- Email: [email protected]
Conference report: The International Conference on Continuous Renal Replacement Therapies: San Diego, California – November 8-10, 1995
/+A
AUSTRALIAN CRITICAL CARE
'k
The International Conference on continuous Renal Replacement Therapies San Diego, California - November &10,1995 Petra Bierer CACCN Inc.
In November 1995, I attended the International Conference on Continuous Renal Replacement Therapies in San Diego, California. This conference brought together critical care nurses, nephrologists, intensivists, pharmacists, nutritionists and haemodialysis nurses from the following countries: the United States, Australia, Sweden, Austria, China, Japan, France, Chile, Argentina, Greece, Germany, Spain and Finland. The purpose of this meeting was to provide new information on the rapidlychanging area of continuous renal replacement therapies (CRRT) for the 700 registrants.
I was fortunate enough to have two papers accepted for presentation: one an oral presentation titled 'Plasma-free haemoglobin levels during continuous veno-venous haemodiafiltration' and the other a poster presentation titled 'Continuous veno-venous haemodiafiltration: monitoring circuit function'. Both papers were well-received and generated a lot of positive discussion.
thereby negating the need for drug-level measurements. Dr Macias, from The Indiana University School of Medicine in Indianapolis, gave an excellent lecture on the 'Choice of dialysatelreplacement fluid anion', which discussed the use of CRRT to control acidlbase balance and the advantages and disadvantages of the available anions, as well as clinical situations in which they are best used. Following this session was a presentation by Dr Bellomo, from the Austin and Repatriation Medical Centre in Victoria. His discussion, aimed at developing 'Consensus nomenclature', presented standardised terminology for CRRT to the conference registrants. Unfortunately, only 30 minutes was set aside, which was obviously not enough time for everyone to agree on 29 definitions. Also, because of the audience's diverse array of experience with CRRT, only six definitions were agreed upon. The following are some of the definitions put forward by Dr Bellomo:
The other Australian nursing speaker was Ian Baldwin, from the Austin and Repatriation Medical Centre in Victoria, who had three poster presentations and also ran the 'Fluid management with CRRT' workshop. Well done, Ian - you were a hit! In addition, several Australian medical papers, either oral or poster presentations, were also well-received. The Australian camp consisted of nursing and medical health professionals from Flinders Medical Centre in Adelaide, The Austin and Repatriation Medical Centre, The Alfred and S t Vincent's in Melbourne, The I t'leorge Hospital, Westmead, Prince Henry's in Sydney and Royal Perth Hospital in Western Australia. The conference was spread over 2 days and split into four sections: 'Technique of CRRT', 'Non-renal indications for CRRT', 'Outcomes with CRRT' and 'Future applications with CRRT'. O n both days, invited speakers gave presentations in the morning and there were concurrent free communication and workshop sessions in the afternoon. Session 1, 'Technique of CRRT', included a lecture on 'Anticoagulation of CRRT circuits', presented by Dr Mehta from the University of California, San Diego. The use of citrate as an anticoagulant and as an additional alkali source was discussed; it is used as an anticoagulant during CRRT in some institutions overseas. 'The management of drug dosing in CRRT' was the topic of Dr Kroh, from Marburg in Germany. Dr Kroh presented a n algorithm which he and his colleagues developed to predict drug dosages, VOLUME 9 NUMBER 1
Haemodialysis: a term defining a prevalently diffusive blood purification treatment in which blood and dialysate are circulated in a countercurrent mode. Haemofiltration: a term which describes an exclusively convective form of blood purification. The ultrafiltrate produced is replaced completely or in part by a sterile solution. Blood purification is achieved by replacement of convective fluid losses. Haemofiltration can be applied intermittently or continuously. Haemodiafiltration: a term describing blood purification treatment in which diffusion and convection are combined. Diffusion: this term describes a type of solute transport across a semipermeable membrane. Such solute has a statistical tendency to reach the same concentration in the available distribution space on both sides of the membrane. Thus, molecules move from the compartment with the higher concentration to the compartment with the lower concentration. Convection describes a type of solute movement across a semipermeable membrane in which solute, together with solvent, is transported by means of a process (filtration) which occurs in response to a transmembrane pressure gradient. Continuous veno-venous haemofiltration (CVVH) is a technique of CRRT whereby blood is driven through a porous membrane by a peristaltic pump via an extracorporeal circuit originating from and terminating in a vein. The ultrafiltrate MARCH 1996
h
#A9
AUSTRALIAN CRITICAL CARE
produced during membrane transit is replaced in its totality or in large part with appropriate replacement solutions t o achieve blood purification. Solute clearance is exclusively convective.
