DialysisandReplacementSolutionsforCRRT JordanM Symons MDUniversityofWashingtonSchoolofMedicineChildren sHospital RegionalMedicalCenterSeattle WAjordan symons seattlechildrens org CRRTSolutions OutlineoftheTalk PurposeofsolutionsinCRRTGoalsforaCRRTsolutionDescriptionofsolutionscurrentlyavailableforCRRTConsiderationsinchoosingasolutionforCRRT Kramer P etal Arteriovenoushaemofiltration Anewandsimplemethodfortreatmentofover hydratedpatientsresistanttodiuretics KlinWochenschr55 1121 2 1977 FirstCAVHCircuit CRRTMachines CurrentGeneration ConvectiveClearanceToincreaseclearancebyconvection increaseultrafiltrationrate willrequiremorereplacementfluids DiffusiveClearanceToincreaseclearancebydiffusion increasedialysateflowrate CharacteristicsoftheIdealCRRTSolution PhysiologicalReliableInexpensiveEasytoprepareSimpletostoreQuicktothebedsideWidelyavailableFullycompatible BaseinCRRTSolutions Hemodialysis firstacetate thenbicarbonatePeritonealdialysis lactateinNorthAmerica bicarbonateinEuropeCRRT lactateorbicarbonate Bicarbonatevs LactateinCRRT BothcanbeusedforbaseBicarbonatesuperiortoacetateinHDPDuseslactateduetotechnicalissues Isbicarbonatepreferabletolactate Zimmermanetal Neph Dial Transpl199914 2387 2391 Bicarbonatevs LactateinCRRT BloodLactateLevels Bicarbonatevs LactateinCRRT BloodLactateLevelsinChildren Maxvoldetal BloodPurif17 27 1999 abstract Bicarbonatevs LactateinCRRT CardiovascularEvents Bicarbonate Lactate BarenbrockMetal KidInt58 1751 1757 2000 OptionsforCRRTSolutions PeritonealdialysateAdaptedpre madesolutionsSaline LactatedRingersMulti bagsystemsCustom madesolutionsLocalpharmacy outsourceOn linedialysateCommerciallyavailableCRRTsolutions BaxterHemofiltrationSolution Lactatebuffered5literbagSmallamountofpotassiumContainscalcium ChemicalContentofBaxterHemofiltrationSolution Hemosol Hospal 5literbag L series lactate withvariableK glucose B0 bicarbonate needstobemixedNotavailableinUS ChemicalContentofHemosol Normocarb DSI BicarbonatebufferedConcentratemustbecompoundedFinalvolume3 24liters 240mlconcentrateaddedto3Lbag ChemicalContentofNormocarb PrismaSate Gambro BicarbonatebufferedSmallamountoflactate5literbag2compartmentstopreventprecipitationTwoionicformulations ChemicalContentofPrismaSate ChoosingaSolution IssuestoConsider AnticoagulationCostCRRTmodalityDiffusion CVVHD Convection CVVH Both CVVHDF Patientsafety AnticoagulationandSolutions MayneedtoconsiderCa contentifusingcitrateforanticoagulation CRRTSolutions Costs Bunchmanetal BloodPurif20 2002 abstract ModalityMayHaveanImpactonChoiceofSolutions DiffusionrequirestheuseofadialysateConvectionrequirestheuseofreplacementfluids What stheDifferenceBetweenDialysateandReplacementFluid DialysateisaDeviceReplacementFluidisaDrug FDAApprovalStatusofCRRTSolutions NormocarbasReplacementFluid FDAModernizationActof1997 TheActcreatesaspecialexemptiontoensurecontinuedavailabilityofcompoundeddrugproductspreparedbypharmaciststoprovidepatientswithindividualizedtherapiesnotavailablecommercially Bunchmanetal AJKD42 6 1248 52 2000 EvaluationofErrorsinPreparationofCRRTSolutions Surveyof3PediatricListserves PediatricCriticalCarePediatricNephrologyPediatricCRRT31programsrespondedtoquery Bunchmanetal BloodPurif22 2004 abstract PrevalenceandConsequencesofErrorsinSolutionPreparation 16 31programsreportederrors 7errorsinreplacementsolutions9errorsindialysatesolutionsConsequencesofimpropersolutions2deaths1nonlethalcardiacarrest6seizures hypo hypernatremia 7withoutcomplications Bunchmanetal BloodPurif22 2004 abstract PolicyChangesResultingfromErrorsinSolutions ChangedtoNormocarbforeitherreplacementordialysate 11 ChangedtoPrismaSatefordialysate 2 PurchasedTPNmixerforsolutions 2 Chemistrylabcheckofeverybag 3 Baglabelcheckbyatleast2staff 10 Bunchmanetal BloodPurif22 2004 abstract CRRTSolutions Summary SolutionsneededtomaximizeclearanceBicarbonatesee