TechnicianStudyReview

Partone
JimCurtis,CHT
ScientificPrinciples
l d i l i RelatedtoDialysis
SOLUTION SOLUTION
A solution is a combination of a solvent and a Asolutionisacombinationofasolventanda
solute.
The solute is any substance that can be Thesoluteisanysubstancethatcanbe
dissolvedintothefluidsolvent.
A l f hi ld b l h Anexampleofthiswouldbesaltwater,where
wateristhesolvent,andsaltisthesolute.
BLOOD BLOOD
Blood is simply a solution, with water as the solvent, Bloodissimplyasolution,withwaterasthesolvent,
andmany,manysolutesincludingelectrolytesand
glucose.
Bloodalsohasmanysuspendedparticlessuchasred
andwhitebloodcells.
Inordertoapplythesescientificprinciplestotreat
ourpatientswemustexposetheirbloodsolutionto
h d l l b bl thedialysatesolutionbyputtingasemipermeable
membranebetweenthem
DIALYSATE DIALYSATE
A solution that uses water as the solvent, and the Asolutionthatuseswaterasthesolvent,andthe
solutesareelectrolytesandglucose.Theelectrolytes
(potassium,calcium,sodium,magnesium,chloride)
areinconcentrationssimilartothatfoundina
patientsblood.
Wecanmanipulateapatient'selectrolytelevelby
whatweputintothedialysate.
SEMIPERMEABLE MEMBRANE SEMIPERMEABLEMEMBRANE
A semipermeable membrane is a barrier that Asemipermeablemembraneisabarrierthat
willallowcertainsizeparticlestopassthrough
it but not larger ones it,butnotlargerones.
Onecommonexampleofthiswouldbea
household colander householdcolander.
Dialyzermembraneshavesmallerpoorsizes,
l h 100 A i lessthan100Angstromunits
DIFFUSION DIFFUSION
Diffusion is the process by which molecules or Diffusionistheprocessbywhichmoleculesor
similarparticlesmovespontaneouslyfroma
region where they are present at a relatively regionwheretheyarepresentatarelatively
highconcentrationintoregionsoflower
concentration concentration.
Theprocessdoesnotdependonstirringor
other mechanical stress othermechanicalstress
Diffusion Diffusion
Factors Affecting Diffusion FactorsAffectingDiffusion
Solution Characteristics SolutionCharacteristics
ConcentrationGradient
Molecular weight Molecularweight
Temperature
M b Ch t i ti MembraneCharacteristics
MembranePermeability
SurfaceArea
FlowGeometry
Concentration Gradient ConcentrationGradient
The more different the concentrations are on Themoredifferenttheconcentrationsareon
twosidesofamembrane,themoresolute
movement there will be (Ficks Law) movementtherewillbe.(Fick sLaw)
Solutesmovefromanareaofgreater
concentration to an area of lower concentrationtoanareaoflower
concentration.
Diff i h h i i Diffusionstopswhentheconcentrationsina
givenareaareequal.
Molecular Weight (size) of the Solutes MolecularWeight(size)oftheSolutes
Solutes with smaller molecular weights diffuse Soluteswithsmallermolecularweightsdiffuse
moreeasilyandquicklythanlargerones.
(Grahams Law) (GrahamsLaw)
Temperature Temperature
Warmer temperatures promote faster Warmertemperaturespromotefaster
diffusion.
Hot Tea HotTea
Coldertemperaturesdecreaserateof
diffusion diffusion.
Ice
DiffusionacrossaSemipermeable
b Membrane
Onlymoleculessmallerthantheporeswill
passthrough p g
Membrane Permeability MembranePermeability
A membrane with more pores allows faster Amembranewithmoreporesallowsfaster
diffusion
Larger pores allow larger molecules to pass Largerporesallowlargermoleculestopass
throughthemembrane.
Thi k d d i f b l l Thicknessanddesignofamembranealsoplay
aroleintherateofdiffusion
Surface Area SurfaceArea
Surface area is the amount of membrane in Surfaceareaistheamountofmembranein
directcontactwithbloodanddialysate.