These were some of the definitions presented, and it is unfortunate that we were unable to achieve a consensus on the most frequentlyused terms. Perhaps in the near future we can develop standardised terminology. It is great, however, that an attempt has been made.
Slow continuous ultrafiltration (SCUF), a form of continuous arterio-venous haemofiltration (CAVH) or CVVH not associated with fluid replacement, is often used in the management of refractory oedema with or without renal failure. It does not achieve clinically significant blood purification and its primary aim is the safe and effective management of fluid overload. If an arterio-venous circuit is used, the technique should be abbreviated to AV-SCUE If a veno-venous circuit is used, the technique should be abbreviated to W-SCUF. Ultrafiltration can occur by way of gravity or be volumetrically controlled.
The second session, 'Non-renal indicators for CRRT', included a discussion of 'Inflammatory mediators in sepsis' by Dr Periera, from Tufts University School of Medicine in Boston. Dr Grootendorst, from Rotterdam in the Netherlands, went on to talk about the role of continuous haemofiltration in sepsis and confirmed that mediators of sepsis are found in ultrafiltrate; however, many useful substances (eg inotropes, antibiotics, IL8 and IL12) are also removed. Data so far indicates that clinically relevant results require very high-volume (100L/day) haemofiltration. T h e question still to be answered is: does the effect of improving haemodynamic stability result from convective removal of mediators or from binding to the haemofilter membrane?
Continuous veno-venous haemodiafiltration (CWHDF) is a technique of CRRT whereby the CVVH circuit is modified by the addition of countercurrent dialysate flow to the ultrafiltrate-dialysate compartment of the haemofilter. Fluid replacement is routinely administered in amounts clinically indicated to replace convective fluid losses either in part or in total. Solute clearance is both convective and diffusive. Continuous veno-venous haemodialysis (CVVHD) is a technique of CRRT whereby the extracorporeal circuit is the same as in C W H C F but a low permeability haemodialyzer is typically used. Slow dialysate flow occurs as in continuous arterio-venous haemodialysis (CAVHD); solute clearance is mostly diffusive and spontaneous and ultrafiltration is minimal.
The role of CRRT in liver failure and cerebral oedema was examined too, as was the role of CRRT for the treatment of refractory congestive cardiac failure: Dr Canaud, from Montpellier in France, discussed ultrafiltration as a useful non-pharmacological means of managing cardiac oedema when patients become resistant to conventional medical treatment. Dr Canaud believes isolated ultrafiltration and/or slow haemofiltration are an integral part of the modern treatment of congestive cardiac failure, and complement conventional conventional drug therapies such as diuretics, vasodilators and ionotropic agents. The third session, 'Outcomes with CRRT', discussed the complications of CRRT and its cost-effectiveness in the ICU
Confederation of Australian Critical Care Nurses SA Branch (Inc.)
I
I
A.N.Z.I.C.S.
