
Size too small Wrong vessel choice or Expand patient’s volume
incorrect catheter position

Catheter Wrong model Kink or memorized kink Change catheter

Wrong position A/V lumens inverted
Clotted High blood viscosity

Tubing Kinked Forgotten clamp Open the clamp or unkink the line
set Clotted Change the set

Based on a table from Prof. Didier Journois, Mapar 2008, p 247

 Running CRRT : practical
CRRT key points to follow during treatment :
- The patient ! Electrolytes, blood oxygenation, hemodynamic
instabilities …
- The alarm messages : an alarm shall not be validated without
understanding its meaning and finding its source. Alarms must not
be validated more than 3 times in a row.
- TMP must be constant. If it increases the hemoconcentration may
be too high or clotting may be progressing.
- TFP alarms : indicates clotting, immediate review of the
anticoagulation protocol must be done.
- Changes bags and syringes whenever required by the machine.
 Running CRRT : practical
Ending the treatment :

- It is recommended to place the return fluid line on the arterial

service line (FLL attached to the sampling port)
- First, return by gravity the blood on the arterial access to rinse the
catheter
- Second return the blood by rotating the blood pump, unless it is
fully clotted within the circuit, until the colour in the bubble trap is
clear pink.
- Disconnect the patient and take care of the catheter.
 CRRT in practice …
Conclusion :
-The rules to succeed are simple and well defined.
-In current practice however many difficulties may happen.
They must be solved one by one in order to continue
treatment.
We thank you for your attention