Larger surface areas allow more diffusion Largersurfaceareasallowmorediffusion.
Smallersurfaceareaallowslessdiffusion
Flow Geometry FlowGeometry
In Dialysis a countercurrent flow of blood to InDialysis,acountercurrentflowofbloodto
dialysate(bloodflowsonewaywhiledialysate
flows the opposite way) allows the fastest flowstheoppositeway)allowsthefastest
diffusion,becausefreshdialysateisalwaysin
contact with blood contactwithblood.
Diffusion in Dialysis DiffusioninDialysis
The hollow fiber in the dialyzer is a semipermeable Thehollowfiberinthedialyzerisasemi permeable
membrane.
Bloodpassesthroughtheinside,andthefiberis p g ,
surroundedbythedialysatesolution.
Moleculeswillpassbackandforthbetweenthe p
bloodanddialysate.
Theywillalwaysmovefromanareaofhigher
concentrationtoanareaoflowerconcentration.
Diffusion in the Dialyzer DiffusionintheDialyzer
Waste products in the patient's blood stream Wasteproductsinthepatient sbloodstream
willdiffuseacrossthemembraneintothe
dialysate dialysate.
Thedialysatewillthenbesenttothedrain,
and fresh dialysate will flow into the dialyzer andfreshdialysatewillflowintothedialyzer
tomaintainahighconcentrationgradientso
that we can remove as much waste products thatwecanremoveasmuchwasteproducts
aspossible.
Diffusion in The Dialyzer 2 DiffusioninTheDialyzer2
Electrolyte balance is also maintained by Electrolytebalanceisalsomaintainedby
diffusion.
To control their concentrations we add Tocontroltheirconcentrations,weadd
electrolytestothedialysatesolution.
Th l l ill ilib l l h lf Thesemoleculeswillequilibrateatalevelhalf
waybetweentheconcentrationsintheblood
d h di l andthedialysate.
Diffusion in the Dialyzer 3 DiffusionintheDialyzer3
The concentration gradient between the Theconcentrationgradientbetweenthe
bloodanddialysateiskeptashighaspossible
by having the blood and dialysate flow in byhavingthebloodanddialysateflowin
oppositedirections(countercurrentflow).If
the fluids moved in the same direction (con thefluidsmovedinthesamedirection(con
currentflow),thesolutesequilibratequickly,
and then just flow through the rest of the andthenjustflowthroughtherestofthe
dialyzertogether.
Diffusion in the Patient DiffusioninthePatient
We change the chemical concentrations of the Wechangethechemicalconcentrationsofthe
bloodinthedialyzer.
That blood then returns to the patient's body, Thatbloodthenreturnstothepatient sbody,
whereitslowlybeginstodilutetherestofthe
blood.
Theconcentrationofsolutesdropsinthe
patientsvascularsystem,Creatinga
concentrationgradientbetweenthebloodin
theveinsandthebloodwithincells.
Diffusion in the Patient 2 DiffusioninthePatient2
These cells have their own membranes Thesecellshavetheirownmembranes
Soluteswillpassthroughthemintothe
vascular system vascularsystem
Wheretheywilleventuallyendupinblood
h h h h di l thatpassesthroughthedialyzer.
Thisprocesscontinuesthroughthelengthof
thedialysistreatment
FILTRATION AND ULTRAFILTRATION FILTRATIONANDULTRAFILTRATION
Filtration is the removal of particles in a Filtrationistheremovalofparticlesina
solutionbymechanicalmeans.Itisgenerally
accomplished by forcing the solution through accomplishedbyforcingthesolutionthrough
afilter,andanymatterthatistoolargetopass
through is trapped or rejected by the filter throughistrappedorrejectedbythefilter.
