Current Technology for CRRT Dr Peter Skippen PICU

Current Technology for CRRT Dr. Peter Skippen, PICU. BC Children’s Hospital, Vancouver. CANADA.

CRRT Technology Outline • The ideal CRRT machine • Hardware options – Homemade – Dedicated fully integrated • Conclusions

CRRT Technology The Ideal Machine for CRRT: I • • Inexpensive / user friendly / flexible Accurate / dedicated pumps Accurate scales Blood flows 5 -300 mls/min – increments of 1 ml/min • • Continuous independent flow measurements Servo controlled Thermoregulation Full range of safety features

CRRT Technology The Ideal Machine for CRRT: II • Safety features – Audible / visual alarms with over-ride – Air / clot detectors – Blood leak detectors – Continuous display of circuit pressures – Continuous Uf urea concentration – Continuous circuit Hct • Minimal alarms - maximum patient safety

CRRT Technology The Ideal Circuit for CRRT • • Minimal priming volume / low resistance Easy priming / recirculation procedure Exchangeable components Biocompatible – Non inflammatory – Hemodynamic stability – Non thrombogenic

CRRT Technology Integrated Hardware Options • Home made devices • Dedicated “all in one” machine – Edwards M 25 – PRISMA – Braun DIAPACT – Fresenius

Edwards BM 25 • 2 integrated modules – Blood module (BM 11) – Balancing module / scales (BM 14)

Edwards BM 25: Blood Pump Module • Blood monitor – pediatric flows: • 5 - 150 mls / min – Increments of 1 ml

Edwards BM 25: Effluent / Replacement Pump Module • Balancing monitor – Substitution pump / filtrate pump – Integrated scales: claimed accuracy 1% (20 mls in 2000 mls) – Replacement fluid heater – TMP monitor – Operational ranges • Replacement fluid 100 - 9000 mls / hr (100 ml increments) • Filtrate pump 100 - 11, 000 mls / hr • Net UFR 0. 1 - 2000 mls / hr

CRRT Technology Edwards BM 25: Advantages • Relatively lower cost • Simplicity – Easy priming • Flexibility – – Separate arterial / venous tubing Use any filter Neonate to adult Any treatment option • with modification • With loss of simplicity • Replacement fluid warmer

CRRT Technology Edwards BM 25: Disadvantages • Only 3 pumps – For CVVHDF, extra pump creates problems • • Does not calculate FF No screen Troubleshooting requires training! Blood / air interface with bubble trap?

PRISMA CRRT Machine • • • Touch screen Complete range of therapies 3 weighing scales – accuracy < +/- 0. 5% • Custom filter / circuitry

PRISMA CRRT Machine: Basic Layout Effluent Replacement Pressure Pods Heparin Syringe Pump Dialysate Blood Scales x 3

PRISMA Screen

PRISMA Screen

CRRT Technology PRISMA Machine: Advantages • • • User friendly interface Step by step instructions Continuous display of treatment conditions Easy / rapid institution of therapies (self prime) Continuous 24 hour recording of treatment history Alarm explanations

CRRT Technology PRISMA Machine: Dis-advantages • • • Need for company specific filter Relatively high cost Limited blood flow ranges Can’t change therapies mid-course Scales sensitive to knocking Learning curve - don’t they all?

CRRT Technology Diapact CRRT • • • Compact, self contained, flexible High resolution screen 3 pumps – – – • • Blood flow 10 -500 mls/min Dialysate - substitution flow 0 -250 mls/min UFR 0 -300 mls/min Automatic priming procedure Substitution fluid warmer Full range of therapies Battery power

CRRT Technology Clinical Issues • Biocompatability • Hemodynamic stability

CRRT Technology Conclusions • Improving technology • Ideal machines / circuits? • Issues to be resolved – Biocompatability / Thrombogenicity – Flexibility – Versatility – Cost