Transcript Profiling Part 3 UF Profiling

Profiling
Ultrafiltration
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© 2007 Gambro Lundia AB 306175553 Rev C
Goals of UF Profiling
•
•
•
•
Provide adequate ultrafiltration (UF)
Minimize symptoms related to hypovolemia
Enhance plasma refill
Allow the patient to reach estimated dry
weight (EDW)
Hypovolemia: Decreased blood volume leads
Plasma refill: Refilling
of the blood
compartment, or
vascular space from
the surrounding tissue
spaces
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to decreased cardiac output which can cause
hypotension
Fluid Spaces in the Body
Average weight Male
70 kg or 154
lbs.
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VASCULAR SPACE
4 LITERS WATER, 5%
INTERSTITIAL SPACE
11 LITERS WATER, 15%
INTRACELLULAR
SPACE
27 LITERS
WATER
40%
Extracellular
60% of Total
Body Weight
is
42 liters
of
water
BONE, MUSCLE, FAT
Two Basic Reasons That Patients End
up With Dialysis Symptoms During
Treatment
•
•
The loss of circulating volume in the vascular
space
The loss of osmolarity as the urea is removed
during dialysis (see section - conductivity
profiling)
Only fluid in the vascular space is
available during dialysis for ultrafiltration.
This amounts to less than 4L in the
average patient
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© 2007 Gambro Lundia AB 306175553 Rev C
Symptom Etiology
With Constant Ultrafiltration
Ultrafiltration
(UF) removes
water volume
from the blood
into the
dialysate,
causing
hypovolemia
Symptoms
of Volume
loss:
•Hypotension
•Cramping
•Dizziness
•Nausea
•Vomiting
•Shock
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Profiling Ultrafiltration:
• Allows the patient to reach their
estimated dry weight (EDW)
• Helps prevent symptoms
• Allows refilling of vascular fluid volume
from the interstitial space (plasma refill)
• Allows higher volume fluid removal at
times when fluid is more readily
available
• Prevents hypotension
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© 2007 Gambro Lundia AB 306175553 Rev C
How to Do UF Profiling
• Identify patients with dialysis related symptoms
• Analyze patient’s treatment records
• Decide if the patient will benefit from a profile
• Choose a profile that matches your analysis
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© 2007 Gambro Lundia AB 306175553 Rev C
Things to Consider for
Ultrafiltration Profiling
• Does the patient have difficulty with fluid
removal?
• Have the MD answer these questions:
– What UF rates can the patient tolerate?
– Will the patient require periods of minimum
UF?
– How will patient co-morbidities affect fluid
removal?
– What type of profile would be best suited for
the patient?
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Individualize the Prescription
Based Upon the Patient’s
Treatment History
• Determine when the patient typically
demonstrates symptoms. Beginning –
mid – end of treatment?
• Does the patient need minimum UF to
complete the treatment?
• Evaluate the pre treatment systolic
blood pressure (SBP)
• Evaluate the patient’s weight gains
between treatments
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Choosing the Right UF
Profiles
• A profile that begins with the highest UF that
can be tolerated by the patient which then
decreases to a minimum will work for patients:
Linear
•
•
•
•
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Progressive
With large weight gains between treatments
Who become hypotensive late in treatment
Who cramp late or at the end of treatment
Step
Steptreatments
With large weight gains between
and present with an elevated BP
© 2007 Gambro Lundia AB 306175553 Rev C
Choosing the Right UF Profiles
• Consider a profile with varying steps for
patients who:
• Need a gradual increase in UF at the beginning
of the treatment to support low BP or cardiac
output
• Need short intervals of minimum UF to allow for
plasma refill
• Have difficulty shifting fluid into the vascular
space (elderly, diabetic or unstable)
• Cramp or are hypotensive randomly during
treatment
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Case Studies
How to select a UF profile
for a patient
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© 2007 Gambro Lundia AB 306175553 Rev C
Carl Kramper weight gains
typically of 3-4 kg and
experiences moderate to
severe leg cramps during
the last 30 minutes of
treatment
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Patient tolerates fluid
removal (higher UF)
at the beginning of
treatment
220
200
180
Symptoms are
relieved at the
end of treatment
with a lower UF
160
140
120
100
80
UF Profile
60
40
3
0
60
90
120
150 180
Time in Minutes
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210 240
220
Systolic BP
Fluid overloaded
200
patients benefit from
180
aggressive UF at
1.8
Kg/h
160
the beginning of the
treatment 140
0.7
120
0.3
100
Step profiles allow
for
80
dramatic decreases
in UF.