Ultrafiltrationreferstofiltrationofverysmall
particles even as small as large molecules particles,evenassmallaslargemolecules
Ultrafiltration in Dialysis UltrafiltrationinDialysis
Water is taken out of the patients blood by Wateristakenoutofthepatientsbloodby
ultrafiltration.
Theremovalofwaterisalsoassistedbytheaddition y
ofglucosetothedialysate.
Ultrafiltration in Dialysis 2 UltrafiltrationinDialysis2
The Dialysis machine creates a hydraulic pressure TheDialysismachinecreatesahydraulicpressure
differencebetweenthesolutionsintheblood
compartmentandthedialysatecompartment
Thepressureishigherinthebloodcompartment.
Thispressureisamechanicalforcethatpushesfluid p p
throughthemembrane.
Convection Convection
Anything dissolved in the solution that is smaller Anythingdissolvedinthesolutionthatissmaller
thanthemembraneporespassesthroughwiththe
water.
Thismovementiscalledsolutedrag.
Largersolutesandparticleswillnotpassthrough. g p p g
OSMOSIS OSMOSIS
Osmosis is the process by which a liquid Osmosisistheprocessbywhichaliquid
passesthroughasemipermeablemembrane
fromanareaoflowsoluteconcentrationtoa
higherconcentration.
Itissimilartodiffusion,exceptthemolecules
aretoolargetopassthroughthesemi
permeablemembrane,sofluidisdrawnacross
h b dil i h l i d themembrane,dilutingthesolution,and
achievingequilibrium.
OSMOSIS OSMOSIS
TheeffectofOsmoticPressure(osmolality)
Osmosis Osmosis
Hydraulic pressure can overcome osmotic Hydraulicpressurecanovercomeosmotic
pressure
If you increased the hydraulic pressure on the Ifyouincreasedthehydraulicpressureonthe
solutionsideofthecontainer,youcould
overcome the osmotic pressure and cause the overcometheosmoticpressure,andcausethe
watertomovefromtheconcentratedsolution
back into the pure water side (Reverse backintothepurewaterside.(Reverse
Osmosis)
Reverse Osmosis ReverseOsmosis
HydraulicPressureovercomingtheeffectof
OsmoticPressure
Important terms relating to osmosis Important termsrelatingtoosmosis
Hypertonic Hypertonic
amoreconcentratedsolutionwitharelativelyhigher
osmolality
H t i Hypotonic
alessconcentratedsolutionwitharelativelylower
osmolalityy
Isotonic
asolutionwithanequalosmolality.
I Di l i th t d h i InDialysisthesetermsareusedwhencomparinga
solutionrelativetoblood
Osmosis in Dialysis OsmosisinDialysis
Osmosis plays another important role in fluid Osmosisplaysanotherimportantroleinfluid
removal.Considerwhathappenswithinthe
body when a patient is being dialyzed Due to bodywhenapatientisbeingdialyzed.Dueto
diffusion,thechemicalconcentrationinthe
blood can be lower than the concentration in bloodcanbelowerthantheconcentrationin
thecells.Duetoultrafiltration,fluidisbeing
removed from the vascular system removedfromthevascularsystem.
Osmosis in Dialysis OsmosisinDialysis
The higher osmolality of the blood in the cells Thehigherosmolalityofthebloodinthecells
willtendtopullfluidoutofthevascular
system at the same time that the dialyzer is systematthesametimethatthedialyzeris
pullingitoff.
Since only a small percentage of the bodys Sinceonlyasmallpercentageofthebody s
fluidisinthevascularsystem,itbecomes
depleted and the patient's blood pressure depletedandthepatient sbloodpressure
drops
Osmosis in Dialysis OsmosisinDialysis
To help with fluid removal we increase the Tohelpwithfluidremovalweincreasethe
osmolalityofthedialysatebyaddingmore
sodium sodium.
Thissodiumdiffusesintotheblood,and
causes a higher osmolality causesahigherosmolality.
Thismaintainsthevolumeinthevascular
d h i ' bl d i k space,andthepatient'sbloodpressureiskept
stable.
