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Welcome

Welcome. Hematocrit Monitoring Product Training. May 2009. Rx only. L5124 Rev. D4 12/08. Agenda. Hematocrit Monitoring Overview. Proven technology and results Used for years in extracorporeal therapies, such as: hemodialysis, apheresis, and cardiopulmonary bypass

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Welcome

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  1. Welcome Hematocrit Monitoring Product Training May 2009 Rx only. L5124 Rev. D4 12/08

  2. Agenda Hematocrit Monitoring Overview • Proven technology and results • Used for years in extracorporeal therapies, such as: • hemodialysis, apheresis, and cardiopulmonary bypass • “Base technology” – used in over 200,000 treatments/year • Simplified and integrated into the next generation of the Aquapheresis console

  3. Hematocrit Monitoring (Hct) AUTOMATICALLY limits the fluid removal rate to help prevent volume depletion due to high ultrafiltration rates and extended treatment times. • “Never too fast, never too much” • Analogy: Thermostat in your Home

  4. Understanding Hct • Hematocrit (Hct) is the % of blood that is red blood cells • the “thickness” of blood • normal value = 45% • fluid overloaded < 40% • By monitoring Hct during Aquapheresis, • changes in blood volume can be estimated • volume depletion can be detected earlier • drops in blood pressure or creatinine rises can be prevented Hct Monitoring is an adjunct to patient care, not a replacement for standard medical care for assessing patient response to fluid removal (e.g. signs/symptoms of hypovolemia/hypotension)

  5. Understanding Hct • Blood passes through a small blood chamber on the Hct Blood Circuit Set (PN: A2000) and is analyzed • Changes are determined by comparing the baseline Hct at the start of treatment (first 5-10 minutes of RUN) to Hct measurements during therapy

  6. Questions/Comments • What clinical literature supports Hct Monitoring? • Data supporting the use of inline, continuous hematocrit monitoring is extensive. A brief sampling follows: • Dasselaar JJ, Huisman RM, DE Jong PE, Franssen CF. Relative blood volume measurements during hemodialysis: Comparisons between three noninvasive devices. Hemodial Int. 2007;11(4):448-455. • De Vries JPPM, Kouw PM, van der Meer NJM, Olthof CG, Oe LP, Donker AJM, de Vries PMJM. Non-invasive monitoring of blood volume during hemodialysis: Its relation with postdialytic dry weight. 1993 Kidney Int 44:851-854. • De Vries JP, Donker AJ, De Vries PM. Prevention of hypovolemia-induced hypotension during hemodialysis by means of an optical reflection method. Int J Artif Organs. 1994 Apr;17(4):209-14. • Kim KE, Neff M, Cohen B, Somerstein M, Chinitz J, Onesti G, Swartz C: Blood volume changes and hypotension during hemodialysis. Trans Amer Soc Artif Int Organs 197016:508-514. • Lopot F. Clinical use of continuous blood volume monitoring. EDTNA ERCA J. 1996;22(4):7-11. • Marenzi G, Lauri G, Grazi M, Assanelli E, Campodonico J, Agostoni P: Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol. 2001 Oct;38(4):963-8. • Prakash S, Reddan D, Heidenheim AP, Kianfar C, Lindsay RM. Central, peripheral, and other blood volume changes during hemodialysis. ASAIO J. 2002;48(4):379-82. • Ronco C, Bellomo R, Ricci Z. Hemodynamic Response to Fluid Withdrawal in Overhydrated Patients Treated with Intermittent Ultrafiltration and Slow Continuous Ultrafiltration: Role of Blood Volume Monitoring. Cardiology 2001;96:196–201 • Schroeder KL, Sallustio JE, Ross EA. Continuous haematocrit monitoring during intradialytic hypotension: Precipitous decline in plasma refill rates. Nephrol Dial Transplant. 2004;19(3):652-656. • Shulman T, Heidenheim AP, Kianfar C, Shulman SM, Lindsay RM. Preserving central blood volume: changes in body fluid compartments during hemodialysis. ASAIO J. 2001 Nov-Dec;47(6):615-8. • Steuer RR, Harris DH, Conis JM. A new optical technique for monitoring hematocrit and circulating blood volume: Its application in renal dialysis. Dialysis Transplant. 1993;22(5):260-264. • Steuer RR, Bell DA, Barrett LL. Optical measurement of hematocrit and other biological constituents in renal therapy. Adv Ren Replace Ther. 1999;6(3):217-224. • Steuer RR, Leypoldt JK, Cheung AK, et al. Hematocrit as an indicator of blood volume and a predictor of intradialytic morbid events. ASAIO J. 1994;40(3):M691-M695. • Steuer RR, Leypoldt JK, Cheung AK, et al. Reducing symptoms during hemodialysis by continuously monitoring the hematocrit. Am J Kidney Dis. 1996;17(4):525-532. • Yashiro M, Hamada Y, Matsushima H, Muso E. Estimation of Filtration Coefficients and Circulating Plasma Volume by Continuously Monitoring Hematocrit during Hemodialysis. ASAIO J. 2002 Jul-Aug;48(4):379-82.

