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

Current Technology for Current Technology for

CRRTCRRT

Dr. Peter Skippen, PICU. BC Children’s Hospital,Dr. Peter Skippen, PICU. BC Children’s Hospital,

Vancouver. CANADA.Vancouver. CANADA.

CRRT TechnologyCRRT Technology

OutlineOutline

• The ideal CRRT machineThe ideal CRRT machine

• Hardware optionsHardware options

– HomemadeHomemade

– Dedicated fully integratedDedicated fully integrated

• ConclusionsConclusions

CRRT TechnologyCRRT Technology

The Ideal Machine for CRRT: IThe Ideal Machine for CRRT: I

• Inexpensive / user friendly / flexibleInexpensive / user friendly / flexible

• Accurate / dedicated pumpsAccurate / dedicated pumps

• Accurate scalesAccurate scales

• Blood flows 5-300mls/minBlood flows 5-300mls/min– increments of 1 ml/minincrements of 1 ml/min

• Continuous independent flow measurementsContinuous independent flow measurements

• Servo controlledServo controlled

• ThermoregulationThermoregulation

• Full range of safety featuresFull range of safety features

CRRT TechnologyCRRT Technology

The Ideal Machine for CRRT: IIThe Ideal Machine for CRRT: II

• Safety featuresSafety features

– Audible / visual alarms with over-rideAudible / visual alarms with over-ride

– Air / clot detectorsAir / clot detectors

– Blood leak detectorsBlood leak detectors

– Continuous display of circuit pressuresContinuous display of circuit pressures

– Continuous Uf urea concentrationContinuous Uf urea concentration

– Continuous circuit HctContinuous circuit Hct

• Minimal alarms - maximum patient safetyMinimal alarms - maximum patient safety

CRRT TechnologyCRRT Technology

The Ideal Circuit for CRRTThe Ideal Circuit for CRRT

• Minimal priming volume / low resistanceMinimal priming volume / low resistance

• Easy priming / recirculation procedureEasy priming / recirculation procedure

• Exchangeable componentsExchangeable components

• BiocompatibleBiocompatible– Non inflammatoryNon inflammatory

– Hemodynamic stabilityHemodynamic stability

– Non thrombogenicNon thrombogenic

CRRT TechnologyCRRT Technology

Integrated Hardware OptionsIntegrated Hardware Options

• Home made devicesHome made devices• Dedicated “all in one” machineDedicated “all in one” machine

– Edwards M 25Edwards M 25– PRISMAPRISMA– Braun DIAPACTBraun DIAPACT

– Fresenius Fresenius

• 2 integrated modules2 integrated modules

– Blood module (BM 11)Blood module (BM 11)

– Balancing module / Balancing module / scales (BM 14)scales (BM 14)

Edwards BM 25Edwards BM 25

Edwards BM 25: Edwards BM 25: Blood Pump ModuleBlood Pump Module

• Blood monitorBlood monitor

– pediatric flows:pediatric flows:

• 5 - 150mls / min5 - 150mls / min

– Increments of 1mlIncrements of 1ml

Edwards BM 25: Edwards BM 25: Effluent / Replacement Pump ModuleEffluent / Replacement Pump Module

• Balancing monitorBalancing monitor– Substitution pump / filtrate pumpSubstitution pump / filtrate pump

– Integrated scales: claimed accuracy Integrated scales: claimed accuracy 1% (20mls in 2000mls)1% (20mls in 2000mls)

– Replacement fluid heaterReplacement fluid heater

– TMP monitorTMP monitor

– Operational rangesOperational ranges• Replacement fluid 100- 9000mls / Replacement fluid 100- 9000mls /

hr (100ml increments)hr (100ml increments)