FLUID DYNAMICS FLUIDDYNAMICS
Fluidisasubstance(liquidorgas)whichchangesshapeata ( q g ) g p
steadyratewhenacteduponbyaforce.
Dynamicsdealswiththemotionandequilibriumofsystems.
Themovementoffluidthroughtubing(flow)issubjectedto
physicalforces.
The flow rate of a fluid is the amount of fluid that flows Theflowrateofafluidistheamountoffluidthatflows
throughthetubingoveraspecifiedperiodoftime.
Theflowvelocityisthespeedthefluidmovesthrougha
specifiedlengthoftubing.
Resistance and Pressure ResistanceandPressure
There is always some resistance to the flow of fluid Thereisalwayssomeresistancetotheflowoffluid
throughatubingduetosimplefriction,butthe
resistancewillgreatlyincreasewhenyoucausea
restriction.
Thepressureinanyfluidsystemwillalwaysbea
functionofflowandresistance.Thegreatertheflow
andthegreatertheresistance,thegreaterthe
pressure pressure
FluidDynamics
in the Blood
TheArterial
Needleisa
restriction.
The pressure
intheBlood
Circuit
Thepressure
isusually
negativeas
thepump
pulls fluid
Pump
pullsfluid
fromthe
patient
fasterthatit
would flow
DI
AL
YZ
ER
wouldflow
out.
TheBloodPumppulls
blood from the patient, and
FluidDynamics
in the Blood
bloodfromthepatient,and
pushesitthroughthe
dialyzerandbacktothe
venousneedle
intheBlood
Circuit
Pump
DI
AL
YZ
ER
FluidDynamics
in the Blood intheBlood
Circuit
TheDialyzeralsoactsasa
restrictionontheBlood.The
fluid looses pressure due to
Pump
fluidloosespressuredueto
frictionasitpassesthrough
thethousandsoftinyhollow
fibers
DI
AL
YZ
ER
FluidDynamics
in the Blood intheBlood
Circuit
Pump
DI
AL
YZ
ER
Thevenousneedleisthefinalrestrictioninthe
system,anddetermineswhattheminimumpressure
inthedialyzerwillbe
Dialysis Devices DialysisDevices
JimCurtis,CHT
Concentrate proportioning Concentrateproportioning
Volumetric proportion Volumetricproportion
involumetricproportioning,allthreestreamsare
calibrated to deliver a fixed volume calibratedtodeliverafixedvolume
Concentrate proportioning Concentrateproportioning
Servo controlled proportioning Servocontrolledproportioning.
aservofeedbackcontrolsystemcomparesthe
conductivity measured by the acid/acetate or conductivitymeasuredbytheacid/acetateor
bicarbonatecontrolconductivitycellwiththe
valueselectedbytheoperator
Volumetric Proportioning VolumetricProportioning
Drake Style Concentrate DrakeStyleConcentrate
IncomingWater34parts
Dialysate
CondoCell
A id C
Bicarb Conc
AcidConc
1part
BicarbConc.
1.83parts
Volumedrivenmeteredpumps
Servo Proportioning ServoProportioning
Cobe Style Concentrate CobeStyleConcentrate
IncomingWater42.28parts
Dialysate
CondoCells
A id C
Bicarb Conc
AcidConc
1part
BicarbConc.
1.72parts
Conductivitycontrolledperistalticpumps
Proportioning Ratios ProportioningRatios
35X (Fresenius Style) 35X(FreseniusStyle)
1:1.225:32.775
36 83X (Drake Style) 36.83X(DrakeStyle)
1:1.83:34
45X(CobeStyle)
1:1.72:42.28
Bicarbonate Dialysis BicarbonateDialysis
requires two concentrates since concentrated requirestwoconcentratessinceconcentrated
calciumandbicarbonatewillproducea
precipitate precipitate.
somesystemsusedrybicarbonatealone(Cobe
and Fresenius Style), andFreseniusStyle),
othersystemsuseconcentratesthatare
bicarbonatemixedwithsodiumchloride(Drake b ca bo a e ed sod u c o de ( a e
Style).
