Transcript Document 7371670

Dialysis and Replacement
Solutions for Pediatric 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.
CAVH: Good for Fluid Balance,
Not So Good for Metabolic Balance
• CAVH removes all molecules slowly
– Good for BP stability (slow UF)
– Not so good for metabolic control
• Need method to increase molecular
clearance without increasing UF rate
Diffusion
• Small molecules
diffuse easily
• Larger molecules
diffuse slowly
• Dialysate required
– Concentration gradient
– Faster dialysate flow
increases mass
transfer
H2 O
Neg Press
•
•
H2 O
H2 O
•
H2 O
•
Convection
Small/large molecules
move equally
Limit is cut-off size of
membrane
Higher UF rate yields
higher convection but
risk of hypotension
May need to Replace
excess UF volume
Solutions in CRRT Address
Molecular Control Issues
• Improved mass transfer using diffusion,
high-grade convection, or combination
– CVVH: a pure convection modality
– CVVHD: a diffusion modality
– CVVHDF: combined convection/diffusion
• Permits correction of metabolic
abnormalities
• Provides “complete” renal replacement
Characteristics of the Ideal
CRRT Solution
•
•
•
•
•
•
•
•
Physiological
Reliable
Inexpensive
Easy to prepare
Simple to store
Quick to the bedside
Widely available
Fully compatible
Options for CRRT Solutions
• Peritoneal dialysate: NO
• Pre-made IV solutions: MAYBE
– Saline, Lactated Ringers
• Multi-bag systems: UNNECESSARY
• Custom-made solutions: RARELY
– Local pharmacy; outsource
• Commercially available CRRT solutions
Commercial Solutions for CRRT:
Several Companies, Multiple Options
• Previously: limited options
– No bicarbonate-based solutions
– US regulations re: “drug” vs. “device”
• Currently: multiple manufacturers each
offering a variety of formulations
– Bicarbonate as primary or only base
• The Choice: may depend on local
policy, vendors, economic pressures
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
Potassium
Chloride
Bicarbonate
Calcium
Magnesium
Concentration After
Mixing (mEq/L)
140
0
107
35
0
1.5
Normocarb HF (DSI)
• Bicarbonate buffered
• Concentrate must be
compounded
• Final volume 3.24 liters
(240ml concentrate
added to 3 L bag)
• 2 ionic formulations
– Normocarb HF 25
– Normocarb HF 35
Chemical Content of Normocarb HF
Ion (mEq/L)
Sodium
Potassium
Chloride
Bicarbonate
Calcium
Magnesium
HF 25 HF 35
140
140
0
0
116.5 106.5
25
35
0
0
1.5
1.5
PrismaSate (Gambro)
•
•
•
•
Bicarbonate buffered
Small amount of lactate
5 liter bag
2 compartments to
prevent precipitation
• Six ionic formulations
Chemical Content of PrismaSate
Ion (mEq/L) BK0/3.5 BGK2/0 BGK4/0/1.2 BGK4/2.5 B22GK4/0 BK2/0
Sodium
140
140
140
140
140
140
Potassium
0
2
4
4
4
2
Chloride
109.5 108
110.2
113
120.5
108
Bicarb
32
32
32
32
22
32
Lactate
3
3
3
3
3
3
Calcium
3.5
0
0
2.5
0
0
Magnesium
1
1
1.2
1.5
1.5
1
Gluc(mg/dL)
0
110
110
110
110
0
PrismaSol (Gambro)
•
•
•
•
Bicarbonate buffered
Small amount of lactate
5 liter bag
2 compartments to
prevent precipitation
• Seven ionic formulations
Chemical Content of PrismaSol
Ion (mEq/L)
Sodium
Potassium
Chloride
Bicarb
Lactate
Calcium
Magnesium
Gluc(mg/dL)
BK
0/3.5
BGK
2/0
BGK
2/3.5
BGK
4/2.5
BGK
4/0
BGK
0/2.5
BK
0/0
140
0
109.5
140
2
108
140
2
111.5
140
4
113
140
4
110.5
32
3
3.5
32
3
0
32
3
3.5
32
3
2.5
32
3
0
32
3
2.5
32
3
0
1
0
1
100
1
100
1.5
100
1.5
100
1.5
100
1.5
0
140 140
0
0
109 106.5
Accusol (Baxter)
•
•
•
•
Bicarbonate buffered
