Understanding Continuous Renal Replacement Therapy

Alright you guys welcome back to another video lesson from ICU Advantage. If this is your first time here to the channel welcome, if not welcome back. And for those of you who don't know me my name is Eddie Watson. Now my goal in creating this channel ICU Advantage was to really try and create some of the the best online critical care educational content out there and to make it free and freely available for you guys. If you'd be interested in getting more of this critical care educational content and you haven't already, make sure and subscribe to the channel down below. When you do though, make sure you hit that bell icon and select all notifications. That way you'll never miss out when I release a new lesson. All right, so in this lesson, we're going to be discussing the basic principles that apply to CRRT. These principles are going to help us to better understand how it is that we're able to filter the blood and essentially mimic the job of the nephron. Understanding these principles is fundamental to understanding how CRT does its job, as well as the various impacts of the different solutions that we use for this machine. Now, these principles will also help you understand the different types of therapy that we can offer, which I am going to talk about in the next lesson. Now, if you remember from the first lesson, which I'm going to link to up above here if you haven't watched that one, The main job of the kidney and the nephron is to maintain fluid, electrolyte, waste, and acid-base balance. And we can mimic these functions through four primary methods, which I'm going to talk about here. And they are diffusion, ultrafiltration, convection, and adsorption. And so first, let's start talking about diffusion. All right, so this is the movement of particles, something we also call solutes, from an area of higher concentration to an area of lower concentration. across a semi-permeable membrane. And so this is an example of a semi-permeable membrane that we're dealing with when we have CRT. So over here on the left side, this is where we have our patient's blood. And if you remember from the last lesson where we talked about the basic setup of the CRT circuit, that the blood is going to flow through the filter from bottom to top. And on the right side, this is where we're going to have our dialysate. And if you remember, we have this flowing top to bottom. Now remember that the blood is flowing in those hollow fiber semi-permeable membrane tubes, but essentially the material that makes up that tube is actually a semi-permeable membrane, which is what we have here. And it's this semi-permeable membrane that's going to allow for selective diffusion. And then really it's the concentration of solutes that are in the dialysate that is what drives the concentration gradient. So as you can see from the picture here, we have less solute in the dialysate and more in the patient's blood. So because of that change, that difference in the concentration gradient, those solutes are going to diffuse across that semi-permeable membrane to reach a state of equilibrium. Now as I just mentioned, we have the blood and the dialysate flowing in countercurrent directions. So the reason that we have this is that by having these flows going countercurrent, is it's actually going to promote the continual clearance, and it does this by ensuring an adequate diffusion gradient is maintained the whole way through. So I know that sounds a little complicated, so let me kind of illustrate that to help make the point. So let's say here we have a semi-permeable membrane, and we've got again our blood on the left side and the dialysate on the right side. And we know that starting out that the blood is going to have higher concentrations of solute compared to the dialysate. So now if we had both of these flows going in the same direction, as that diffusion is taking place, we'd see the concentration of solutes in the dialysate increasing, and then the blood, which is moving along in the same direction... as it works its way towards the end, because of the high concentration of solutes in the dialysate, we're going to have less of a concentration gradient going on. And therefore, we're going to see less clearance out of the blood towards the end of the filter. And so as we go along, those concentrations are decreasing in the blood, but they're also increasing in the dialysate. And this is going to make it harder to get that last little bit of diffusion to take place. Whereas if we have the dialysate flowing in the opposite direction of the blood, When that blood reaches the end of the filter and it has a lower amount of solute concentration, instead of having a diolisate with a high concentration of solutes that we see in the example here, instead we're going to have it interacting with diolisate with a very low concentration, still giving us that concentration gradient, and as it continues to move down, we still remain with a lower concentration than what's in the blood. And so thus, by having this countercurrent flow, we can get the maximum amount of solute clearance through diffusion. So hopefully that makes sense for you guys. So as you can see from the drawing here in the blood, we have things like blood cells and large molecules such as proteins that are going to be too big to cross the membrane. Therefore, only the desired solutes are going to be able to cross. So diffusion is going to be effective at clearing small molecules, but not large ones. And really the size and type of membrane is going to impact this clearance. Essentially, the filter's permeability is going to be affected by things like our filter pore size, the number of pores that we find in that membrane, as well as just the general membrane thickness. And this all does vary based on the type of filter that you're using. Now like I said, the concentration of solutes in the dialysate is