Bicarbonate Dialysis 2 BicarbonateDialysis2
mismatch of the different types of mismatchofthedifferenttypesof
concentratesavailablecanyieldaexpected
conductivity conductivity.
reliancesolelyontheconductivitytoensure
safety is cautioned all relevant factors should safetyiscautioned,allrelevantfactorsshould
beconsidered(includingpH).
AAMI standard A3.1.1 AAMIstandardA3.1.1
Recognition and application of appropriate Recognitionandapplicationofappropriate
concentratestoproducethedesireddialysate
is the responsibility of the operator istheresponsibilityoftheoperator.
alarmsetpointsshallbesetat 5percentfrom
the nominal value of the particular dialysate in use thenominalvalueoftheparticulardialysateinuse
andshallactivateavisualandanaudiblealarm.
AAMI standard A3.1.1 (2) AAMIstandardA3.1.1(2)
a volumetric proportioning system must have an avolumetricproportioningsystemmusthavean
onlineconductivitymonitordownstreamofthe
mixingpoint.
systemsfordualproportioningtoproduce
bicarbonatedialysateusingconductivityservo
controlshallhaveseparateonlineconductivity
cellstocontrolandmonitoreachproportioning
system system.
Conductivity Measurement ConductivityMeasurement
Anelectricalcurrentissentfromoneprobeto
another.Themoredissolvedelectrolytes,the
moreelectricitywillpass(thehigherthe
conductivity)
14.2
Signal Receiver
Deareation Device DeareationDevice
Should remove all entrained air Shouldremoveallentrainedair
Dissolvedairinthedialysatecircuitmay
adversely affect the dialysis system monitors adverselyaffectthedialysissystemmonitors,
hemodialyzerefficiency,ultrafiltrationcontrol,
and patient safety andpatientsafety.
Airmaycrossthemembraneandcreatefoam
i h bl d inthebloodcompartment.
Deareation Device DeareationDevice
Air Trap
Flow
AirTrap
Flow
Restrictor
DeareationPump
(createsavacuum)
Temperature control Temperaturecontrol
Maintains the dialysate within the Maintainsthedialysatewithinthe
physiologicalrange.
a temperature greater than 42 degrees atemperaturegreaterthan42degrees
Centigradedenaturesproteinandresultsin
hemolysis hemolysis
atemperaturelessthan35degrees
C i d d hilli d Centigrademayproducechillingand
hypothermia
Temperature control Temperaturecontrol
A visual and an audible response is required Avisualandanaudibleresponseisrequired
foratemperaturealarm.
Dialysate flow will be diverted from the Dialysateflowwillbedivertedfromthe
dialyzerduringatemperaturealarm.
Blood Leak Detector BloodLeakDetector
designed to monitor the occurrence of a designedtomonitortheoccurrenceofa
ruptureinthemembraneofadialyzer
detects changes in optical density in dialysate detectschangesinopticaldensityindialysate
downstreamofthedialyzer.
i i f d li h b i l emitsaninfraredlightbeamacrossanoptical
paththroughthedialysateontoareceiver
i h li h oppositethelightsource.
Blood Leak Detector BloodLeakDetector
Blood entering the optical path would Bloodenteringtheopticalpathwould
decreasetheintensityofthelightandsignala
change in density of the dialysate changeindensityofthedialysate.
Thechangeindensityactivatesthealarm
sequence sequence.
Thesensitivityofthebloodleakalarmsystemis
0 35 ml/L 0.35ml/L
Blood Leak Detector BloodLeakDetector
IN
OUT
Dialysate
postdialyzer
Light Source
LightReceptor
LightSource
Blood Leak Detector BloodLeakDetector
The blood pump should stop automatically for Thebloodpumpshouldstopautomaticallyfor
abloodleakalarm.
Blood side pressure should never be less than Bloodsidepressureshouldneverbelessthan
dialysatesidepressure.
