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

0

1

2

3

4

5

6

7

8

5 10 15 20 25 30 35 400

Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324

Normal

Death

Blo

od

Vo

lum

e (l

ite

rs)

Extracellular Fluid Volume (liters)

0

1

2

3

4

5

6

7

8

5 10 15 20 25 30 35 400

Adapted from Guyton, AC: Textbook of Medical Physiology, 1991, pg.324

Normal

DeathHypovolemia

C

B

AEdema

Bloo

d Vo

lum

e (li

ters

)

Extracellular Fluid Volume (liters)

ShiftDue

to:

Low O2MedsUFRNa+TempPosture

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

0 1 2 3 4

0

-5

-10

-15

-20

27

29

31

33

35

%B

V (

Lo

ss)

Hc

t

Hct =RCVBV

X 100

Profile A• Ultrafiltration and

plasma refill– Equal, or positive

slope or slope less than -3%• Special considerations

may apply

Hypertension, 2010

RPV Principles

11

Note: BV∆%

Note: UF Removed

RPV Principles

12

-8.6% ÷ 3.3 hour = -2.6% per hour

= Profile A

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

RPV Principles

14

-12.8% ÷ 3 hours = - 4.3%/hour

= Profile B

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,2005Brewer & Goldstein,

2004

RPV Principles

16

-20.9 ÷ 2 = -10.4

= Profile C

Prevent Treatment ComplicationsE – Electrolytes V – Volume removed–ultrafiltration A – Anemia/albumin/allergiesL – Lying back, feet on floor – positionU – Urinary outputA – Anti-hypertensives or other medsT – Temperature I – Ideal dry weightO – Oxygenation of tissuesN – 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

ReferencesAgarwal, 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-in-

hemodialysis-from-emergent-biotechnology-to-clinicalpractice/automated-blood-

volume-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.1525-

139X.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.