what's going to drive that concentration gradient. And for our dialysate solution, this is typically going to contain concentrations of sodium, chloride, and magnesium that are going to be in amounts equal to that of normal serum levels. And so we're only going to see these solutes diffuse in cases where the patient either has high or low concentrations in the blood. Now the next solute that's probably one of the most important ones that we have in here is actually going to be our potassium. And oftentimes when we're starting patients on CRT, we're going to see very high levels of potassium. And so what we might actually do is start the patient on a therapy delivering a very low level of potassium in our dialysate. An example of this would be one of our 2K baths. But since the potassium is going to clear pretty quickly, we need to make sure that we're closely monitoring and make that transition to a more normal level, such as one of our 4k baths, as our patients begin to normalize their potassium level. Now serum bicarb levels are typically going to be low in patients with renal failure. So typically we use a dialysate solution that contains bicarb to aid in the diffusion into the blood. And then finally waste products such as our urea and our creatinine. they're not going to be present in our dialysate. Therefore, these are going to diffuse and be filtered out of the blood. Now, when we're talking about diffusion that's taking place from blood to dialysate in a filter, this is something that we actually refer to as hemodialysis. All right, so that's the principle of diffusion and hemodialysis. Hopefully that makes sense for you guys because let's go ahead and move on. And let's talk about the next principle, something that we call ultrafiltration. So one of the keys to this principle is knowing that fluid is able to cross a semipermeable membrane in response to a pressure gradient. And this pressure gradient can be the result of one of three things. It can be either osmotic pressure, oncotic pressure, or hydrostatic pressure. So now if you remember back to that first lesson when we were talking about the nephron and specifically the function of the glomerulus, we have those efferent arterioles, which is carrying that blood away from the glomerulus, that those were of a smaller size than the efferent arterioles bringing the blood in, as well as they were able to constrict and relax, working to regulate pressure, basically creating hydrostatic pressure in the glomerulus. And this is what would help force water out of the blood. Ultrafiltration is essentially that same process. We're going to be moving fluid through the semi-permeable membrane across a pressure gradient. Now when talking about our circuit, we can actually create this pressure gradient in a couple different ways. We can either create positive pressure on the blood side, pushing the blood through the filter, or we can create negative pressure via the effluent pump, but either way creating this pressure gradient from one side to the other. And we can adjust both of these pressures to impact the amount of the pressure gradient. And the difference in pressure across this membrane is something that we call our transmembrane pressure or our TMP. And it's ultimately this TMP that determines the ultrafiltrate production. By adjusting this pressure gradient, either increasing the positive pressure on one side or the negative pressure on the other side or a combination of the both, we can control the amount of fluid that's removed from the blood and ultimately from the patient. Now when we have this process of ultrafiltration again within our circuit and a filter, this is something that we call hemofiltration. So the big takeaway here with ultrafiltration and hemofiltration is that it's removing fluid from the blood and ultimately the patient. All right, so let's go ahead and move on. And now let's talk about the principle of convection. And convection is actually tied to hemofiltration, as it is a principle of such. So here with convection, we have a one-way movement of solutes through a semipermeable membrane with the flow of water. So again, as you can remember with ultrafiltration, we have our water that's moving across our semi-permeable membrane. But if we have enough flow of this water, we're also going to see some of these solutes that move across the membrane with it. And this is something that we refer to as solute drag, as the solutes are being dragged across the membrane. across that membrane with the flow of fluid. Now when we start talking convection here, this is actually going to be effective at clearing small, medium, and large size molecules that are able to fit through that semi-permeable membrane pore. Now the greater and faster the flow that we have, the more clearance that we can achieve. And ultimately, the molecule size as well as the membrane type are going to impact the flow of these solutes. Now because it often requires a large removal of fluid to achieve these flows, this means we're also going to be removing a large volume of fluid from the patient. So then we have to replace this volume back to the patient via the replacement solution. And typically the solution that we're going to use for this replacement solution is going to have the same level of electrolytes and bicarb that we normally find in normal physiology. And if you remember from the last lesson where we were talking about that circuit, We actually have two different spots that we can give this replacement solution to the patient. We can either give it before the filter or after the filter as the blood is returning to the patient. And interestingly, one of the things when I first started doing CRT that really kind of tripped me up was that how adding solution after the filter would have any kind of impact on our solute clearance as it was just basically going straight to the patient. And I'm going to explain that more here in just