1. Current Technology for CRRT Dr. Peter Skippen, PICU. BC Children’s Hospital, Vancouver. CANADA.

2. CRRT Technology Outline The ideal CRRT machineThe ideal CRRT machine Hardware optionsHardware options –Homemade –Dedicated fully integrated ConclusionsConclusions

3. CRRT Technology The Ideal Machine for CRRT: I Inexpensive / user friendly / flexibleInexpensive / user friendly / flexible Accurate / dedicated pumpsAccurate / dedicated pumps Accurate scalesAccurate scales Blood flows 5-300mls/minBlood flows 5-300mls/min –increments of 1 ml/min Continuous independent flow measurementsContinuous independent flow measurements Servo controlledServo controlled ThermoregulationThermoregulation Full range of safety featuresFull range of safety features

4. CRRT Technology The Ideal Machine for CRRT: II Safety featuresSafety features –Audible / visual alarms with over-ride –Air / clot detectors –Blood leak detectors –Continuous display of circuit pressures –Continuous Uf urea concentration –Continuous circuit Hct Minimal alarms - maximum patient safetyMinimal alarms - maximum patient safety

5. CRRT Technology The Ideal Circuit for CRRT Minimal priming volume / low resistanceMinimal priming volume / low resistance Easy priming / recirculation procedureEasy priming / recirculation procedure Exchangeable componentsExchangeable components BiocompatibleBiocompatible –Non inflammatory –Hemodynamic stability –Non thrombogenic

6. CRRT Technology Integrated Hardware Options Home made devicesHome made devices Dedicated “all in one” machineDedicated “all in one” machine –Edwards M 25 –PRISMA –Braun DIAPACT –Fresenius

7. 2 integrated modules2 integrated modules –Blood module (BM 11) –Balancing module / scales (BM 14) Edwards BM 25

8. Edwards BM 25: Blood Pump Module Blood monitorBlood monitor –pediatric flows: 5 - 150mls / min –Increments of 1ml

9. Edwards BM 25: Effluent / Replacement Pump Module Balancing monitorBalancing monitor –Substitution pump / filtrate pump –Integrated scales: claimed accuracy 1% (20mls in 2000mls) –Replacement fluid heater –TMP monitor –Operational ranges Replacement fluid 100- 9000mls / hr (100ml increments) Filtrate pump 100 - 11,000mls / hr Net UFR 0.1 - 2000mls / hr

10. CRRT Technology Edwards BM 25: Advantages Relatively lower costRelatively lower cost SimplicitySimplicity –Easy priming FlexibilityFlexibility –Separate arterial / venous tubing –Use any filter –Neonate to adult –Any treatment option with modification With loss of simplicity Replacement fluid warmerReplacement fluid warmer

11. CRRT Technology Edwards BM 25: Disadvantages Only 3 pumpsOnly 3 pumps –For CVVHDF, extra pump creates problems Does not calculate FFDoes not calculate FF No screenNo screen Troubleshooting requires training!Troubleshooting requires training! Blood / air interface with bubble trap?Blood / air interface with bubble trap?

12. PRISMA CRRT Machine Touch screenTouch screen Complete range of therapiesComplete range of therapies 3 weighing scales3 weighing scales –accuracy < +/- 0.5% Custom filter / circuitryCustom filter / circuitry

13. PRISMA CRRT Machine: Basic Layout Replacement Dialysate Effluent Blood Heparin Syringe Pump Pressure Pods Scales x 3

14. PRISMA Screen

16. CRRT Technology User friendly interfaceUser friendly interface Step by step instructionsStep by step instructions Continuous display of treatment conditionsContinuous display of treatment conditions Easy / rapid institution of therapies (self prime)Easy / rapid institution of therapies (self prime) Continuous 24 hour recording of treatment historyContinuous 24 hour recording of treatment history Alarm explanationsAlarm explanations PRISMA Machine: Advantages

17. CRRT Technology Need for company specific filterNeed for company specific filter Relatively high costRelatively high cost Limited blood flow rangesLimited blood flow ranges Can’t change therapies mid-courseCan’t change therapies mid-course Scales sensitive to knockingScales sensitive to knocking Learning curve - don’t they all?Learning curve - don’t they all? PRISMA Machine: Dis-advantages

18. CRRT Technology Compact, self contained, flexibleCompact, self contained, flexible High resolution screenHigh resolution screen 3 pumps3 pumps –Blood flow 10-500mls/min –Dialysate - substitution flow 0-250 mls/min –UFR 0-300mls/min Automatic priming procedureAutomatic priming procedure Substitution fluid warmerSubstitution fluid warmer Full range of therapiesFull range of therapies Battery powerBattery power Diapact CRRT

19. CRRT Technology Clinical Issues BiocompatabilityBiocompatability Hemodynamic stabilityHemodynamic stability

20. CRRT Technology Conclusions Improving technologyImproving technology Ideal machines / circuits?Ideal machines / circuits? Issues to be resolvedIssues to be resolved –Biocompatability / Thrombogenicity –Flexibility –Versatility –Cost