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  • Blood Flow Q: The Transmembrane Pressure (TMP) Gradient

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    Nicholas Helmstetter
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    Renal replacement therapy uses dialysis to remove excess fluid and toxins from patients with renal failure. The key components of a hemodialysis circuit include blood flow rate, dialysate flow rate, the dialyzer, and ultrafiltration. Indications for urgent renal replacement therapy include acidosis, electrolyte imbalances, intoxications, fluid overload, and uremic symptoms refractory to medical management.

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    ICU One Pager RRT

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    Renal replacement therapy uses dialysis to remove excess fluid and toxins from patients with renal failure. The key components of a hemodialysis circuit include blood flow rate, dialysate flow rate, the dialyzer, and ultrafiltration. Indications for urgent renal replacement therapy include acidosis, electrolyte imbalances, intoxications, fluid overload, and uremic symptoms refractory to medical management.

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    197 views1 page

    Blood Flow Q: The Transmembrane Pressure (TMP) Gradient

    Uploaded by

    Nicholas Helmstetter
    Renal replacement therapy uses dialysis to remove excess fluid and toxins from patients with renal failure. The key components of a hemodialysis circuit include blood flow rate, dialysate flow rate, the dialyzer, and ultrafiltration. Indications for urgent renal replacement therapy include acidosis, electrolyte imbalances, intoxications, fluid overload, and uremic symptoms refractory to medical management.

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    RENAL REPLACEMENT THERAPY by Nick Mark MD ONE onepagericu.

    com Link to the


    most current
    DEFINITION: COMPONENTS OF A HEMODIALYSIS CIRCUIT & PARAMETERS SET:
    @nickmmark version →
    Renal Replacement Therapies (RRT) are
    ULTRAFILTRATION (UF) is the filtration of water BLOOD FLOW RATE (QB) is the flow Anticoagulant ANTICOAGULATION may be used
    used in patients in the IUC with renal failure
    to remove excess fluid or to clear the from the blood, driven by the transmembrane pressure rate of blood through the dialysis circuit. (CITRATE or HEPARIN ) to reduce thrombosis in the circuit. It
    blood of toxins (such as urea or potassium). (TMP) gradient between the blood & effluent. TMP can Higher flows enable greater clearance/UF is typically reversed on return.
    be titrated by adjusting the effluent pump & pressure. & have lower thrombosis risk but may “Arterial”
    · Clearance (K) is the volume of blood Filter Temporary
    𝑷𝒇𝒊𝒍𝒕𝒆𝒓 + 𝑷𝒓𝒆𝒕𝒖𝒓𝒏 require larger access & have more
    cleared of a solute (typically urea) per time. 𝑼𝑭 ∝ 𝑻𝑴𝑷 𝑻𝑴𝑷 = − 𝑷𝒆𝒇𝒇𝒍𝒖𝒆𝒏𝒕 pressure Blood or access central venous
    𝟐 adverse hemodynamic effects. Pump pressure
    Clearance depends on Blood flow (QB ), dialysis catheter
    dialysate flow (QD) and the dialyzer. There Ultrafiltration (UF) provides clearance by convection
    are two primary mechanisms involved: (also called solute drag) removing small & medium sized
    molecules. Effluent
    · Diffusion (with dialysis) clears smaller pressure
    molecules (<200 D), while convection (with Heater
    DIALYSATE SOLUTION is an Effluent
    UF) clears small & medium sized (< 50kD) warms
    isotonic fluid containing electrolytes, “Venous”
    molecules. Pump
    bicarbonate/acetate, glucose, & returning or return
    sometimes other small molecules. blood pressure
    INDICATIONS:
    Urgent/emergency RRT may be indicated The dialysate is chosen to match

    QD
    for conditions refractory to medical therapy: serum osmolality & to correct any

    QB
    DIALYZER
    DIALYSATE FLOW
    · A: Acidosis (usually severe metabolic) blood chemistry abnormalities; e.g:

    BLOOD FLOW
    Anticoagulant
    · E: Electrolyte derangements 𝑲𝒔𝒆𝒓𝒖𝒎 + 𝑲𝒅𝒊𝒂𝒍𝒚𝒔𝒂𝒕𝒆 = 𝟕 𝒎𝑬𝒒/𝑳
    Dialysate reversal
    (hyperkalemia, hypercalcemia, etc) EFFLUENT DIALYSATE
    · I: Intoxications (APAP, Barbiturates, DIALYSATE FLOW RATE (QD) pressure
    Lithium, carbamazepine, metformin, is a countercurrent flow of dialysate AV
    through the dialyzer. Higher flow

    REPLACEMENT
    methanol, salicylates, thallium, fistula
    rates enable greater clearance of Tunneled central
    theophylline, valproate, etc); see ExTRIP

    FLUID
    small molecules via diffusion. venous dialysis
    guidelines
    catheter
    · O: Fluid Overload (pulmonary edema
    refractory to diuretics, uncontrolled DIALYZER is rigid case that encloses thousands of Dialysate Bubble
    hypertension, etc). Volume removal may semi-permeable polymer tubules. Blood flows through Pump detector
    also hasten liberation from ventilation. the tubules & dialysate flows in the opposite direction
    · U: Symptomatic Uremia (causing severe outside (countercurrent). Dialyzers differ in surface area, REPLACEMENT FLUID (RF) can be VASCULAR ACCESS can be permanent (such as an AV
    altered mental status, uremic pericarditis, hydraulic permeability (KUF), permeability to medium used to restore fluid volume removed fistula or an AV graft) accessed using needles, semi-permanent
    bleeding diathesis, etc) sized molecules (flux of β2 microglobulin), & permeability by UF in the dialyzer. Replacement (a tunneled CVC), or temporary (such as a non-tunneled CVC).
    to small molecules diffusion (mass transfer coefficient) fluid can be given pre- or post-dialyzer. NB: The “arterial” (red) side describes blood coming out of the
    MODALITIES OF RRT IN THE ICU: patient; it does NOT mean that it comes out of an artery.
    IHD SLEDD (Sustained low CRRT (Continuous renal CRRT Mode Description Schematic
    (Intermittent HD) efficiency daily dialysis) replacement therapy)
    Slow continuous UF; UF removes fluid but provides almost
    3-5 hr session using ~12 hr session using 24 hr (continuous) session using SCUF no clearance and does not correct pH; no replacement
    Description
    standard HD machine standard HD machine a CRRT machine fluid required. Corrects volume overload only. UF

    Typically done by dialysis RNs Typically done by CCRNs Continuous venovenous hemofiltration. Provides
    Logistics
    Requires fresh water & drain connections Uses sterile fluid bags CVVH convective clearance by filtering a large volume of blood; RF

    CC BY-SA 3.0 v1.0 (2021-02-17)


    Vascular Access Fistula/Graft or CVC Usually requires CVC Requires CVC (a.k.a.CVVHF) Replacement fluid restores volume lost. Corrects uremia, UF
    lytes, pH and can remove volume.
    > 300 ml/min ~ 200 ml/min < 200 ml/min
    QB / QD Continuous venovenous hemodialysis. Provides diffusive
    > 500 ml/min 100-200 ml/min <50 ml/min (depends on mode)
    CVVHD clearance by running dialysate opposite blood flow. No
    Highest; ideal for Low; ideal for slower correction replacement fluid used. Gently corrects uremia, lytes, pH Dialysate
    Clearance Moderate
    hyperK or toxins of abnormalities & fluid removal
    Continuous venovenous hemodiafiltration. High clearance
    Hemodynamics Hypotension common Causes less hypotension Causes the least hypotension achieved using both UF & dialysate flow (both convection RF
    CVVHDF & diffusion). Replacement fluid used. Allows fluid removal
    Risk of disequilibrium Risk of hypoPhos, unclear Thrombosis risk, immobility, UF Dialysate
    Other risks and correction of electrolyte/pH. Good for toxin removal.
    syndrome med pharmacokinetics higher cost

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