60
Lower UF at the 40
middle
and90
30 60
end of treatment will reduce
the patient’s symptoms
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1.0
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UF Profile
120
150 180
Time in Minutes
210 240
Harriet Hart arrives with a systolic
blood pressure of 85 and a weight
gain of 3 Kg. If her SBP falls
below 75 she becomes
symptomatic
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Less UF
should be used
220
at the beginning of
200while the SBP
treatment
is low. Increase the UF
180
during periods when the
SBP
160is higher
Decrease the UF
toward the end of
treatment as the
patient
approaches her
dry weight to
prevent symptoms
140
120
100
80
60
40
30
60 90
120
150
Time in Minutes
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180
210
240
220
Using a Step Profile, you can
create multiple minimum UF
periods which will allow
plasma refill to occur.
Decrease the UF toward the
end of treatment as the patient
approaches her dry weight to
prevent symptoms
200
180
160
140
120
100
80
60
40
30
60 90
12
0
150
Time in Minutes
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180
210
240
Katy Glycemia is hypertensive and
diabetic. She has large fluid gains
of 4-6 Kg between treatments and
has symptoms of hypotension
about 45 minutes into the treatment
as well as mid and late treatment
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Assessment and Plan
• Assessment:
– Large fluid gains
– Severe hypotensive episodes
– Poor plasma refill
• Plan
– Support plasma refill, especially during the
first part of the treatment
– Prevent hypovolemia
– Consider conductivity profiling in addition to
UF profiling
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220
200
Utilize a
Conductivity
profile to support
solute removal
180
160
140
120
100
80
60
40 30
60
90
120 150
Time in Minutes
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Arrows
indicate
plasma refill
times240
180 210
220
UF and Conductivity Profiling
can be used simultaneously
with similar step curves
200
180
160
140
120
100
80
60
40 30
60
90
120 150 180 210 240
Time in Minutes
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220
200
Systolic BP
180
160
140
120
UF and Conductivity Profiling
100
can be used simultaneously
with 80
similar progressive curves
60
40 30
60
90
120 150 180 210 240
Time in Minutes
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© 2007 Gambro Lundia AB 306175553 Rev C
Summary of UF Profiling
• Allows unlimited variation of ultrafiltration
rates so that fluid can be removed from the
vascular space while preventing symptoms
• Allows periods of automatic plasma refilling
to allow adequate fluid removal
• Decreases the patient’s symptoms
• May be used simultaneously with conductivity
profiling
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© 2007 Gambro Lundia AB 306175553 Rev C
References
Heinrich, W.L. & Victor, R.G., “Autonomic Neuropathy and Hemodynamic Stability in EndStage Renal Disease Patients”, Principles and Practice in Dialysis, Williams and Wilkins,
Baltimore, 1994.
Wilson, S., Alvarez, D., A Primer on Ultrafiltration Profiling and Sodium Modeling for
Dialysis Patients, Contemporary Dialysis and Nephrology, April 2000, pp 34-36.
Bonomini, V., Coli, L., Scolari, M.P., Profiling Dialysis: A New Approach to Dialysis
Intolerance, Nephron 1997; 75:1-6
Leunissen, K.M.L., Kooman, J.P., van der Sande, F.M., van Kuijk, W.H.M., Hypotension
and Ultrafiltration Physiology in Dialysis, Blood Purif 2000; 18:251-254
Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and Ultrafiltration Profiling on
Hemodialysis Related Symptoms, J Am Soc Nephrol 12: 151-156 2000
Jensen, B.M., Dobbe, S. A., Squillace, D.P., McCarthy, J.T., (April 1994) Clinical Benefits
of High and Variable Sodium Concentration Dialysate in Hemodialysis Patients, ANNA
Journal, Vol. 21, No. 2.
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© 2007 Gambro Lundia AB 306175553 Rev C
References
Gambro Basics 1 Gambro Education 1994
Petitclerc, T. and Jacobs, C. Dialysis sodium concentration: what is optimal and can it be
individualized? , Nephrol Dial Transplant Editorial Comments1995, 596-599.
Coli, L., Ursino, M., Dalmastri, V., Volpe, F., LaManna, G., Avanzolini, G., Stefoni, S.,
Bonomini, V., A simple mathematical model applied to selection of the sodium profile
during profiled haemdialysis, Nephrol Dial Transplant (1998) 13:404-416
Donauer,J., Kolblin, D., Bek, M., Krause, A., Bohler, J., Ultrafiltration Profiling and
Measurement of Reletive Blood Volume as Strategies to Reduce Hemodialysis-Related
Side Effects, AJKD, Vol 36, No 1 (July), 2000:pp115-123
Stiller, S., Bonnie-Schorn, E., Grassmann, A., Uhlenbusch-Korwer, Mann, A Critical
Review of Sodium Profiling for Hemodialysis, Seminars in Dialysis, Vol 14, No 5
(September-October) 2001 pp. 337-347
Locatelli, F., DiFilippo, S., Manzoni, C., Corti, M., Andrulli, S., Pontoriero, G., Monitoring
sodium removal and delivered dialysis by conductivity, The International Journal of
Artificial Organs/Vol. 18/no. 11, 1995/pp716-721
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