CRRT Machines Akash Deep Director - PICU King’s College Hospital London Chair Renal/CRRT Section European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

CRRT Machines Evolution of CRRT and machines Ideal CRRT machine Outline of few available CRRT machines internationally

CRRT Historical Perspective Continuous Arterio-Venous Hemofiltration(CAVH): first CRRT modality described in 1977 for hemodyanamically unstable AKI patients Considered a ‘derivative’ therapy to chronic hemofiltration Continuous arterio-venous hemodialysis(CAVHD) developed in mid-1980’s to improve small solute clearance Problems with continuous AV therapies Circuit blood flow dependent on patient’s blood pressure Need for large bore arterial catheter( bleeding, thrombosis)

Historical Perspective Development of early veno-venous CRRT systems: “adaptive technologies” (late-1980’s to mid-1990’s) Double lumen venous catheters revolutionary Roller Blood pump – blood flow could be programmed Ancillary pumps to control rates of dialysate (CVVHD) or replacement fluid (CVVH) – accurate delivery Semi-integrated systems: blood pump, ultrafiltration controller, and fluid pump all in same module (“open loop”)

CRRT Technology evolution

My CRRT Machine Safety Performance User friendly

Ideal CRRT machine Inexpensive User Friendly Adequate technical devices and supplies Specific extracorporeal circuits Precise UF control systems Compatible fluids for replacement Adequate anticoagulation regimens Thermoregulation Accurate monitoring systems to improve quality of management, safety, and performance

Safety Ideal extracorporeal circuit must incorporate continuous pressure measurements and continuous displays of pressures from: Inlet and outlet lumens of the catheter Inlet and outlet of the filter Ultrafiltrate and dialysate ports. This information integrated with adequate alarms is of crucial importance in allowing ICU staff to maintain filter efficiency and circuit patency and to detect potential sources of clotting and ensuring patient safety.

Newer CRRT Machines Integrated blood modules Pressure sensors as safety checks – check on access issues and circuit clotting/clogging Fluid balancing controls Blood flow rates up to 500 ml/min Increased dialysate and replacement fluid flow rates Highly permeable membranes

Newer CRRT Machines Higher surface area dialyzers Simplified priming procedures User friendly operator interface -wide color screen allows easy access to the required information and on-line help for most of the functions Data extraction capabilities Automatic data printing Transportability of machine – treatment provided at different parts of hospital

Summary- New machines Machines of today have to have safety features in place In addition capable of performing high tech modalities with extreme precision and accuracy.

Descriptors Dialyzer - Any dialyzer -Cartridge Pumps -Number -Purpose Modes Min/Max Ultrafiltration rate Min/Max effluent flow Volume Control - Volumetric - Gravimetric Alarms Safety features Blood warmer

CRRT Machines Prisma Prismaflex Diapact Aquarius NxStage Fresenius 2008 K Carpidiem - Neonatal

Prisma(Gambro) Preassembled cartridge with lines and dialyser Compact large monitor with touch screen features 4 pumps and 3 scales -SCUF -CVVH -CVVHD -CVVHDF - PLASM EXCHANGE Flow rates - QB 0-180 ml/min - QD 0- 2500 ml/hr - QRF 0-2000 ml/hr - Total Effluent 5000ml/hr Replacement Fluid - Pre - Post - Simultaneous pre- and post-

Problems with PRISMA Rigidity of prescription and performance - pre-fixed filter and circuit set with only 2 surface areas available Pre-designed circuit with either pre or post dilution – NO interchange of therapy possible Blood flow limited to 180 mls/min Heater for dialysate/replacement fluid not an option

Prismaflex ( Baxter-Gambro) New features to perform therapies with high fluid volume exchange 5 pumps, 4 scales Disposable set with pre-connected high flow dialyzer and circuit -SCUF -CVVH -CVVHD -CVVHDF TPE/MARS ( future use) Fifth pump- Pre- Blood-Pump : Allows for citrate infusion just after connection between arterial access and blood line Blood Inlet at the bottom of dialyser Flow rates - Blood pump bigger than Prisma QB 10-450ml/min - Total effluent 10,000ml/ hr - Maximum UF of 2000ml/ hr Replacement Fluid – Pre and /or post In-line blood heater Blood heater Effluent pump Pre-blood pump Blood pump

Prismaflex Gravimetric fluid balance system provide check & balance for precise fluid exchange & accurate patient fluid removal Real-time dose indicator assesses prescription delivery Deaeration chamber collects & removes air while minimizing clotting Can change pre- and post- infusion mixing points during a treatment using the same set by pinch valves without interrupting therapy Membranes: M and HF series (ST)

Aquarius ( Nikkiso ) Automatic priming 4 pumps and 6 pump models (newer version) AND 2 scales - Citrate & Calcium pumps for RCA Therapies -SCUF - CVVH, CVVHD, CVVHDF - TPE - Hemoperfusion Flow rates - QB: 30-450 ml/min ( adult) - Dialysate/Replacement- up to 10L/hr - Filtrate- up to 12L/hr - Up to 20L can be hung on scales Replacement Fluid - Pre- and/ or post-dilution Heparin syringe

Colour Coding

NxStage System One Bag Changes - Free from waste bag changes - Eliminates blood pump stopping for bag changes Portable with no plumbing/electrical needs Cartridge - Drop- in loading and engagement of all pumps and safety systems - One set delivers all therapies - No prime intervention - No blood/air interface in cartridge Optimizes BF and reduces clotting Volumetric balancing chambers incorporated into the cartridge - Will not allow fluid imbalance to overridden alarms

A Dedicated Neonatal CRRT Machine? CA.R.PE.DI.E.M. (Cardio–Renal Pediatric Dialysis Emergency Machine) Miniaturized, transportable Weight range- 2- 9.9 kg(BSA 0.15-0.5M2) Lines and filters to limit extracorporeal blood volume Hardware and software accurate for low flows and low UF volumes Dedicated rather than adapted

Characteristics 6 inches of user interface 3 40-mm-diameter roller pumps 2 scales 3 pressure transducers. 3 pre-assembled circuits Polysulphone membranes - surface area of 0.075, 0.147, and 0.245 m2 priming volumes - 27.2, 33.5, and 41.5 ml, with the circuit included (extracorporeal blood volume) Blood pump flow rate – 5-50 mls/min Max total UF/dialysis/ HF - 5mls/ min Treatment set up – Blood flow, dialysate/HF, net UF regulation

CARPIDIEM By Ronco

My machine No suggestion to choose a model or prefer one over the other MAKE SURE IT DOES WHAT YOU INTEND TO ACHIEVE LOCAL USAGE, STAFF FAMILIARITY,PATIENT POPULATION FINANCIAL IMPLICATIONS SUPPORT SYSTEM IMMENSELY IMPORTANT ONGOING TRAINING OF STAFF - SIMULATION

Acknowledgement Tim Bunchman and pCRRT Foundation CRRT online