Substitution fluids & dialysates for CRRT - CRRT Online

as these measures could have been obtained from the padded and filtered acceleration time seriesthat is a part of the processing scheme. The second purpose of our article is to evaluate whetherthe post-processing method used by ITACA and PEER NGA has introduced biases or distortionsin the intensity measures. This is an important topic, because the intensity measures used forsuch things as deriving ground-motion prediction equations are often those from organizationsproviding data obtained using post-processing methods. The bulk of the article is devoted tothis topic.Using Initial Conditions with Pad-Stripped Filtered AccelerationsThe processing methods discussed in this article are illustrated with the EW component ofmotion recorded by an analog Kinemetrics SMA-1 strong-motion accelerograph at station Dinar-Meteorology Station ( R 5 km , V30 198 m/s ) from the 01 October 1995 Dinar earthquakeHYPS(M 6.4). The record is from the Turkish database (Akkar et al., 2010), and additionalinformation about the station and the earthquake can be found in Anderson et al. (2001). Therecord was padded with zeros and then filtered with an acausal bandpass with corner frequenciesof 0.15 Hz and 30 Hz (these values are from the Turkish database). Figure 1 is a plot of thefiltered acceleration time series, with and without pads. No pre-event filter transient is obviousin the top graph, which illustrates our previous comment about the appearance of padded andfiltered accelerations. Such a transient exists, however, as is clearly shown when the ordinatescale is expanded greatly (Figure 1b). Even though relatively small in amplitude, thesetransients are important in the derivation of velocity, displacement, and response spectra, butthey are not available in the pad-stripped data. Ignoring the filter transient and integrating padstrippedaccelerations with the common assumption that the initial velocity and displacementsare 0.0 usually leads to long-period errors appearing as a drift in the displacement time series(Figure 2). In addition, computing response spectra from the pad-stripped acceleration timeseries, again with the common assumption of 0.0 initial conditions, leads to significantdifferences at long period relative to the response spectrum obtained from the paddedaccelerations (which we consider to be the correct response spectrum for the given choice offilter corner frequencies), as shown in Figure 3.C:\pad-stripped_initial_conditions\paper\using_pad-stripped_acausally_filtered_strongmotion_data_v3.4.doc3

Henderson 1996Convective transportbloodmembraneconcentrationC 1 C 2Q fS = 1C = 1 C 2Distance

Hemofiltration - clearanceClark et al ArtifOrgans 2003Post-dilutionK = Q F x SKQ FSclearance ml/minultrafiltration rate ml/minsieving coefficient

Filtration fractionBlood flowProteindepositionultrafiltrate

Gibbs – Donnan effect

Hemofiltration - clearanceClark et al ArtifOrgans 2003Post-dilution mode• small solutes S ~ 1.0 K ~ Q F• filtration fractionσ Q F /plasma water flow rateσ hct and albuminσ Q B

Predilutional hemofiltrationClark et al ArtifOrgans 2003K = Q F xSQ BW + Q SQ BWK clearance ml/minQ F ultrafiltration rate ml/minS sieving coefficientQ BWblood water flow rate ml/minQ S substitution fluid rate ml/min

Lower Predilution clearancesTroyanov et al NephrolDialTransplant 2003% ↓ clearance vs post dilution4035302520151050ureaphosphatecreatinineβ2-MmultiflowM60/M100Qb 125-150Qs 75ml/minUF 4.5 l/h

Pre vs post dilution isovolemic CRRT1.2Sieving coefficient1.110.9UreaCreat0.86 5 4 2 1 0pre0 1 2 4 5 6Uchino et al IntensivCareMed 2003post

Pre vs post dilution isovolemic CRRT21001800urea*Urea loss mmol/day1500120090060030006 5 4 2 1 0pre0 1 2 4 5 6Uchino et al IntensivCareMed 2003post

Pre vs post dilution isovolemic CRRT1cationsSieving coefficient0.90.80.7NaKMgCa0.66 5 4 2 1 0pre0 1 2 4 5 6Uchino et al IntensivCareMed 2003post

Pre vs post dilution isovolemic CRRT700sodiumMass balance mmol/day600500400300200100*06 5 4 2 1 0pre0 1 2 4 5 6Uchino et al IntensivCareMed 2003post

Hemofiltration -Pre-dilution mode• More sodium loss ↑ Na in replacement fkuidσ Na from other iv fluidsσ Converse pre-dilution

post dilution CRRTsodiumUF Sodium concentration mmol/l160150140130120Lactate BicarbonateLactateBicarbonateNa140

What does this mean ?• High volume Predilution– Possible -ve balance• NamEq/lNaPrismaSateBGK4/0/1.2140Duosol4556136NxStageRFP-454130PrismaSateB22GK4/0140Mg1.21.51.51.5• High volume Postdilution– Positive balance

Hypocalcemia in the ICUZivin et al AmJKidDis 2001% patients10080604020UnivWashingtonStudy199 ptsionisedCa ++ < 1.16mmol/l0ICUpatientsICU buthospitalized48 h discharge non ICU

Pre vs post dilution isovolemic CRRT30total calciumMass balance mmol/day20100-10-20-30-40*-506 5 4 2 1 0preUchino et al IntensivCareMed 0 1 20032 4 5 6post

Hemofiltration -Pre-dilution mode• More calcium loss ↑ Ca in replacement fkuidσ Ca from other iv fluidsσ Converse post-dilution

post dilution CRRT2Calcium & MagnesiumUF concentration mmol/l1.510.5CaCaMgMgCa1.75mmol/lMg0.75 & 0.5mmol/l0Lactate BicarbonateLactateBicarbonate