Australla and New Zealand Care Soclety
VOLUME 9 NUMBER 1
MARCH 1996
PA4
AUSTRALIAN CRITICAL CARE
setting, and predicting outcomes in acute renal failure. Dr Bihari, from S t George's in Sydney, presented a very informative study, 'Cost-effectiveness in the ICU setting', which he undertook while working at Guyk Hospital in London. The paper discussed patients with multi-system organ failure who experienced acute renal failure. Dr Bihari told us that patients with multi-system organ failure form only a small minority of ICU admissions but consume a disproportionate share of available resources. The 1993 study looked at 1106 patients admitted to the general ICU at Guy's Hospital in London. Of these, 92 (8.3 per cent) had multi-system organ failure and were treated with CVVHD. Daily organ failure scores were calculated for all patients, as were daily ICU costs. For patients who survived and left the hospital, quality of life was assessed at 6 months (Nottingham Health Profile, Sickness Impact Profile) so that patient outcomes could be related to the cost of intensive care. Dr Bihari stated that, while mortality rates are high, quality of life is well-preserved in the majority of surviving cases. Since, in the absence of intensive care, mortality is likely to be 95 per cent, the hospital survival rate of 30 per cent with an overall effective cost per hospital survivor of US$58, 072 probably reflects 'value for money'. Dr Bihari believes C W H D forms part of the intensive care of this group of patients and that it should not be considered in isolation. Finally, session 4, titled 'Future applications with CRRT', included presentations ranging from 'Prophylactic use of CRRT in patients with normal renal function' to 'Future technology for CRRT'. This last paper was presented by Dr Ronco, from Italy, who stated there was a need for newly-designed venous catheters to reduce the amount of recirculation, permit increased blood flow and reduce
infections caused by the access. He went on to discuss the future direction of haemofilters and how heparin-bound surfaces are still under evaluation. The process of evolution towards a reduction in thickness and an optimisation of pore size and distribution, hydrophilic structure and biocompatibility of haemofilters is ongoing. Unfortunately, there were very few nursing speakers, despite the conference taking a multidisciplinary approach to CRRT. I believe I was the only nurse to present a research paper in the free communication sessions and that Ian Baldwin was one of two nurses to be involved in the workshops. Both Ian and I had papers in the poster presentations, as did a few nurses from the United States. The remaining oral and poster papers were presented by doctors, pharmacists or nutritionists. Overall, the conference was very informative and it was great to meet so many people from Australia, the United States and Europe. It is reassuring, too, to know that in Australia we are not at all behind in CRRT. In fact, we are moving ahead in leaps and bounds, particularly when it comes to undertaking research projects and understanding CRRT. This is reflected at our annual National Scientific Meeting on Intensive Care. I would like to thank the Confederation of Australian Critical Care Nurses Inc. (CACCN) for awarding me a travel grant to assist my trip to the United States. The opportunity to present two nursing research papers at an international conference was a milestone in my career. I urge all nurse researchers out there to present their papers at local, national or international meetings. I have presented on all three levels and it is an amazing feeling.
e Critical Care Nurses Inc.
terencefsemmar) rants Iegrees in Critical Care (Masters/Doctorate)
September 6,199t
$1000
Tf.u ~ o vgrants e are currently available to any member of the Confederation of Australian Critical Cur=Nurses Znc. Nominations are called for from members
I
" " ' "
A minimum of 12 months m e late p, ite bran - $ I endorsement by ( of develop&ent in critical care nursing. The reason for applying being the Asement to prqvide a formal report to & dian tical h~ fi in- being nominated cmpletion date of the rosearch. - "he- ducatian pan& are offerw' lo CACCh memo - wnr-, ~usrramnave wen accepren rar p m r a n o n latianal Scientific Meetine. -
@
-
i - e ~ u s l rev'c. i a ucmueu a y y u u a u u k t L u L u t State branch endorsement involves confinnationof membership and a summary of your activities and contributions towards critical care nursing and your state branch. This information may take up to 1 month to process, so please apply earl2 to ensure you don't miss out!