Ul fil i h ld b i i i d Ultrafiltrationshouldbeminimized
automaticallyormanuallytodecreasetheloss
f bl d ofblood.
Bypass Valve BypassValve
Interrupts the flow of dialysate to the dialyzer Interruptstheflowofdialysatetothedialyzer
duringanimproperdialysatecondition.
Dialysate flow will be automatically diverted Dialysateflowwillbeautomaticallydiverted
fromthedialyzertothedrainduringa
dialysate alarm condition dialysatealarmcondition.
Bypass Valve BypassValve
An audible and visual alarm response will be Anaudibleandvisualalarmresponsewillbe
evidentduringabypasscondition.
Bypass function Bypassfunction
Dialysate temperature above 42 degrees Dialysatetemperatureabove42degrees
Centigradewillcausehemolysis.
Temperature limits are usually set at 35 Temperaturelimitsareusuallysetat35
degreesCentigradeforthelowlimitand39
degrees Centigrade for the high limit degreesCentigradeforthehighlimit.
Bypass function Bypassfunction
A dialysate conductivity varying more than 5 Adialysateconductivityvaryingmorethan 5
percentfromthenominalvalueofthe
concentration in use shall cause a dialysate concentrationinuseshallcauseadialysate
alarm.
Ultrafiltration Control UltrafiltrationControl
Fluid removal is dependent upon the Fluidremovalisdependentuponthe
transmembranepressurescreatedbythe
differential between the bloodside and differentialbetweentheblood sideand
dialysatesidepressures.
TPM UF Control (Cannot use hi flux or hi efficiency TPMUFControl(Cannotusehifluxorhiefficiency
dialyzers)
Volumetric UF Control VolumetricUFControl
FlowmetricUFControl
TMP Ultrafiltration Control TMPUltrafiltrationControl
The blood side pressure is dependent on the Thebloodsidepressureisdependentonthe
bloodpumprate,thegaugeofthefistula
needle in use and the adequacy of the access needleinuseandtheadequacyoftheaccess
flow.
The dialysate side pressure is regulated by an Thedialysatesidepressureisregulatedbyan
adjustablerestrictivevalvelocatedupstream
of the dialyzer ofthedialyzer.
Volumetric UF controlled VolumetricUFcontrolled
Machine utilizes a balancing chamber system Machineutilizesabalancingchambersystem.
Thebalancechamberassuresthatequal
amounts of fluid enter and exit the dialyzer amountsoffluidenterandexitthedialyzer.
Thechamberisdividedintotwoequal
chambers with each chamber divided by an chambers,witheachchamberdividedbyan
elasticmembrane.
Balancing Chamber BalancingChamber
BalancingChamber
Flowmetriccontrol
ultrafiltration ultrafiltration
Uses flow measuring devices that are in line Usesflowmeasuringdevicesthatareinline
beforeandafterthedialyzer.
The ultrafiltration is measures by the Theultrafiltrationismeasuresbythe
differencebetweentheflowrateintothe
dialyzer and the flow rate out of the dialyzer dialyzerandtheflowrateoutofthedialyzer.
AmicroprocessoradjuststheTMPtoachieve
h d i d l fil i thedesiredultrafiltrationrate.
