CRRT Machines
Akash Deep
Director - PICU
King’s College Hospital
London
Chair
Renal/CRRT Section
European Society of Paediatric and
Neonatal Intensive Care (ESPNIC)
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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)
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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
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My CRRT Machine
• Safety
• Performance
• User friendly
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Ideal CRRT machine
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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
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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.
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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.
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Descriptors
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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
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CRRT Machines
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Prisma
Prismaflex
Diapact
Aquarius
NxStage
Fresenius 2008 K
Carpidiem - Neonatal
Prisma(Gambro)
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Preassembled cartridge with lines
and dialyser
Compact large monitor with touch
screen features
4 pumps and 3 scales
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-SCUF
-CVVH
-CVVHD
-CVVHDF
- PLASM EXCHANGE
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Flow rates
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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-
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Problems with PRISMA
• Rigidity of prescription and performance - prefixed 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
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Prismaflex ( Baxter-Gambro)
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Effluent
pump
Blood
heater
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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
Preblood
pump
Blood pump
-CVVH
-CVVHD
-CVVHDF
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TPE/MARS ( future use)
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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
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• In-line blood heater
Prismaflex
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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 postinfusion mixing points during a
treatment using the same set by
pinch valves without interrupting
therapy
Membranes: M and HF series
(ST)
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Aquarius ( Nikkiso )
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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
Heparin • Flow rates
syringe
- 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
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Colour Coding
NxStage System One
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Bag Changes
- Free from waste bag changes
- Eliminates blood pump stopping for bag
changes
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Portable with no plumbing/electrical needs
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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
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Volumetric balancing chambers
incorporated into the cartridge
- Will not allow fluid imbalance to overridden
alarms
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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
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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
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CARPIDIEM By Ronco
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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
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Acknowledgement
• Tim Bunchman and pCRRT Foundation
• CRRT online
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