-
For further information and application forms, please write to or telephone:
I
The Trust Manager PO Box 605, Hornsby, NSW 2077 Tel: (02)482 7712. VOLUME 9 NUMBER l
MARCH 1996
I I I
AUSTRALIAN CRITICAL CARE
'k
The International Conference on continuous Renal Replacement Therapies San Diego, California - November &10,1995 Petra Bierer CACCN Inc.
In November 1995, I attended the International Conference on Continuous Renal Replacement Therapies in San Diego, California. This conference brought together critical care nurses, nephrologists, intensivists, pharmacists, nutritionists and haemodialysis nurses from the following countries: the United States, Australia, Sweden, Austria, China, Japan, France, Chile, Argentina, Greece, Germany, Spain and Finland. The purpose of this meeting was to provide new information on the rapidlychanging area of continuous renal replacement therapies (CRRT) for the 700 registrants.
I was fortunate enough to have two papers accepted for presentation: one an oral presentation titled 'Plasma-free haemoglobin levels during continuous veno-venous haemodiafiltration' and the other a poster presentation titled 'Continuous veno-venous haemodiafiltration: monitoring circuit function'. Both papers were well-received and generated a lot of positive discussion.
thereby negating the need for drug-level measurements. Dr Macias, from The Indiana University School of Medicine in Indianapolis, gave an excellent lecture on the 'Choice of dialysatelreplacement fluid anion', which discussed the use of CRRT to control acidlbase balance and the advantages and disadvantages of the available anions, as well as clinical situations in which they are best used. Following this session was a presentation by Dr Bellomo, from the Austin and Repatriation Medical Centre in Victoria. His discussion, aimed at developing 'Consensus nomenclature', presented standardised terminology for CRRT to the conference registrants. Unfortunately, only 30 minutes was set aside, which was obviously not enough time for everyone to agree on 29 definitions. Also, because of the audience's diverse array of experience with CRRT, only six definitions were agreed upon. The following are some of the definitions put forward by Dr Bellomo:
The other Australian nursing speaker was Ian Baldwin, from the Austin and Repatriation Medical Centre in Victoria, who had three poster presentations and also ran the 'Fluid management with CRRT' workshop. Well done, Ian - you were a hit! In addition, several Australian medical papers, either oral or poster presentations, were also well-received. The Australian camp consisted of nursing and medical health professionals from Flinders Medical Centre in Adelaide, The Austin and Repatriation Medical Centre, The Alfred and S t Vincent's in Melbourne, The I t'leorge Hospital, Westmead, Prince Henry's in Sydney and Royal Perth Hospital in Western Australia. The conference was spread over 2 days and split into four sections: 'Technique of CRRT', 'Non-renal indications for CRRT', 'Outcomes with CRRT' and 'Future applications with CRRT'. O n both days, invited speakers gave presentations in the morning and there were concurrent free communication and workshop sessions in the afternoon. Session 1, 'Technique of CRRT', included a lecture on 'Anticoagulation of CRRT circuits', presented by Dr Mehta from the University of California, San Diego. The use of citrate as an anticoagulant and as an additional alkali source was discussed; it is used as an anticoagulant during CRRT in some institutions overseas. 'The management of drug dosing in CRRT' was the topic of Dr Kroh, from Marburg in Germany. Dr Kroh presented a n algorithm which he and his colleagues developed to predict drug dosages, VOLUME 9 NUMBER 1
Haemodialysis: a term defining a prevalently diffusive blood purification treatment in which blood and dialysate are circulated in a countercurrent mode. Haemofiltration: a term which describes an exclusively convective form of blood purification. The ultrafiltrate produced is replaced completely or in part by a sterile solution. Blood purification is achieved by replacement of convective fluid losses. Haemofiltration can be applied intermittently or continuously. Haemodiafiltration: a term describing blood purification treatment in which diffusion and convection are combined. Diffusion: this term describes a type of solute transport across a semipermeable membrane. Such solute has a statistical tendency to reach the same concentration in the available distribution space on both sides of the membrane. Thus, molecules move from the compartment with the higher concentration to the compartment with the lower concentration. Convection describes a type of solute movement across a semipermeable membrane in which solute, together with solvent, is transported by means of a process (filtration) which occurs in response to a transmembrane pressure gradient. Continuous veno-venous haemofiltration (CVVH) is a technique of CRRT whereby blood is driven through a porous membrane by a peristaltic pump via an extracorporeal circuit originating from and terminating in a vein. The ultrafiltrate MARCH 1996
h
#A9
AUSTRALIAN CRITICAL CARE
produced during membrane transit is replaced in its totality or in large part with appropriate replacement solutions t o achieve blood purification. Solute clearance is exclusively convective.