Flowmetric UF Controller Flow metricUFController
Dialyzer
Pressure
Pump
FlowMeters
Extracorporeal Circuit ExtracorporealCircuit
Blood Pump BloodPump
Peristalticpumpcontrolsbloodflowrate
Pressure Alarms PressureAlarms
ArterialandVenous
Monitorspressureandalarmswhenparameters
violated
St bl d Stopsbloodpump
Extracorporeal Circuit 2 ExtracorporealCircuit2
Air in blood detector Airinblooddetector
Ultrasonicdevicessensesairinblood
Stops blood pump clamp line clamp Stopsbloodpump,clamplineclamp
VenousLineClamp
Mechanicallystopsflowofbloodthroughtubing
Gadgets and Gizmos GadgetsandGizmos
Profilingultrafiltration
Profilingsodium Profilingsodium
Profilingbicarbonate
Clearancetestingduringtherun
(conductive) (conductive)
Gadgets and Gizmos 2 GadgetsandGizmos2
Recirculation measurement Recirculationmeasurement
saline,temperature,ultrasound,hematocrit
Bloodtemperaturemonitoring
Push button sodium bolus delivery Pushbuttonsodiumbolusdelivery
Blood/SalineSensor
Ultrafilters
GadgetsandGizmos3
Blood volume monitoring Bloodvolumemonitoring
AutomaticDisinfectionandRinse
Automatedbloodpressuremonitoring
Patient specific prescription cartridge Patientspecificprescriptioncartridge
Dialyzersand
Di l i Ad DialysisAdequacy
Thedialyzeriswherethetire
meetstheroad...PeterLepanto
DIALYZER CHARACTERISTICS DIALYZERCHARACTERISTICS
Membrane Material MembraneMaterial
Biocompatibility
Solute Removal Clearance SoluteRemoval Clearance
Diffusion
Convection
Adsorption
Dialyzer Membranes DialyzerMembranes
Cellulose Synthetic Cellulose
Cuprophan
Synthetic
PAN Cuprophan
CupromoniumRayon
Hemophan
PAN
AN69
PMMA Hemophan
CelluloseAcetate
Cellulose Triacetate
PMMA
Polysulphone
Polyflux CelluloseTriacetate Polyflux
Purema
BIOCOMPATIBILITY BIOCOMPATIBILITY
The choice of membrane material affects how Thechoiceofmembranematerialaffectshow
thebloodwillreactwhenincontactwiththe
membrane membrane
R i Bi i bili ReactionstoBioincompatability
IndicatorsofBioincompatability
Reactions to Bioincompatability ReactionstoBioincompatability
Mild / unnoticed Mild/unnoticed
DAA
S h l i h k Severe anaphylacticshock
INDICATORSOF
BIOINCOMPATABILITY
Compliment activation Complimentactivation
increaseincirculatingC3alevel
Decrease in white blood cells Decreaseinwhitebloodcells
Hypercoagulation
COMPLIMENT ACTIVATION COMPLIMENTACTIVATION
C3a C3a
Baseline
WBCs
TIME
SOLUTE REMOVAL SOLUTEREMOVAL
Diffusion Diffusion
Convection
d i Adsorption
Dialyzer Clearance DialyzerClearance
Clearance (K) specifications for dialyzers indicate the Clearance(K)specificationsfordialyzersindicatethe
amountofaspecificSolutewillbeclearedfromthe
patientsbloodinagivenamountoftime
Forexample,ifthespecssayadialyzerhasa
clearanceof350ml/minataQbof400ml/min,it
meansthatinoneminute350mlsofbloodwillbe
clearedofurea,andtheremaining50ml/minwill
have the same amount of urea that it started with havethesameamountofureathatitstartedwith
Solute Removal: Diffusion SoluteRemoval:Diffusion
Indiffusion,moleculesmovefromanareaofhigh , g
concentrationtoanareaoflowconcentration.The
highertheconcentrationgradient,themorerapid
the diffusion thediffusion
Diffusive clearances are dependant upon: Diffusiveclearancesaredependantupon:
bloodflowrates
dialysateflowrates y
membranesurfacearea
Solute Removal: Convection SoluteRemoval:Convection
Also known as Solute Drag, molecules move Alsoknownas SoluteDrag ,moleculesmove
withthefluidasitcrossesthemembrane.
