Sieberth HG, Mann H, Stummvoll HK (eds): Continuous Hemofiltration. Contrib Nephrol. Basel, Karger, 1991, vol 93, pp 149- 151
Go-Slow Dialysis Instead of Continuous Arteriovenous Hemofiltration R. Hombrouckx, A .M. Bogaert, F. Leroy, J. Y. De Vos, L. Larno Dialysis Unit, Kliniek Hogerlucht, Ronse, Belgium
For acute patients in hospitals without a dialysis infrastructure, continuous arteriovenous hemofiltration (CA VH) [1, 2] has proved to be a valuable epuration technique. However, problems of clotting, insufficient ultrafiltration, inadequate clearances in severely catabolic patients limited its use [3]. We tried to combine the advantages of classical dialysis and of the CA VH for treating acute patients. Therefore, we dialyzed the patient with a blood flow of ca. 80 mljmin, by use of a single needle blood pump on a central venous catheter, during ca. 10 h daily in combination with a closed low volume recirculating bicarbonate dialysate. Materials The following materials were used: double head pump BL 760 (Belleo, Mirandola, Italy) [4, 51; recirculating dialysate monitor BL 747 (Belleo) [6]; central catheter: Vas-cath SC 2100 (Gambro) [7,8]; blood lines: BL 360 (venous) + BL 307 (arterial) (Belleo); artificial kidney: can be of any type.
Methods
Discussion The advantages of 'go-slow dialysis' are that the epuration is softer and more continuous compared to the classical open dialysate high flow hemodialysis: no symptoms of disequilibrium, sudden hypotensions, cramps, nausea, vomiting, etc., occurred. An easy body fluid and electrolyte composition monitoring is possible. Further, blood flow and ultrafiltration are completely independent of the arterial pressure of the patient or eventually of the venous resistance (in case of CA VH on a shunt); also,
Downloaded by: Université de Paris 193.51.85.197 - 1/16/2020 5:57:37 PM
An 8-French central catheter is introduced in the subclavian [9], jugular or femoral vein; the patient is dialyzed during ca. 10 h with a blood flow of 80 ml/min using the Belleo double head pump at very low pump head speeds, the ultrafiltration is monitored by the pressure setting in the circuit between the two pump heads, and the dialysate system is a closed recirculating low volume bicarbonate dialysate system of 40 liters, eventually replaced once or twice by fresh dialysate after 3- 4 h dialysis (dialysate flow, 500 ml/min).
Hombrouckx/Bogaert/Leroy/De Vos/Larno
150
they are independent of the type of kidney, length and type of blood lines, height of ultrafiltration reservoir, etc. Ultrafiltration and blood flow are mutually independent because of a separated blood flow setting and ultrafiltration setting possibility; furthermore, by the use of bicarbonate dialysate, there is no risk for lactic acidosis, which can easily occur in severely ill patients with some degree of hypoxemia hypotension, diabetes, liver insufficiency, etc. The low volume dialysate system permits an individualization of the dialysate: there is the possibility of adding sodium, potassium, glucose, oxygen, etc. to the dialysate, also of heparin, which results in an extremely low systematic heparinization with less bleeding tendency in the patient. Like CA VH, go-slow dialysis rarely provokes, in contrast to the classical short dialysis, stress ulcers in acute patients. As for CA VH, an intravenous hyperalimentation is made possible. There are relatively low risks of thrombosis in the blood circuit and the vessels; no regular flushing of the artificial kidney is needed, and in contrast to CA VH, the solute removal and the clearance ratios are sufficiently high even for highly catabolic patients. Complementary advanges over CA VH are that no surgery is needed, there is no waste of time in the actue phase as only one catheter is needed, and that this catheter is placed intravenously and not intra-arterially, without risk for bleeding, vascular defect or arterial thrombosis. The patients are less immobilized than in CAVH, and there are less infectious complications of vascular access site. Any type of artificial kidney can be used, not necessarily biocompatible membranes; there is an easy temperature control during the epuration and the costs are less than for CA VH. On the other hand, a nephrologist and a dialysis infrastructure are required but the specialized (trained) paramedical staff has only to intervene in order to start and end the dialysis, and once or twice for changing the dialysate tank. In between the patient is monitored by automatic blood pressure measuring and heart monitoring, under control of the nurses of the intensive care unit. The normal therapeutic measurements continue during the go-slow dialysis. Occasionally there is a dialysis alarm (for example when changing a patient's position), and at that moment the intensive care nurses warn the dialysis nurses for correcting the deficient parameter (this only occurs once or twice daily).