  7. Questions/Comments What is the best value for the Hct Limit? 0-4% variation from baseline is common due to postural/position shifts “Nominal” value set @ 5% (specificity + sensitivity) . If too sensitive (eg UF keeps stopping but patient still not at weight) then adjust setting up eg 6%, etc. If not sensitive enough (UF does not stop & patient is becoming symptomatic) then adjust setting down eg 4%, etc. Values of 8-10% common in hemodialysis literature, but with different patient population / disease states values of 4-8% are expected. Marenzi G et al JACC 2001 Oct;38(4):963-8. Ronco C et al. Cardiology 2001;96:196–201. Ookawara S et. al. Nephron 2001;87:27-34. Hct Monitoring is an adjunct to patient care, not a replacement for standard medical care for assessing patient response to fluid removal (e.g. signs/symptoms of hypovolemia/hypotension)

  8. Questions/Comments How and when is Hct an indicator of volume depletion? Currently with standard diuretic care, symptoms such as a rise in serum creatinine or a drop in blood pressure are used to titrate therapy. Many consider these methods as late indications of volume depletion. Renal malperfusion and other detrimental effects have already occurred by then. Hct Monitoring has been shown in multiple studies to provide an earlier indication of volume depletion and allow a proactive method to avoid the detrimental renal impact. “Blood volume measurement is a useful tool to prevent major complications during extracorporeal ultrafiltration… a reduction in the circulating blood volume may further decrease cardiac output, leading to a further impairment of organ perfusion. This can be avoided if the circulating volume is maintained and the ultrafiltration rate is driven by the refilling capacity of the cardiovascular system of the patient.” Ronco C et al Cardiology 2001;96:196–201.

  9. Agenda • Hematocrit Monitoring Details • Terms • Enabling/Disabling • Baselining • Setting Hct Limit • Hct Limit Messages • Status Display • Graphing

  10. Hct Sensor Clip Blood chamber Hct Dock Hematocrit Monitoring (Hct) The following is used to describe the Hematocrit Monitoring Option: Hct Sensor Clip: Describes the sensor clip attached to the blood chamber on the blood circuit that measures the value of the patient’s hematocrit. Dock: Describes the docking station at the rear of the console which the Hct sensor clip should be attached to when not connected to the blood chamber. This disables Hct Control. Reattaching will re-enable. Blood Chamber: This describes the cuvette on the withdrawal line of the blood circuit the Hct sensor clip attaches to measure the Hct.

  11. Correct Incorrect Enabling/Disabling Hct • Enabled = If clip on blood chamber • Clip needs to be oriented correctly and “clicked” in • perpendicular to blood chamber • Disabled = If clip on dock. • User will be asked to press ACCEPT Clip Blood chamber Dock

  12. Baselining Hct • Baselining • Patient in same body position for ~30 mins prior • Beginning of 1st time in RUN • Done ONCE • 200 ml saline/blood through chamber • Air bubbles / saline may cause underestimation of Hct • 5 to 10 minutes depending upon blood flow • “Baselining” appears in Hct window • Total Fluid removed now displayed at the base of the screen.

  13. Setting Hct Limit • 2 Ways to Set the Limit: • Before baselining: • blood volume only, 0-10% range, 0.1 increments • Any time after baselining: • Hct, 20-50 range, 0.1 increments • Associated blood volume % shown onscreen • The Hct Limit will automatically be enabled if the limit is LESS THAN 5% blood volume depletion. • The user will be required to press ACCEPT if the limit is greater than a 5% blood volume depletion. • When alerted, press the ACCEPT key to accept the default Hct Limit or press the HCT key and set the Hct Limit using the UP and DOWN arrow keys (up to 10%)

  14. Hct Limit Messages

  15. Hct Limit Messages

  16. Hct Limit Messages

  17. Hct Limit Messages

  18. Hct Limit Messages

  19. Hct Limit Messages

  20. Hct Limit Messages

  21. Hct Limit Messages

  22. Status Display

  23. Graphing Hct

  24. Q&A • Setup / Priming • Enabling / Disabling • Setting / Adjusting • Messages • Graphing

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