1. Ultrafiltration Control using Hematocrit Monitoring 2013 ANNA North Carolina Statewide Symposium and the Southeastern Kidney Council NC Annual Meeting “Unique Challenges for the Nephrology Professional” Kimberly F. Clarkson, MSN, RN, CNN May 22, 2013

2. Objectives Describe blood volume monitoring Identify trend and graph development during hemodialysis Evaluate nursing assessment considerations to decrease intradialytic mortality

3. Relative Blood Volume Monitoring Measures hematocrit in arterial blood –Crit-Line® Technology Optical transmission detecting blood volume changes –Blood volume change – surrogate marker for vascular refilling –Increase in hematocrit relative to decrease in fluid removal Interface display of changes Affords a “window” into intravascular space Davenport, 2009

4. Prevention through Optical Technology Components –Blood chamber, sensor clip, monitor Non-invasive monitoring –Blood volume change percent –Hematocrit Graphic display –Based on Guyton curve

5. Guyton’s Curve Dr. Guyton (September 8, 1919 - April 3, 2003) –Physiologist; primarily circulatory system –Cardiac output related to peripheral circulation –Demonstrated oxygen demand regulated cardiac output Overturned previous conventional wisdom –Heart itself does not control output –Developed graphic representation Fundamental base in medical school Guyton Curve Hall, 2003

6. Fluid Volume Distribution Volume distribution; 70 kilogram male example –Intracellular Approximately 23 L –Extracellular Approximately 17 L –Intravascular Approximately 5 L; cannot accommodate > 7 L

7. Guyton’s Curve Applied 0 1 2 3 4 5 6 7 8 5101520253035 400 Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324 Normal Death Blood Volume (liters) Extracellular Fluid Volume (liters) 0 1 2 3 4 5 6 7 8 5101520253035 40 0 Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324 Normal Death Hypovolemia C B A Edema Blood Volume (liters) Extracellular Fluid Volume (liters) Shift Due to: Low O2 Meds UFR Na+ Temp Posture

8. Optical Data Transformed – Graphic Image The Crit-Line® monitor provides objective data and visual display of: Relative Plasma Volume slope as an indicator of volume status Degree of Relative Blood Volume Slope –Remember Guyton Curve Intradialytic plasma refill ability or inability –In comparison to ultrafiltration Intradialytic plasma refill with minimal ultrafiltration

9. The Inverse Relationship

10. Profile A Ultrafiltration and plasma refill –Equal, or positive slope or slope less than -3% Special considerations may apply Hypertension, 2010

11. RPV Principles 11 Note: BV∆% Note: UF Removed

12. RPV Principles 12 -8.6% ÷ 3.3 hour = -2.6% per hour = Profile A

13. Profile B Ultrafiltration rate exceeds plasma refill rate –Studies range from - 1.33% per hour to -8% per hour Not to exceed -16% at end of 3 to 4 hour treatment Agarwal, 2010

14. RPV Principles 14 -12.8% ÷ 3 hours = - 4.3%/hour = Profile B

15. Profile C Patient “crash” –Patient experiences symptom –Blood volume change Exceeds -8% per hour, or Exceeds -16% at end of 3 to 4 hour dialysis session Rodriguez et. al,2005 Brewer & Goldstein, 2004

16. RPV Principles 16 -20.9 ÷ 2 = -10.4 = Profile C

17. Prevent Treatment Complications E – Electrolytes V – Volume removed–ultrafiltration A – Anemia/albumin/allergies L – Lying back, feet on floor – position U – Urinary output A – Anti-hypertensives or other meds T – Temperature I – Ideal dry weight O – Oxygenation of tissues N – Nurse responsibility

18. Summary Hematocrit monitoring affords a proactive approach to –Achieve ideal dry weight –Prevent intradialytic complications –Prevent hospitalizations Affords validation of nursing interventions –Real time measurement –Data provision – graphical representation –Individualized patient

19. References