• Filtrate pump 100 - 11,000mls / hrFiltrate pump 100 - 11,000mls / hr

• Net UFR 0.1 - 2000mls / hrNet UFR 0.1 - 2000mls / hr

CRRT TechnologyCRRT Technology

Edwards BM 25: AdvantagesEdwards BM 25: Advantages

• Relatively lower costRelatively lower cost

• SimplicitySimplicity– Easy primingEasy priming

• FlexibilityFlexibility– Separate arterial / venous tubingSeparate arterial / venous tubing

– Use any filterUse any filter

– Neonate to adultNeonate to adult

– Any treatment option Any treatment option

• with modificationwith modification

• With loss of simplicityWith loss of simplicity

• Replacement fluid warmerReplacement fluid warmer

CRRT TechnologyCRRT Technology

EdwardsEdwards BM 25: Disadvantages BM 25: Disadvantages

• Only 3 pumpsOnly 3 pumps– For CVVHDF, extra pump creates For CVVHDF, extra pump creates

problemsproblems

• Does not calculate FFDoes not calculate FF

• No screenNo screen

• Troubleshooting requires training!Troubleshooting requires training!

• Blood / air interface with bubble trap?Blood / air interface with bubble trap?

PRISMA CRRT MachinePRISMA CRRT Machine

• Touch screenTouch screen

• Complete range of therapiesComplete range of therapies

• 3 weighing scales 3 weighing scales

– accuracy < +/- 0.5%accuracy < +/- 0.5%

• Custom filter / circuitryCustom filter / circuitry

PRISMA CRRT Machine: Basic LayoutPRISMA CRRT Machine: Basic Layout

ReplacementReplacement

DialysateDialysate

EffluentEffluent

BloodBlood

Heparin Heparin Syringe PumpSyringe Pump

Pressure Pods

Scales x 3Scales x 3

PRISMA ScreenPRISMA Screen

PRISMA ScreenPRISMA Screen

CRRT TechnologyCRRT Technology

• User friendly interfaceUser friendly interface

• Step by step instructionsStep by step instructions

• Continuous display of treatment Continuous display of treatment conditionsconditions

• Easy / rapid institution of Easy / rapid institution of therapies (self prime)therapies (self prime)

• Continuous 24 hour recording of Continuous 24 hour recording of treatment historytreatment history

• Alarm explanationsAlarm explanations

PRISMA Machine: AdvantagesPRISMA Machine: Advantages

CRRT TechnologyCRRT Technology

• Need for company specific filterNeed for company specific filter

• Relatively high costRelatively high cost

• Limited blood flow rangesLimited blood flow ranges

• Can’t change therapies mid-courseCan’t change therapies mid-course

• Scales sensitive to knockingScales sensitive to knocking

• Learning curve - don’t they all?Learning curve - don’t they all?

PRISMA Machine: Dis-advantagesPRISMA Machine: Dis-advantages

CRRT TechnologyCRRT Technology

• Compact, self contained, flexibleCompact, self contained, flexible

• High resolution screenHigh resolution screen

• 3 pumps3 pumps– Blood flow 10-500mls/minBlood flow 10-500mls/min

– Dialysate - substitution flow 0-250 mls/minDialysate - substitution flow 0-250 mls/min

– UFR 0-300mls/minUFR 0-300mls/min

• Automatic priming procedureAutomatic priming procedure

• Substitution fluid warmerSubstitution fluid warmer

• Full range of therapiesFull range of therapies

• Battery powerBattery power

Diapact CRRTDiapact CRRT

CRRT TechnologyCRRT Technology

Clinical IssuesClinical Issues

• BiocompatabilityBiocompatability

• Hemodynamic stabilityHemodynamic stability

CRRT TechnologyCRRT Technology

ConclusionsConclusions

• Improving technologyImproving technology

• Ideal machines / circuits?Ideal machines / circuits?

• Issues to be resolvedIssues to be resolved

– Biocompatability / ThrombogenicityBiocompatability / Thrombogenicity

– FlexibilityFlexibility

– VersatilityVersatility

– CostCost