Atlas of Hemofiltration

Abstract

Continuous renal replacement therapy (CRRT) has evolved over the years into a sophisticated therapy with many variations. Haemofiltration has become commonplace on the intensive care unit, and its management is now computerized. While many critical care texts contain chapters on the background and therapeutic place of CRRT, few give a really simple ‘how-to-do-it’ guide. The authors of this book provide just that. Their stated aim is to give their patients the best chance of surviving, and they feel that assisting others to create an effective CRRT programme will help achieve this. The notion of simplicity is lost in the first three chapters of the book. These give the background theory to CRRT which, although simple in concept, is difficult to describe simply. Even in these three chapters there is some overlap, with diffusion, convection and ultrafiltration being defined several times, the most straightforward description being in chapter 3. Chapters 4–12 regain the simple approach and describe the machines available for CRRT in some detail. The Prisma machine is used on our unit so we are most qualified to comment on this chapter. Essentially, it is a very honest summary of the machine, particularly of its advantages and disadvantages; the Prisma is indeed user friendly, but at a price. The recently introduced plasmapheresis facility for the machine is not mentioned but is newly available. If the same level of insight applies to the chapters on other machines, they are certainly fair. The following chapters are a motley collection on different aspects of haemofiltration, such as paediatric renal replacement therapy and anticoagulation. The chapter on vascular access is towards the end of the book, a decision that seems rather strange since, before renal replacement therapy can be initiated, venous access must be established. The troubleshooting chapter is particularly useful. In it, common problems are described using case histories. The authors then discuss the problems, offering explanations and solutions. The problems highlighted are practical and common, and the solutions given based on experience and common sense. The chapter on nursing management is full of practical hints and addresses some important problems, such as heat loss, that are not covered elsewhere. This chapter also contains a description of how the authors teach others the techniques of CRRT. They use a resuscitation mannequin as a simple simulator for setting up haemofiltration circuits. This adds reality to the teaching and is a useful tip. The principles behind changes in drug dosing with renal failure and CRRT are complex, but, nevertheless, their application is often relatively simple and easy to summarize. Because of this, the chapter on how to adjust drug dosage during CRRT was disappointing. One complex example is a table of drug sieving coefficients: finding out how to use this table by reading the text is complicated. A summary table of increased or decreased doses would have been simpler and easier to interpret. There are also good reviews of this subject that are not even referenced. In fact, although there is much written on haemofiltration, only a few of the chapters in this book quote references. More suggestions for follow up reading would have been useful. Our main disappointment with this book is its lack of visual impact. It is in black and white, which makes the sophisticated CRRT machines look like museum pieces. The cover is attractively colourful and atlases are usually in colour, which helps to provide detail and outline boundaries, but these details are missing from this atlas. Nevertheless, this is a useful book both as a teaching reference and as a first-line troubleshooting guide. It is a users’ guide to haemofiltration that will probably find a place in every intensive care unit.