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
Objectives
• Describe blood volume monitoring
• Identify trend and graph development
during hemodialysis
• Evaluate nursing assessment
considerations to decrease intradialytic
mortality
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
Prevention through Optical
Technology
• Components
– Blood chamber, sensor
clip, monitor
• Non-invasive
monitoring
– Blood volume change
percent
– Hematocrit
• Graphic display
– Based on Guyton curve
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
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
Guyton’s Curve Applied
8
8
Edema
(liters)
Volume(liters)
BloodVolume
Blood
7
7
6
6
B
Normal
Normal
55
Shift
Due
to:
4
4
C
3
3
Hypovolemia
Death
Death
A
Low O2
Meds
UFR
Na+
Temp
Posture
2
2
Adapted
AC:
Adaptedfrom
fromGuyton,
Guyton, AC:
Textbook
of Medical
Physiology,
Textbook
of Medical
Physiology,1991,
1991,pg.324
pg.324
1
1
00
0
0
55
10
10
15
15
20
20
25
25
Extracellular Fluid
Fluid Volume
Volume (liters)
(liters)
Extracellular
30
30
35
35
40
40
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
The Inverse Relationship
Profile A
• Ultrafiltration and
plasma refill
– Equal, or positive
slope or slope less
than -3%
• Special considerations
may apply
Hypertension, 2010
Note: BV∆%
Note: UF Removed
RPV Principles
11
-8.6% ÷ 3.3 hour = -2.6% per hour
= Profile A
RPV Principles
12
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
-12.8% ÷ 3 hours = - 4.3%/hour
= Profile B
RPV Principles
14
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,
-20.9 ÷ 2 = -10.4
= Profile C
RPV Principles
16
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
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
References
Agarwal, R. (2010). Hypervolemia is associated with increased mortality among hemodialysis
patients. Hypertension. 56(3). p. 512-7. doi: 10.1161/HYPERTENSIONAHA.110.154815
Brewer, M., M., & Goldstein, S., L. (2004). Blood volume monitoring to achieve target weight in
pediatric hemodialysis patients. Pediatric Nephology. 19(4). p. 432-437.
Chapdelaine, I., Deziel, C. & Madore, F. (2011). Automated blood volume regulation during
hemodialysis; Progress in hemodialysis. Emergent Biotechnology to Clinical Practice.
Accessed April 5, 2013 from http://www.intechopen.com/books/progress-inhemodialysis-from-emergent-biotechnology-to-clinicalpractice/automated-bloodvolume-regulation-during-hemodialysis
Davenport, A. (2009). Can advances in hemodialysis machine technology prevent intradialytic
hypotension? Seminars in Dialysis. 22(3), 231-236. DOI:10.1111/j.1525139X.2009.00614.x
Goldstein, S., Smith, C., & Currier, H. (2003). Non-invasive interventions to decrease
hospitalization and associated costs for pediatric patients receiving hemodialysis.
Journal of the American Society of
Nephrology. 14. p. 2127-2131.
Guyton, A., C. (1976). Textbook of Medical Physiology (5th ed.). Philadelphia: W.B. Saunders
Hall, J., D. (2003). In memorandum. Circulation. 107. p. 2990-2992.
doi:10.1161/01.CIR.0000080480.62058.4A
Rodriguez, H., J., Domenici, R., Diroll, A., & Goykhman, I. (2005). Assessment of dry weight by
monitoring changes in blood volume during hemodialysis using Crit-Line. Kidney
International. 68. p. 854-861.