Transcript Pediatric solutions For HF

Dialysis and Replacement
Solutions for CRRT
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, WA
[email protected]
CRRT Solutions:
Outline of the Talk
• Purpose of solutions in CRRT
• Goals for a CRRT solution
• Description of solutions currently
available for CRRT
• Considerations in choosing a solution
for CRRT
First CAVH Circuit
Kramer, P, et al.
Arteriovenous
haemofiltration: A
new and simple
method for
treatment of overhydrated patients
resistant to
diuretics. Klin
Wochenschr
55:1121-2, 1977.
CRRT Machines:
Current Generation
Convective Clearance
To increase clearance
by convection,
increase ultrafiltration
rate (will require more
replacement fluids)
D
Diffusive Clearance
To increase clearance
by diffusion, increase
dialysate flow rate
Characteristics of the Ideal
CRRT Solution
•
•
•
•
•
•
•
•
Physiological
Reliable
Inexpensive
Easy to prepare
Simple to store
Quick to the bedside
Widely available
Fully compatible
Base in CRRT Solutions
• Hemodialysis: first acetate, then
bicarbonate
• Peritoneal dialysis: lactate in North
America; bicarbonate in Europe
• CRRT: lactate or bicarbonate?
Bicarbonate vs. Lactate in CRRT
• Both can be used for base
• Bicarbonate superior to acetate in HD
• PD uses lactate due to technical issues
Is bicarbonate preferable to lactate?
Bicarbonate vs. Lactate in CRRT:
Blood Lactate Levels
Group 1 (Lactate first) Group 2 (Bicarb first)
Baseline
Bicarbonate
Lactate
16.3 + 1.5
2.4 + 0.8
18.9 + 2.0
1.4 + 0.2
0 – 48 hours
Bicarbonate
Lactate
48 – 96 hours
Bicarbonate
Lactate
Receiving Lactate
22.2 + 1.4
2.6 + 0.4
Receiving Bicarb
24.2 + 2.3
1.8 + 0.6
Receiving Bicarb
22.2 + 1.1
1.5 + 0.1
Receiving Lactate
24.8 + 0.6
3.1 + 0.7
Zimmerman et al, Neph, Dial & Transpl 1999 14:2387-2391
Bicarbonate vs. Lactate in CRRT:
Blood Lactate Levels in Children
4
Lactate Level
3.5
3
2.5
2
1.5
1
0.5
0
Baseline
HCO3 soln
8 hrs
LR soln
16 hrs
Maxvold et al, Blood Purif 17:#27, 1999 [abstract]
24 hrs
Bicarbonate vs. Lactate in CRRT:
Cardiovascular Events
Bicarbonate
Barenbrock M et al, Kid Int 58:1751-1757, 2000
Lactate
Options for CRRT Solutions
• Peritoneal dialysate
• Adapted pre-made solutions
– Saline, Lactated Ringers
• Multi-bag systems
• Custom-made solutions
– Local pharmacy; outsource
• On-line dialysate
• Commercially available CRRT solutions
Baxter Hemofiltration Solution
• Lactate buffered
• 5 liter bag
• Small amount of
potassium
• Contains calcium
Chemical Content of Baxter
Hemofiltration Solution
Ion
Concentration (mEq/L)
Sodium
140
Calcium
3.5
Magnesium
1.5
Potassium
2
Chloride
117
Lactate
30
Glucose (mg/dL)
100
Hemosol (Hospal)
• 5 liter bag
• “L” series (lactate) with
variable K+, glucose
• “B0” (bicarbonate) needs
to be mixed
• Not available in US
Chemical Content of Hemosol
Ion (mmol/L)
Sodium
Calcium
Magnesium
Potassium
Chloride
Lactate
Bicarbonate
Glucose
L0, LG2, LG4
140 – 142
1.75
0.75
0/2/4
105 – 109.5
40
0
+/-
B0
140
1.75
0.5
0
109.5
3
32
0
Normocarb (DSI)
• Bicarbonate buffered
• Concentrate must be
compounded
• Final volume 3.24 liters
(240ml concentrate
added to 3 L bag)
Chemical Content of Normocarb
Ion
Sodium
Calcium
Magnesium
Potassium
Chloride
Bicarbonate
Concentration After
Mixing (mEq/L)
140
0
1.5
0
107
35
PrismaSate (Gambro)
•
•
•
•
Bicarbonate buffered
Small amount of lactate
5 liter bag
2 compartments to
prevent precipitation
• Two ionic formulations
Chemical Content of PrismaSate
Ion (mEq/L)
BK0/3.5 BGK2/0
Sodium
140
140
Calcium
3.5
0
Magnesium
1
1
Potassium
0
2
Chloride
109.5
108
Lactate
3
3
Bicarbonate
32
32
Glucose (mg/dL)
0
110
Choosing a Solution:
Issues to Consider
• Anticoagulation
• Cost
• CRRT modality
– Diffusion (CVVHD)
– Convection (CVVH)
– Both (CVVHDF)
• Patient safety
Anticoagulation and Solutions
Solution
May need to
consider Ca++
content if using
citrate for
anticoagulation
Calcium?