Downloaded by: Université de Paris 193.51.85.197 - 1/16/2020 5:57:37 PM
Conclusion
The advantages of the continuous method of treatment, that is CA VH, are combined with the advantages of a single needle dialysis system, which makes the epuration technique quite independent from parameters such as
Go-Slow Dialysis Instead of Continuous Arteriovenous Hemofiltration
151
the patient's arterial pressure, venous resistance, arterial blood flow, etc. Blood flow (in order to obtain a certain clearance) and ultrafiltration (pressure in the blood compartment of the artifical kidney in order to obtain a certain ultrafiltration rate) can be regulated totally independently of each other. An impregnation of the membrane by heparin through the dialysate side allows a very low systematic anticoagulation. The use of bicarbonate is superior to that of lactate especially in acutely ill patients. Unfortunately a dialysis infrastructure is needed, but once installed, the interventions of the dialysis nurse are minimal.
2
3
4 5
6
7 8 9
References Kramer P, Wigger W, Rieger J, Matthaei D, Scheler F: Arteriovenous hemofiltration: A new and simple method for treatment of overhydrated patients resistant to diuretics. Klin Wochenschr 1977;55:1121. Juan P, Bosch JP, Ronco C: Continuous arteriovenous hemofiltration in Maher S (ed): Replacement of Renal Function by Dialysis, ed 3. New York, Kluwer Academic Publishers, 1989, chap 15, pp 347-354. Kaplan AA: Enhanced efficiency during CAVH: La Greca G, Fabris A, Ronco C (eds): Clinical Trials with Predilution and Vacuum Suction in CAVH. Milan, Wichtig, 1986, p 49. Van Waeleghem JP, Boone L. Ringoir S: New technique on the one needle system during haemodialysis. Eur Dial Transplant Nurses Assoc 1973;1:10. De Vos JY, Van Wetter Ph, De Rekeneire G, Vanderbeken M, Larno L, Hombrouckx R: Introduction of an arterial expamion chamber (AEC) using a low compliance artificial kidney on the double head pump (DHP). Single Needle Dialysis Monogram EDTNA-ERCA, pp 17-22. De Vos JY, Larno L, De Rekeneire G, Leroy F, Hombrouckx R: Acute dialysis: Advantages of a low volume closed recirculating bicarbonate dialysate system. EDTN A, Madrid 1982, p 46. Shaldon S, Chiandussi L, Higgs B: Haemodialysis by percutaneous catheterisation of the femoral artery and vein with regional heparinisation. Lancet 1961;ii:857. Bambauer R, Jutzler GA: Erfahrungen mit grosslumigen Verweilkathetern in der V. jugularis interna als Zugang fUr akute Hiimodialysen. Klin Wocheschr 1982;60:285. Quinton WE, Dillard D, Scribner BH: Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960;6: 104.
R. Hombrouckx, MD, Dialysis Unit, Kliniek Hogerlucht, Hogerluchtstraat 6, B-9600 Ronse (Belgium)
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2
Go-Slow Dialysis Instead of Continuous Arteriovenous Hemofiltration R. Hombrouckx, A .M. Bogaert, F. Leroy, J. Y. De Vos, L. Larno Dialysis Unit, Kliniek Hogerlucht, Ronse, Belgium
For acute patients in hospitals without a dialysis infrastructure, continuous arteriovenous hemofiltration (CA VH) [1, 2] has proved to be a valuable epuration technique. However, problems of clotting, insufficient ultrafiltration, inadequate clearances in severely catabolic patients limited its use [3]. We tried to combine the advantages of classical dialysis and of the CA VH for treating acute patients. Therefore, we dialyzed the patient with a blood flow of ca. 80 mljmin, by use of a single needle blood pump on a central venous catheter, during ca. 10 h daily in combination with a closed low volume recirculating bicarbonate dialysate. Materials The following materials were used: double head pump BL 760 (Belleo, Mirandola, Italy) [4, 51; recirculating dialysate monitor BL 747 (Belleo) [6]; central catheter: Vas-cath SC 2100 (Gambro) [7,8]; blood lines: BL 360 (venous) + BL 307 (arterial) (Belleo); artificial kidney: can be of any type.
Methods
Discussion The advantages of 'go-slow dialysis' are that the epuration is softer and more continuous compared to the classical open dialysate high flow hemodialysis: no symptoms of disequilibrium, sudden hypotensions, cramps, nausea, vomiting, etc., occurred. An easy body fluid and electrolyte composition monitoring is possible. Further, blood flow and ultrafiltration are completely independent of the arterial pressure of the patient or eventually of the venous resistance (in case of CA VH on a shunt); also,
Downloaded by: Université de Paris 193.51.85.197 - 1/16/2020 5:57:37 PM
An 8-French central catheter is introduced in the subclavian [9], jugular or femoral vein; the patient is dialyzed during ca. 10 h with a blood flow of 80 ml/min using the Belleo double head pump at very low pump head speeds, the ultrafiltration is monitored by the pressure setting in the circuit between the two pump heads, and the dialysate system is a closed recirculating low volume bicarbonate dialysate system of 40 liters, eventually replaced once or twice by fresh dialysate after 3- 4 h dialysis (dialysate flow, 500 ml/min).