a minute, but eventually it was explained properly to me that by adding this fluid, it allowed us to pull more fluid via the hemofiltration, and this resulted in seeing additional convection and ultimately more solute clearance. But at first, it seemed quite backwards that by giving them this solution as it was going to the patient, how was this impacting any sort of clearance of solutes? Now, speaking of this replacement solution, we need to talk about something that we refer to as pre-dilution versus post-dilution. So like I said, we can return replacement fluids to the patient's blood. either before the filter or after the filter. Before the filter is what we call pre-dilution, and after the filter is what would be our post-dilution. And there are advantages and disadvantages to doing both. Now if we give this solution pre-dilution via our pre-blood pump or our PVP, that this is going to dilute the blood going into the filter and leads to less solute clearance. But by having dilute blood in the filter, that this is going to help reduce the clotting of the filter and really preserve the life of the circuit. Now on the flip side, if we give this replacement solution post-dilution via our post-filter replacement, then this is going to lead to more concentrated blood in the filter and ultimately it clotting sooner, but having more concentrated blood leads to better solute clearance. So typically when we're starting out, what we actually do is a mix of both. And oftentimes I find that we're going to run at least starting out equal amounts of... pre and post dilution. And ultimately, the belief tends to be that we actually want a little bit of both. We don't want to give all of the solution either pre or post because of some of those negative consequences. Now, one thing to remember, though, is we're giving the patients a lot of fluid into their blood via this replacement solution, but all of the volume that we give them is actually going to be pulled off via hemofiltration. So it doesn't have any impact on the patient's fluid volume balance. Our patient's fluid volume is only going to be adjusted by the balance of the overall fluid that we pull off, something that we refer to as the patient fluid removal rate, and this can lead to either positive, negative, or really an equal balance of fluids, although more than often we're running them either equal or negative. So essentially we're usually either keeping them balanced with their fluid state or we're slowly working to remove some fluid. Alright, so hopefully that made sense with convection, and you can see how it's actually tied to the other principle of ultrafiltration. And then finally, the last principle I want to talk about here is something that we call adsorption. Now, adsorption is one of the unique properties of CRT that we don't fully get with intermittent hemodialysis. Essentially what this is, is it's the adherence of solutes and other biological matter to the surface of the membrane. So you can imagine that... As time goes on, we begin to see things basically adhering or really sticking to our semi-permeable membrane here. And as time goes on, we see this begin to build up. And as we see higher and higher levels of this adsorption taking place, that this can actually lead to something that we call the filter is clogging. Basically, this means it becomes less effective. Now, the membrane type is going to affect these adsorptive properties. And really, the efficiency of a particular filter to... adsorb this material. One really good example of this is something like the cytosorb filter that's specifically designed to adsorb higher levels of cytokine to aid in patients with cytokine storm. So essentially some filters are going to have more adsorptive properties than other filters. And this adsorption may have a small effect on the clearance of some solutes from the patient's blood. All right, so those are the four principles of CRT. It's these four foundational principles that really guide the different modes of therapy that we run for our patients and really help to mimic the functioning of the nephron and the kidney to ultimately work to filter waste from our patients, control the fluid volume balance, the electrolyte and acid-base imbalance in our patients. Now there are some things that we do in addition to just these principles that kind of work to ensure that we're achieving the proper levels of electrolytes and acid-base balance, but the core of what CRT is doing is based on these four principles here. In the next lesson, I'm going to be talking about the different modes and therapies that we can offer for CRT, and you have to have an understanding of these principles to understand how these modes are different from one another. So with that said, that's going to end this lesson here today. I really hope that you guys enjoyed this lesson. If you did, please leave the video a like. It really goes a long way to help support this channel. As well as go down in the comments, let me know what you thought of the video. I love reading you guys'comments and I try to respond to every single one that you guys leave for me. If you haven't already, make sure and subscribe to the channel down below. As well as a special shout out to our awesome YouTube members and Patreon members out there. The support that you guys provide really goes a long way in helping to support this channel and what I do here with it. And so for that, I'm so appreciative. thank you guys so much. If you'd be interested in showing additional support for this channel, you can either join the YouTube membership down below or head on over to the Patreon page and check out some of the additional perks that you get in doing so. Make sure you guys stay tuned for the next lesson. Otherwise, in the meantime, check out a couple awesome videos I'm going to link to right here for you guys. As always, thank you guys so much for watching and you have a great day.