Baxter Hemofiltration
Solution
Yes
Hemosol
Yes
Normocarb
No
PrismaSate
BK0/3.5 – Yes
BGK2/0 – No
Pharmacy Custom
Made
User Choice
CRRT Solutions: Costs
Base
Normocarb
Bicarbonate
Baxter
Hemofiltration
Lactate
Solution
Pharmacy
User choice
Custom Made
Cost/bag Preparation Industry
Time
Standard
($US)
27.06
5 min
Yes
30.45
3 min
Yes
29.38
45 min
No
Bunchman et al, Blood Purif 20: 2002 [abstract]
Modality May Have an Impact
on Choice of Solutions
• Diffusion requires the use of a dialysate
• Convection requires the use of
R
replacement fluids
D
R
What’s the Difference Between
Dialysate and Replacement Fluid?
Dialysate is a Device
Replacement Fluid is a Drug
FDA Approval Status of
CRRT Solutions
Solution
Baxter Hemofiltration
Solution
Hemosol
PrismaSate
Pharmacy Custom
Made
Normocarb
Approved as
Dialysate?
Approved as
Replacement?
Yes
No
Yes in Europe/
No in the US
Yes in Europe/
No in the US
Yes
No
?
?
Yes
No*
Normocarb as Replacement Fluid
FDA Modernization Act of 1997:
“The Act creates a special exemption to ensure
continued availability of compounded drug products
prepared by pharmacists to provide patients with
individualized therapies not available commercially”.
Bunchman et al, AJKD 42(6):1248-52, 2000
Evaluation of Errors in Preparation
of CRRT Solutions
• Survey of 3 Pediatric Listserves:
– Pediatric Critical Care
– Pediatric Nephrology
– Pediatric CRRT
• 31 programs responded to query
Bunchman et al, Blood Purif 22: 2004 [abstract]
Prevalence and Consequences of
Errors in Solution Preparation
• 16/31 programs reported errors:
– 7 errors in replacement solutions
– 9 errors in dialysate solutions
• Consequences of improper solutions
– 2 deaths
– 1 non lethal cardiac arrest
– 6 seizures (hypo/hypernatremia)
– 7 without complications
Bunchman et al, Blood Purif 22: 2004 [abstract]
Policy Changes Resulting
from Errors in Solutions
• Changed to Normocarb for either
replacement or dialysate (11)
• Changed to PrismaSate for dialysate (2)
• Purchased TPN mixer for solutions (2)
• Chemistry lab check of every bag (3)
• Bag label check by at least 2 staff (10)
Bunchman et al, Blood Purif 22: 2004 [abstract]
CRRT Solutions: Summary
• Solutions needed to maximize clearance
• Bicarbonate seems superior to lactate
• Pharmacy made solutions give greatest
flexibility but have increased risks/costs
• Several industry-made solutions; none
currently approved for replacement
• Still no perfect “solution” for this problem
Thanks!