What does this mean ?• High volume Predilution– Possible -ve balance• Ca & MgmEq/lMgPrismaSateBGK4/0/1.21.2Duosol45561.5NxStageRFP-4541.5Monosol1.0Mg1.21.51.51.5• High volume Postdilution– Positive balance• Ca & Mg

Pre vs post dilution isovolemic CRRT1.3anions1.2Total CO 2Sieving coefficient1.110.9PiCl0.86 5 4 2 1 0pre0 1 2 4 5 6Uchino et al IntensivCareMed 2003post

Pre vs post dilution isovolemic CRRT1000chlorideMass balance mmol/day7505002500*-2506 5 4 2 1 0preUchino et al IntensivCareMed 0 1 20032 4 5 6post

Hemofiltration -Post-dilution mode• More phosphate lossσ Pi from other iv fluidsσ pre-dilution smaller losses

post dilution CRRTchlorideUF chloride concentration mmol/l120115110105100Lactate BicarbonateLactateBicarbonateCl115&109.5

What does this mean ?• High volume Predilution– Possible +ve balance• ChloridemEq/lClPrismaSateBGK4/0/1.2110.2Duosol4556117NxStageRFP-454110.5PrismaSateB22GK4/0120.5Bic32252522• High volume Postdilution– Possible -ve balance

Lactate fluids for CRRTmmol/lHaemovex 2®Monosol® Filtrasol®lactate 44.5 30 44.5sodium 142 140 138chloride 103 115 98calcium 2.0 1.75 1.65magnesium 0.75 0.75 0.70

CRRT replacement fluidsDavenport et al Lancet 1988range of fluidsChloride 105 95Lactate 35 46hyper -chloremicmetabolicacidosishypo -chloremicmetabolicalkalosis

Hyperlactatemia during CRRTDavenport et al NephrolDialTransplant 1997change in arterial H + nmol/l107.552.50-2.5-50 40 80 120 160 200UF lactate mmol17 lCVVHLac 43CKDAKIALF

Base excess during CRRT0Base excess mmol/l-2-4-6-8-10BicarbonateLactate with addedbicarbonatepre 1 2Duration CRRT daysLactate

Serum Bicarbonate during CRRTserum bicarbonate mmol/l282420BicarbonateLactateLactate withaddedbicarbonate16pre 1 2Duration CRRT days

Buffer base for CRRTMacLean et al KI 200010fall in arterial H + nmol/l7.552.50-2.52 l/hCVVHD53 ptsBicLac-51050 1150 1250Amount of base administered mmol/24 h

Temperature losses duringdialysis37.0 o C36.5 o C37.0 o C36.5 o Cc36.2 o C36.4 o C

Citrate anticoagulation for CRRTVan der Voort BloodPurif 2007Mass balance mmol/day403020100-10*LeeuwardenAmsterdam20 ptsCVVHFmean (SD)* p

Citric- and Acetic Acid dialysatesChemicalMeasureCitrate DialysateAcetic Acid DialysateSodiummmol/L138,0138,0Calciummmol/L1,251,25Magnesiummmol/L0,50,5Potassiummmol/L2,02,0Chloridemmol/L105,0105,3Acetatemmol/L0,34,0Citratemmol/L0,8-Glucoseg/L1,01,0Bicarbonatemmol/L35,234,2

Crossover StudyAcetateCITRATEiCa 2+ , Regular DialysateiCa 2+ , Citrate Dialysatemmol/l1,601,401,201,000,800,600,400,200,00Start 1 Hour 2 Hours 3 Hours End End + 1 H.mmol/l1,601,401,201,000,800,600,400,200,00Start 1 Hour 2 Hours 3 Hours End End + 1 H.Citrate, Regular DialysateCitrate, Citrate Dialysatemmol/l4,003,503,002,502,001,501,000,500,00Start 1 Hour 2 Hours 3 Hours End End + 1 H.mmol/l4,003,503,002,502,001,501,000,500,00Start 1 Hour 2 Hours 3 Hours End End + 1 H.*AJKD;Vol 35, No 3, March 2000: pp 493-499

Longer-Term StudyPre dialysis HCO 3 - , Citrate DialysatePre dialysis BUN, Citrate Dialysate29100mmol/l2725232119mg/dl90807060504017Start Week 4 Week 8 Week 1230Start Week 4 Week 8 Week 12Urea Reduction Ratio URR (p < 0,03)Delivered Kt/V (p < 0,01)901,35BUN mg/d l75604530150URR =68 +/- 5,9% URR =73 +/- 5,3%Pre BUNPost BUNPre BUNPost BUNFirst dialysisLast dialysisKt/V1,331,311,291,271,251,231,211,191,171,151,23 +/- 0,19First dialysis1,34 +/- 0,20Last dialysisAJKD;Vol 35, No 3, March 2000: pp 493-499

Citrate DialysateBlood Purif 2007;25:183-208

On-line fluids for HDFMaximum allowed contamination100806040200waterfor injsterilewaterbicarbultrapuredialysate dialysis fluidMicro-bacteriologicalcontaminationCFU /mlEndotoxinIU/ 10ml

Nitrite levels in tap waterNitrite concentration mg/lNitrite concentration mg/l0.20.150.10.05ULNdomesticwater0.1 mg/l0D D JanuaryFeb March Apr May June July2000 2001 year

Replacement fluids & dialysatesSummary• electrolyte compositionσ high volume therapyσ pre vs post dilutionσ citrate