These were some of the definitions presented, and it is unfortunate that we were unable to achieve a consensus on the most frequentlyused terms. Perhaps in the near future we can develop standardised terminology. It is great, however, that an attempt has been made.
Slow continuous ultrafiltration (SCUF), a form of continuous arterio-venous haemofiltration (CAVH) or CVVH not associated with fluid replacement, is often used in the management of refractory oedema with or without renal failure. It does not achieve clinically significant blood purification and its primary aim is the safe and effective management of fluid overload. If an arterio-venous circuit is used, the technique should be abbreviated to AV-SCUE If a veno-venous circuit is used, the technique should be abbreviated to W-SCUF. Ultrafiltration can occur by way of gravity or be volumetrically controlled.
The second session, 'Non-renal indicators for CRRT', included a discussion of 'Inflammatory mediators in sepsis' by Dr Periera, from Tufts University School of Medicine in Boston. Dr Grootendorst, from Rotterdam in the Netherlands, went on to talk about the role of continuous haemofiltration in sepsis and confirmed that mediators of sepsis are found in ultrafiltrate; however, many useful substances (eg inotropes, antibiotics, IL8 and IL12) are also removed. Data so far indicates that clinically relevant results require very high-volume (100L/day) haemofiltration. T h e question still to be answered is: does the effect of improving haemodynamic stability result from convective removal of mediators or from binding to the haemofilter membrane?
Continuous veno-venous haemodiafiltration (CWHDF) is a technique of CRRT whereby the CVVH circuit is modified by the addition of countercurrent dialysate flow to the ultrafiltrate-dialysate compartment of the haemofilter. Fluid replacement is routinely administered in amounts clinically indicated to replace convective fluid losses either in part or in total. Solute clearance is both convective and diffusive. Continuous veno-venous haemodialysis (CVVHD) is a technique of CRRT whereby the extracorporeal circuit is the same as in C W H C F but a low permeability haemodialyzer is typically used. Slow dialysate flow occurs as in continuous arterio-venous haemodialysis (CAVHD); solute clearance is mostly diffusive and spontaneous and ultrafiltration is minimal.
The role of CRRT in liver failure and cerebral oedema was examined too, as was the role of CRRT for the treatment of refractory congestive cardiac failure: Dr Canaud, from Montpellier in France, discussed ultrafiltration as a useful non-pharmacological means of managing cardiac oedema when patients become resistant to conventional medical treatment. Dr Canaud believes isolated ultrafiltration and/or slow haemofiltration are an integral part of the modern treatment of congestive cardiac failure, and complement conventional conventional drug therapies such as diuretics, vasodilators and ionotropic agents. The third session, 'Outcomes with CRRT', discussed the complications of CRRT and its cost-effectiveness in the ICU
Confederation of Australian Critical Care Nurses SA Branch (Inc.)
I
I
A.N.Z.I.C.S.