Now my goal in creating this channel ICU Advantage was to really try and create some of the the best online critical care educational content out there and to make it free and freely available for you guys. If you'd be interested in getting more of this critical care educational content and you haven't already, make sure and subscribe to the channel down below. When you do though, make sure you hit that bell icon and select all notifications.

That way you'll never miss out when I release a new lesson. All right, so in this lesson, we're going to be discussing the basic principles that apply to CRRT. These principles are going to help us to better understand how it is that we're able to filter the blood and essentially mimic the job of the nephron. Understanding these principles is fundamental to understanding how CRT does its job, as well as the various impacts of the different solutions that we use for this machine.

Now, these principles will also help you understand the different types of therapy that we can offer, which I am going to talk about in the next lesson. Now, if you remember from the first lesson, which I'm going to link to up above here if you haven't watched that one, The main job of the kidney and the nephron is to maintain fluid, electrolyte, waste, and acid-base balance. And we can mimic these functions through four primary methods, which I'm going to talk about here. And they are diffusion, ultrafiltration, convection, and adsorption.

And so first, let's start talking about diffusion. All right, so this is the movement of particles, something we also call solutes, from an area of higher concentration to an area of lower concentration. across a semi-permeable membrane.

And so this is an example of a semi-permeable membrane that we're dealing with when we have CRT. So over here on the left side, this is where we have our patient's blood. And if you remember from the last lesson where we talked about the basic setup of the CRT circuit, that the blood is going to flow through the filter from bottom to top. And on the right side, this is where we're going to have our dialysate. And if you remember, we have this flowing top to bottom.

Now remember that the blood is flowing in those hollow fiber semi-permeable membrane tubes, but essentially the material that makes up that tube is actually a semi-permeable membrane, which is what we have here. And it's this semi-permeable membrane that's going to allow for selective diffusion. And then really it's the concentration of solutes that are in the dialysate that is what drives the concentration gradient.

So as you can see from the picture here, we have less solute in the dialysate and more in the patient's blood. So because of that change, that difference in the concentration gradient, those solutes are going to diffuse across that semi-permeable membrane to reach a state of equilibrium. Now as I just mentioned, we have the blood and the dialysate flowing in countercurrent directions. So the reason that we have this is that by having these flows going countercurrent, is it's actually going to promote the continual clearance, and it does this by ensuring an adequate diffusion gradient is maintained the whole way through.

So I know that sounds a little complicated, so let me kind of illustrate that to help make the point. So let's say here we have a semi-permeable membrane, and we've got again our blood on the left side and the dialysate on the right side. And we know that starting out that the blood is going to have higher concentrations of solute compared to the dialysate. So now if we had both of these flows going in the same direction, as that diffusion is taking place, we'd see the concentration of solutes in the dialysate increasing, and then the blood, which is moving along in the same direction... as it works its way towards the end, because of the high concentration of solutes in the dialysate, we're going to have less of a concentration gradient going on.

And therefore, we're going to see less clearance out of the blood towards the end of the filter. And so as we go along, those concentrations are decreasing in the blood, but they're also increasing in the dialysate. And this is going to make it harder to get that last little bit of diffusion to take place. Whereas if we have the dialysate flowing in the opposite direction of the blood, When that blood reaches the end of the filter and it has a lower amount of solute concentration, instead of having a diolisate with a high concentration of solutes that we see in the example here, instead we're going to have it interacting with diolisate with a very low concentration, still giving us that concentration gradient, and as it continues to move down, we still remain with a lower concentration than what's in the blood. And so thus, by having this countercurrent flow, we can get the maximum amount of solute clearance through diffusion.

So hopefully that makes sense for you guys. So as you can see from the drawing here in the blood, we have things like blood cells and large molecules such as proteins that are going to be too big to cross the membrane. Therefore, only the desired solutes are going to be able to cross.

So diffusion is going to be effective at clearing small molecules, but not large ones. And really the size and type of membrane is going to impact this clearance. Essentially, the filter's permeability is going to be affected by things like our filter pore size, the number of pores that we find in that membrane, as well as just the general membrane thickness. And this all does vary based on the type of filter that you're using.

Now like I said, the concentration of solutes in the dialysate is what's going to drive that concentration gradient. And for our dialysate solution, this is typically going to contain concentrations of sodium, chloride, and magnesium that are going to be in amounts equal to that of normal serum levels. And so we're only going to see these solutes diffuse in cases where the patient either has high or low concentrations in the blood. Now the next solute that's probably one of the most important ones that we have in here is actually going to be our potassium.

