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

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

2. 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)

3. 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”)

4. CRRT Technology evolution

7. My CRRT Machine
Safety
Performance
User friendly

8. 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

9. 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.

11. 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

12. 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

13. 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.

14. 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

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

16. 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 ml/min
- QD ml/hr
- QRF ml/hr
- Total Effluent 5000ml/hr
Replacement Fluid
- Pre
- Post
- Simultaneous pre- and post-

17. 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

18. 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 ml/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

19. 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)

21. 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: 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

22. Colour Coding

25. 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

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

27. 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 m2
priming volumes , 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

28. CARPIDIEM By Ronco

31. 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

32. Acknowledgement
Tim Bunchman and pCRRT Foundation
CRRT online