Hombrouckx/Bogaert/Leroy/De Vos/Larno
150
they are independent of the type of kidney, length and type of blood lines, height of ultrafiltration reservoir, etc. Ultrafiltration and blood flow are mutually independent because of a separated blood flow setting and ultrafiltration setting possibility; furthermore, by the use of bicarbonate dialysate, there is no risk for lactic acidosis, which can easily occur in severely ill patients with some degree of hypoxemia hypotension, diabetes, liver insufficiency, etc. The low volume dialysate system permits an individualization of the dialysate: there is the possibility of adding sodium, potassium, glucose, oxygen, etc. to the dialysate, also of heparin, which results in an extremely low systematic heparinization with less bleeding tendency in the patient. Like CA VH, go-slow dialysis rarely provokes, in contrast to the classical short dialysis, stress ulcers in acute patients. As for CA VH, an intravenous hyperalimentation is made possible. There are relatively low risks of thrombosis in the blood circuit and the vessels; no regular flushing of the artificial kidney is needed, and in contrast to CA VH, the solute removal and the clearance ratios are sufficiently high even for highly catabolic patients. Complementary advanges over CA VH are that no surgery is needed, there is no waste of time in the actue phase as only one catheter is needed, and that this catheter is placed intravenously and not intra-arterially, without risk for bleeding, vascular defect or arterial thrombosis. The patients are less immobilized than in CAVH, and there are less infectious complications of vascular access site. Any type of artificial kidney can be used, not necessarily biocompatible membranes; there is an easy temperature control during the epuration and the costs are less than for CA VH. On the other hand, a nephrologist and a dialysis infrastructure are required but the specialized (trained) paramedical staff has only to intervene in order to start and end the dialysis, and once or twice for changing the dialysate tank. In between the patient is monitored by automatic blood pressure measuring and heart monitoring, under control of the nurses of the intensive care unit. The normal therapeutic measurements continue during the go-slow dialysis. Occasionally there is a dialysis alarm (for example when changing a patient's position), and at that moment the intensive care nurses warn the dialysis nurses for correcting the deficient parameter (this only occurs once or twice daily).
Downloaded by: Université de Paris 193.51.85.197 - 1/16/2020 5:57:37 PM
Conclusion
The advantages of the continuous method of treatment, that is CA VH, are combined with the advantages of a single needle dialysis system, which makes the epuration technique quite independent from parameters such as
Go-Slow Dialysis Instead of Continuous Arteriovenous Hemofiltration
151
the patient's arterial pressure, venous resistance, arterial blood flow, etc. Blood flow (in order to obtain a certain clearance) and ultrafiltration (pressure in the blood compartment of the artifical kidney in order to obtain a certain ultrafiltration rate) can be regulated totally independently of each other. An impregnation of the membrane by heparin through the dialysate side allows a very low systematic anticoagulation. The use of bicarbonate is superior to that of lactate especially in acutely ill patients. Unfortunately a dialysis infrastructure is needed, but once installed, the interventions of the dialysis nurse are minimal.
2
3
4 5
6
7 8 9
References Kramer P, Wigger W, Rieger J, Matthaei D, Scheler F: Arteriovenous hemofiltration: A new and simple method for treatment of overhydrated patients resistant to diuretics. Klin Wochenschr 1977;55:1121. Juan P, Bosch JP, Ronco C: Continuous arteriovenous hemofiltration in Maher S (ed): Replacement of Renal Function by Dialysis, ed 3. New York, Kluwer Academic Publishers, 1989, chap 15, pp 347-354. Kaplan AA: Enhanced efficiency during CAVH: La Greca G, Fabris A, Ronco C (eds): Clinical Trials with Predilution and Vacuum Suction in CAVH. Milan, Wichtig, 1986, p 49. Van Waeleghem JP, Boone L. Ringoir S: New technique on the one needle system during haemodialysis. Eur Dial Transplant Nurses Assoc 1973;1:10. De Vos JY, Van Wetter Ph, De Rekeneire G, Vanderbeken M, Larno L, Hombrouckx R: Introduction of an arterial expamion chamber (AEC) using a low compliance artificial kidney on the double head pump (DHP). Single Needle Dialysis Monogram EDTNA-ERCA, pp 17-22. De Vos JY, Larno L, De Rekeneire G, Leroy F, Hombrouckx R: Acute dialysis: Advantages of a low volume closed recirculating bicarbonate dialysate system. EDTN A, Madrid 1982, p 46. Shaldon S, Chiandussi L, Higgs B: Haemodialysis by percutaneous catheterisation of the femoral artery and vein with regional heparinisation. Lancet 1961;ii:857. Bambauer R, Jutzler GA: Erfahrungen mit grosslumigen Verweilkathetern in der V. jugularis interna als Zugang fUr akute Hiimodialysen. Klin Wocheschr 1982;60:285. Quinton WE, Dillard D, Scribner BH: Cannulation of blood vessels for prolonged hemodialysis. Trans Am Soc Artif Intern Organs 1960;6: 104.
R. Hombrouckx, MD, Dialysis Unit, Kliniek Hogerlucht, Hogerluchtstraat 6, B-9600 Ronse (Belgium)
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