Convectiveclearancesaredependantupon:
molecular weight cutoff molecularweightcutoff
DialyzerKUF
ultrafiltration rate ultrafiltrationrate
Solute Removal: Adsorption SoluteRemoval:Adsorption
Manymolecules,suchaproteins,adheretothewall y p
ofthedialyzermembrane.Whilethesesubstances
areremovedfromtheblood,theydonotenterthe
dialysate. y
RemovalofsolutesbyAdsorptionisdependant
upon:
surfacearea
membranematerial
howmuchmaterialthemembranehasalreadyadsorbed
BACK FILTRATION BACKFILTRATION
Backfiltration is the movement of fluid from Backfiltrationisthemovementoffluidfrom
thedialysatecompartmentintotheblood
compartment of the dialyzer compartmentofthedialyzer.
E d i f Endotoxintransfer
Thisconcernismoretheoreticalthanreal
Convectiveclearances
Backfiltration: Convective Clearances Backfiltration:ConvectiveClearances
Backfiltration is exactly the mechanism in Backfiltrationisexactlythemechanismin
whichdialyzersareabletoremovelarge
molecular weight substances during a dialysis molecularweightsubstancesduringadialysis
treatment.Theflowoffluidintotheblood
compartment on the venous end causes the compartmentonthevenousendcausesthe
flowoffluid,andsolutes,outonthearterial
end Backfiltration makes convection happen end.Backfiltrationmakesconvectionhappen.
Backfiltration
Blood inlet
Dialysate
Inlet
Blood
Outlet
Dialysate
Outlet
Forefiltration
Backfiltration
Arterial End of Dialyzer
Venous End of Dialyzer
y
y
Getting Enough Treatment
How We Measure the Dose of Dialysis HowWeMeasuretheDoseofDialysis
d i ( ) UreaReductionRate(URR)
UreaKineticModeling(Kt/V)
Urea Reduction Rate UreaReductionRate
URRissimplymeasuringthelevelofBUN
inapatientsbloodatthebeginningof
dialysis,andattheendofthetreatment,
andcalculatinghowmuchtheBUNlevel
was reduced wasreduced
Factors affecting URR
Dialyzer Clearance
FactorsaffectingURR
DialyzerClearance
Dialyzercharacteristics
Blood flow rates Bloodflowrates
TimeonDialysis
URR Example
Pre Dialysis BUN is 100
URRExample
PreDialysisBUNis100
PostDialysisBUNis35
h l i 00*( ( / )) TheFormulais100*(1(Post/Pre))
100*(1(35/100))
=100*(1(.35))
=100* 65 = 65% URR 100 .65 65%URR
WhatYOUcandotoimproveyour
i URR
Turn up blood pump speed quickly at the
patientsURR
Turnupbloodpumpspeedquicklyatthe
beginningofthetreatment
Give adequate heparin and report on Giveadequateheparin,andreporton
excessiveclottinginthedialyzer
B f l h d i BUN l BecarefulwhendrawingBUNsamples
Urea Kinetic Modeling UreaKineticModeling
UreaKineticModelingisameansofmeasuring
the dose of dialysis by multiplying the dialyzer thedoseofdialysisbymultiplyingthedialyzer
clearance(K)bythetimeondialysis(t),and
dividing this product by the patients volume dividingthisproductbythepatientsvolume
(V)
Factors affecting Kt/V
Dialyzer Clearance (K) in ml/min
FactorsaffectingKt/V
DialyzerClearance(K),inml/min
Dialyzercharacteristics
Blood flow rates Bloodflowrates
TimeonDialysis(t),inminutes
Thepatientsvolume(V),inccs
Kt/V Example #1
Dialyzer provides a clearance of 350 ml/min
Kt/VExample#1
Dialyzerprovidesaclearanceof350ml/min
Patientruns31/2hours(210minutes)
i l i 8 li ( 8 000 ) Patientsvolumeis58liters(58,000ccs)
Kt/V=350*210/58,000=1.27
Kt/V Example #2
Desired Kt/V is 1 2
Kt/VExample#2
DesiredKt/Vis1.2
Dialyzerclearanceis350ml/minPatients
volume is 55 liters volumeis55liters
Whatistherequiredtime?
Kt/V=1.2=350*X/55,000
66,000=350*X ,
189=XYouneedtorun3hours,9minutes