Ultrafiltration control using hematocrit monitoring
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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.

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Ultrafiltration control using hematocrit monitoring

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

Objectives

  • Describe blood volume monitoring

  • Identify trend and graph development during hemodialysis

  • Evaluate nursing assessment considerations to decrease intradialytic mortality


Relative blood volume monitoring

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

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

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

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

8

A

Edema

7

6

B

Low O2

Meds

UFR

Na+

Temp

Posture

8

5

Normal

Shift

Due

to:

7

4

Blood Volume (liters)

C

3

6

Hypovolemia

2

Death

5

1

0

4

Adapted from Guyton, AC:

Textbook of Medical Physiology, 1991, pg.324

3

Normal

40

0

5

10

15

20

25

30

35

2

Extracellular Fluid Volume (liters)

Blood Volume (liters)

1

0

0

40

5

10

15

20

25

30

35

Death

Adapted from Guyton, AC:

Textbook of Medical Physiology, 1991, pg.324

Extracellular Fluid Volume (liters)

Guyton’s Curve Applied


Optical data transformed graphic image

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

35

33

Hct

31

29

RCV

27

X 100

Hct

=

0

BV

-5

%BV (Loss)

-10

-15

-20

0

1

2

3

4

The Inverse Relationship


Profile a

Profile A

  • Ultrafiltration and plasma refill

    • Equal, or positive slope or slope less than -3%

      • Special considerations may apply

Hypertension, 2010


Ultrafiltration control using hematocrit monitoring

Note: UF Removed

Note: BV∆%


Ultrafiltration control using hematocrit monitoring

-8.6% ÷ 3.3 hour = -2.6% per hour

= Profile A


Profile b

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


Ultrafiltration control using hematocrit monitoring

-12.8% ÷ 3 hours = - 4.3%/hour

= Profile B


Profile c

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,2005

Brewer & Goldstein, 2004


Ultrafiltration control using hematocrit monitoring

-20.9 ÷ 2 = -10.4

= Profile C


Prevent treatment complications

Prevent Treatment Complications

E – Electrolytes

V – Volume removed–ultrafiltration

A – Anemia/albumin/allergies

L – Lying back, feet on floor – position

U – Urinary output

A – Anti-hypertensives or other meds

T – Temperature

I – Ideal dry weight

O – Oxygenation of tissues

N – Nurse responsibility


Summary

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


References

References


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