No lactate
2.5 liter bag
2 compartments to
prevent precipitation
• Five ionic formulations
Chemical Content of Accusol
Ion (mEq/L) 5B9248 5B9249 5B9250 5B9251 5B9252
Sodium
140
140
140
140
140
Potassium
4
2
0
2
2
Chloride
113.5 111.5 109.5 116.3 113.5
Bicarb
35
35
35
30
30
Lactate
0
0
0
0
0
Calcium
3.5
3.5
3.5
2.8
0
Magnesium
1
1
1
1.5
1.5
Gluc (mg/dL) 100
100
0
100
100
Duosol (B.Braun)
•
•
•
•
Bicarbonate buffered
No lactate
5 liter bag
2 compartments to
prevent precipitation
• Three ionic formulations
Chemical Content of Duosol
Ion (mEq/L)
Sodium
Potassium
Chloride
Bicarb
Lactate
Calcium
Magnesium
Gluc (mg/dL)
4450
4451
4452
136
2
107
25
0
0
1.5
0
140
0
109
35
0
3
1
100
140
2
111
35
0
3
1
100
NxStage PureFlow (NxStage)
• Part of NxStage System
One for acute care
• 5 liter bags
• Choice of buffers
– Lactate: 3 formulations;
single-chamber bag
– Bicarbonate: 5 formulations;
dual-chamber bag
Chemical Content of
NxStage PureFlow (1)
Ion (mEq/L)
Sodium
Potassium
Lactate Buffer
RFP-204 RFP-205 RFP-207
140
140
140
1
3
1
Chloride
Bicarbonate
Lactate
105
0
40
112
0
35
100
0
45
Calcium
Magnesium
Glucose (mg/dL)
3
1
100
3
1
100
3
1
100
Chemical Content of
NxStage PureFlow (2)
Ion (mEq/L)
Sodium
Potassium
Bicarbonate Buffer
RFP-400 RFP-401 RFP-402 RFP-453 RFP-454
140
140
140
130
130
2
4
0
2
4
Chloride
Bicarbonate
Lactate
111
35
0
113
35
0
109
35
0
108.5
25
0
110.5
25
0
Calcium
Magnesium
Gluc (mg/dL)
3
1
100
3
1
100
3
1
100
0
1.5
100
0
1.5
100
Choosing a Solution:
Issues to Consider
•
•
•
•
Cost
Anticoagulation
Patient safety
CRRT modality
– Diffusion (CVVHD)
– Convection (CVVH)
– Both (CVVHDF)
Anticoagulation and Solutions
May need to consider Ca++ content if using
citrate for anticoagulation
Solution
Normocarb HF
Calcium?
No
Accusol
PrismaSate
PrismaSol
4 Yes; 1 No
2 Yes; 4 No
4 Yes; 3 No
Duosol
NxStage PureFlow
2 Yes; 1 No
6 Yes; 2 No
Evaluation of Errors in Preparation
of CRRT Solutions
• Survey of 3 Pediatric Listserves:
– Pediatric Critical Care, Nephrology, CRRT
• 16/31 programs reported solution
compounding errors
• Consequences of improper solutions
– 2 deaths
– 1 non lethal cardiac arrest
– 6 seizures (hypo/hypernatremia)
– 7 without complications
Barletta et al, Pediatr Nephrol. 21(6):842-5, 2006 Jun
FDA Approval Status of
CRRT Solutions
Solution
Normocarb HF
PrismaSate
PrismaSol
Accusol
Duosol
NxStage PureFlow
FDA Label
Replacement
Dialysate
Replacement
Dialysate
Dialysate
Dialysate
Putting it All Together: One Approach
R
• CRRT with citrate
regional anticoag
• DIALYSATE:
commercial bicarbbased solution
D
• REPLACEMENT:
normal saline
• Adjust blend, change
saline if indicated
On-Line Dialysate with SLED:
An Alternative to Solutions in CRRT
• Extended sessions
using standard dialysis
equipment
• Dialysate made on-line
from concentrates
• Simple, convenient,
MUCH cheaper
• Dialysate is not sterile
Citrasate
(Advanced Renal Technologies)
• “A” concentrate for
dialysis
• Liquid or bulk powder
• Citrate used as
acidifying agent
• Local anticoagulation
greatly reduces need
for heparin
CRRT Solutions: Summary
• Solutions needed to maximize clearance
• Bicarbonate has superseded lactate
• Industry-made solutions are available
including some approved for replacement
• Pre-mixed, sterile solutions for CRRT are
simple, safe, may be costly
• On-line dialysate for SLED is clean (not
sterile), simple, cheap
• The best “solution” may still be pending
Thanks!