And oftentimes when we're starting patients on CRT, we're going to see very high levels of potassium. And so what we might actually do is start the patient on a therapy delivering a very low level of potassium in our dialysate. An example of this would be one of our 2K baths. But since the potassium is going to clear pretty quickly, we need to make sure that we're closely monitoring and make that transition to a more normal level, such as one of our 4k baths, as our patients begin to normalize their potassium level.

Now serum bicarb levels are typically going to be low in patients with renal failure. So typically we use a dialysate solution that contains bicarb to aid in the diffusion into the blood. And then finally waste products such as our urea and our creatinine.

they're not going to be present in our dialysate. Therefore, these are going to diffuse and be filtered out of the blood. Now, when we're talking about diffusion that's taking place from blood to dialysate in a filter, this is something that we actually refer to as hemodialysis.

All right, so that's the principle of diffusion and hemodialysis. Hopefully that makes sense for you guys because let's go ahead and move on. And let's talk about the next principle, something that we call ultrafiltration. So one of the keys to this principle is knowing that fluid is able to cross a semipermeable membrane in response to a pressure gradient. And this pressure gradient can be the result of one of three things.

It can be either osmotic pressure, oncotic pressure, or hydrostatic pressure. So now if you remember back to that first lesson when we were talking about the nephron and specifically the function of the glomerulus, we have those efferent arterioles, which is carrying that blood away from the glomerulus, that those were of a smaller size than the efferent arterioles bringing the blood in, as well as they were able to constrict and relax, working to regulate pressure, basically creating hydrostatic pressure in the glomerulus. And this is what would help force water out of the blood. Ultrafiltration is essentially that same process.

We're going to be moving fluid through the semi-permeable membrane across a pressure gradient. Now when talking about our circuit, we can actually create this pressure gradient in a couple different ways. We can either create positive pressure on the blood side, pushing the blood through the filter, or we can create negative pressure via the effluent pump, but either way creating this pressure gradient from one side to the other. And we can adjust both of these pressures to impact the amount of the pressure gradient. And the difference in pressure across this membrane is something that we call our transmembrane pressure or our TMP.

And it's ultimately this TMP that determines the ultrafiltrate production. By adjusting this pressure gradient, either increasing the positive pressure on one side or the negative pressure on the other side or a combination of the both, we can control the amount of fluid that's removed from the blood and ultimately from the patient. Now when we have this process of ultrafiltration again within our circuit and a filter, this is something that we call hemofiltration.

So the big takeaway here with ultrafiltration and hemofiltration is that it's removing fluid from the blood and ultimately the patient. All right, so let's go ahead and move on. And now let's talk about the principle of convection.

And convection is actually tied to hemofiltration, as it is a principle of such. So here with convection, we have a one-way movement of solutes through a semipermeable membrane with the flow of water. So again, as you can remember with ultrafiltration, we have our water that's moving across our semi-permeable membrane. But if we have enough flow of this water, we're also going to see some of these solutes that move across the membrane with it.

And this is something that we refer to as solute drag, as the solutes are being dragged across the membrane. across that membrane with the flow of fluid. Now when we start talking convection here, this is actually going to be effective at clearing small, medium, and large size molecules that are able to fit through that semi-permeable membrane pore.

Now the greater and faster the flow that we have, the more clearance that we can achieve. And ultimately, the molecule size as well as the membrane type are going to impact the flow of these solutes. Now because it often requires a large removal of fluid to achieve these flows, this means we're also going to be removing a large volume of fluid from the patient. So then we have to replace this volume back to the patient via the replacement solution. And typically the solution that we're going to use for this replacement solution is going to have the same level of electrolytes and bicarb that we normally find in normal physiology.

And if you remember from the last lesson where we were talking about that circuit, We actually have two different spots that we can give this replacement solution to the patient. We can either give it before the filter or after the filter as the blood is returning to the patient. And interestingly, one of the things when I first started doing CRT that really kind of tripped me up was that how adding solution after the filter would have any kind of impact on our solute clearance as it was just basically going straight to the patient. And I'm going to explain that more here in just a minute, but eventually it was explained properly to me that by adding this fluid, it allowed us to pull more fluid via the hemofiltration, and this resulted in seeing additional convection and ultimately more solute clearance. But at first, it seemed quite backwards that by giving them this solution as it was going to the patient, how was this impacting any sort of clearance of solutes?