Australla and New Zealand Care Soclety
VOLUME 9 NUMBER 1
MARCH 1996
PA4
AUSTRALIAN CRITICAL CARE
setting, and predicting outcomes in acute renal failure. Dr Bihari, from S t George's in Sydney, presented a very informative study, 'Cost-effectiveness in the ICU setting', which he undertook while working at Guyk Hospital in London. The paper discussed patients with multi-system organ failure who experienced acute renal failure. Dr Bihari told us that patients with multi-system organ failure form only a small minority of ICU admissions but consume a disproportionate share of available resources. The 1993 study looked at 1106 patients admitted to the general ICU at Guy's Hospital in London. Of these, 92 (8.3 per cent) had multi-system organ failure and were treated with CVVHD. Daily organ failure scores were calculated for all patients, as were daily ICU costs. For patients who survived and left the hospital, quality of life was assessed at 6 months (Nottingham Health Profile, Sickness Impact Profile) so that patient outcomes could be related to the cost of intensive care. Dr Bihari stated that, while mortality rates are high, quality of life is well-preserved in the majority of surviving cases. Since, in the absence of intensive care, mortality is likely to be 95 per cent, the hospital survival rate of 30 per cent with an overall effective cost per hospital survivor of US$58, 072 probably reflects 'value for money'. Dr Bihari believes C W H D forms part of the intensive care of this group of patients and that it should not be considered in isolation. Finally, session 4, titled 'Future applications with CRRT', included presentations ranging from 'Prophylactic use of CRRT in patients with normal renal function' to 'Future technology for CRRT'. This last paper was presented by Dr Ronco, from Italy, who stated there was a need for newly-designed venous catheters to reduce the amount of recirculation, permit increased blood flow and reduce
infections caused by the access. He went on to discuss the future direction of haemofilters and how heparin-bound surfaces are still under evaluation. The process of evolution towards a reduction in thickness and an optimisation of pore size and distribution, hydrophilic structure and biocompatibility of haemofilters is ongoing. Unfortunately, there were very few nursing speakers, despite the conference taking a multidisciplinary approach to CRRT. I believe I was the only nurse to present a research paper in the free communication sessions and that Ian Baldwin was one of two nurses to be involved in the workshops. Both Ian and I had papers in the poster presentations, as did a few nurses from the United States. The remaining oral and poster papers were presented by doctors, pharmacists or nutritionists. Overall, the conference was very informative and it was great to meet so many people from Australia, the United States and Europe. It is reassuring, too, to know that in Australia we are not at all behind in CRRT. In fact, we are moving ahead in leaps and bounds, particularly when it comes to undertaking research projects and understanding CRRT. This is reflected at our annual National Scientific Meeting on Intensive Care. I would like to thank the Confederation of Australian Critical Care Nurses Inc. (CACCN) for awarding me a travel grant to assist my trip to the United States. The opportunity to present two nursing research papers at an international conference was a milestone in my career. I urge all nurse researchers out there to present their papers at local, national or international meetings. I have presented on all three levels and it is an amazing feeling.
e Critical Care Nurses Inc.
terencefsemmar) rants Iegrees in Critical Care (Masters/Doctorate)
September 6,199t
$1000
Tf.u ~ o vgrants e are currently available to any member of the Confederation of Australian Critical Cur=Nurses Znc. Nominations are called for from members
I
" " ' "
A minimum of 12 months m e late p, ite bran - $ I endorsement by ( of develop&ent in critical care nursing. The reason for applying being the Asement to prqvide a formal report to & dian tical h~ fi in- being nominated cmpletion date of the rosearch. - "he- ducatian pan& are offerw' lo CACCh memo - wnr-, ~usrramnave wen accepren rar p m r a n o n latianal Scientific Meetine. -
@
-
i - e ~ u s l rev'c. i a ucmueu a y y u u a u u k t L u L u t State branch endorsement involves confinnationof membership and a summary of your activities and contributions towards critical care nursing and your state branch. This information may take up to 1 month to process, so please apply earl2 to ensure you don't miss out!
-
For further information and application forms, please write to or telephone:
I
The Trust Manager PO Box 605, Hornsby, NSW 2077 Tel: (02)482 7712. VOLUME 9 NUMBER l
MARCH 1996
I I I