Now, speaking of this replacement solution, we need to talk about something that we refer to as pre-dilution versus post-dilution. So like I said, we can return replacement fluids to the patient's blood. either before the filter or after the filter. Before the filter is what we call pre-dilution, and after the filter is what would be our post-dilution.

And there are advantages and disadvantages to doing both. Now if we give this solution pre-dilution via our pre-blood pump or our PVP, that this is going to dilute the blood going into the filter and leads to less solute clearance. But by having dilute blood in the filter, that this is going to help reduce the clotting of the filter and really preserve the life of the circuit. Now on the flip side, if we give this replacement solution post-dilution via our post-filter replacement, then this is going to lead to more concentrated blood in the filter and ultimately it clotting sooner, but having more concentrated blood leads to better solute clearance. So typically when we're starting out, what we actually do is a mix of both.

And oftentimes I find that we're going to run at least starting out equal amounts of... pre and post dilution. And ultimately, the belief tends to be that we actually want a little bit of both. We don't want to give all of the solution either pre or post because of some of those negative consequences.

Now, one thing to remember, though, is we're giving the patients a lot of fluid into their blood via this replacement solution, but all of the volume that we give them is actually going to be pulled off via hemofiltration. So it doesn't have any impact on the patient's fluid volume balance. Our patient's fluid volume is only going to be adjusted by the balance of the overall fluid that we pull off, something that we refer to as the patient fluid removal rate, and this can lead to either positive, negative, or really an equal balance of fluids, although more than often we're running them either equal or negative.

So essentially we're usually either keeping them balanced with their fluid state or we're slowly working to remove some fluid. Alright, so hopefully that made sense with convection, and you can see how it's actually tied to the other principle of ultrafiltration. And then finally, the last principle I want to talk about here is something that we call adsorption. Now, adsorption is one of the unique properties of CRT that we don't fully get with intermittent hemodialysis. Essentially what this is, is it's the adherence of solutes and other biological matter to the surface of the membrane.

So you can imagine that... As time goes on, we begin to see things basically adhering or really sticking to our semi-permeable membrane here. And as time goes on, we see this begin to build up. And as we see higher and higher levels of this adsorption taking place, that this can actually lead to something that we call the filter is clogging.

Basically, this means it becomes less effective. Now, the membrane type is going to affect these adsorptive properties. And really, the efficiency of a particular filter to...

adsorb this material. One really good example of this is something like the cytosorb filter that's specifically designed to adsorb higher levels of cytokine to aid in patients with cytokine storm. So essentially some filters are going to have more adsorptive properties than other filters. And this adsorption may have a small effect on the clearance of some solutes from the patient's blood. All right, so those are the four principles of CRT.

It's these four foundational principles that really guide the different modes of therapy that we run for our patients and really help to mimic the functioning of the nephron and the kidney to ultimately work to filter waste from our patients, control the fluid volume balance, the electrolyte and acid-base imbalance in our patients. Now there are some things that we do in addition to just these principles that kind of work to ensure that we're achieving the proper levels of electrolytes and acid-base balance, but the core of what CRT is doing is based on these four principles here. In the next lesson, I'm going to be talking about the different modes and therapies that we can offer for CRT, and you have to have an understanding of these principles to understand how these modes are different from one another.

So with that said, that's going to end this lesson here today. I really hope that you guys enjoyed this lesson. If you did, please leave the video a like.

It really goes a long way to help support this channel. As well as go down in the comments, let me know what you thought of the video. I love reading you guys'comments and I try to respond to every single one that you guys leave for me.

If you haven't already, make sure and subscribe to the channel down below. As well as a special shout out to our awesome YouTube members and Patreon members out there. The support that you guys provide really goes a long way in helping to support this channel and what I do here with it. And so for that, I'm so appreciative. thank you guys so much.

If you'd be interested in showing additional support for this channel, you can either join the YouTube membership down below or head on over to the Patreon page and check out some of the additional perks that you get in doing so. Make sure you guys stay tuned for the next lesson. Otherwise, in the meantime, check out a couple awesome videos I'm going to link to right here for you guys. As always, thank you guys so much for watching and you have a great day.

Transcript for:Understanding Continuous Renal Replacement Therapy

Transcript for:
Understanding Continuous Renal Replacement Therapy