Session Number 122 CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT): IT CAN BE AS EASY AS ABC AND 123 Stephanie R. Maillie, MSN, RN, PCCN, CCRN, CCNS Critical Care Clinical Nurse Specialist – MICU & MPCU Albert Einstein Medical Center, Albert Einstein HealthCare Network Philadelphia, PA Content Description Evidence is starting to strongly support the utilization of CRRT in many types of ICU patients. However, the initiation, implementation and maintenance of CRRT can be overwhelming for the ICU nurse. This presentation will describe the concept of CRRT and how it can benefit certain ICU patients. Discussion of the essential need for collaboration between the ICU and Dialysis nurses will be emphasized and successful implementation of an educational and competency program will be highlighted. Learning Objectives At the end of this session, the participant will be able to: 1. 2. 3. 4. 5. Understand the process of Acute Renal Failure. Understand the principles of CRRT. Identify the types and management of CRRT. Identify the complications of CRRT. Manage and troubleshoot a Fresenius CRRT machine. Summary of Key Points/Outline I. Basic Anatomy and Physiology of the Kidney and Acute Renal Failure II. Traditional Interventions and Treatments for ARF III. Principles of Dialysis Diffusion Osmosis – Reverse Osmosis Adsorption Convection Ultrafiltration IV. CRRT Historical Perspective – RRT, CAVH versus CVVH Types – SLED/SHIFT/SCUF/CVVH/CVVHD/CVVDF Solute vs. Fluid Management Patient Selection – why, the benefits – EBP, SCCM guidelines Anticoagulation Complications Best Vascular Access Different Machines – Fresinius, Nx Stage, Prismo V. Collaborative Practice with CRRT – knowing each other’s responsibilities ICU versus Nephrology ICU RN versus Dialysis RN responsibilities Management and Monitoring and Documentation Trouble shooting Alarms Flushing the System Returning blood back to the patient Taking the Patient off – ER versus Non-ER VI. Implementation of Education Quarterly Classes – Evidence supports Training Demonstration, Return Demonstration, Competency Qualitative feedback Bibliography/Webliography Chrysochoou, G. et al, 2008. Renal replacement therapy in the critical care unit. Critical Care Nursing Quarterly, 31:4, 282-290. Dellinger, R.P. et al, 2008. Surviving sepsis campaign: international guidelines for the management of severe sepsis and septic shock. SCCM/Critical Care Medicine, 36:1; 296-327. VA/NIH Acute Renal Failure Trial Network, 2008. Intensity of renal support in critically ill patients with acute kidney injury. NEJM; 359: 7-20. Speaker Contact Information [email protected] CRRT: Critical Care Collaboration with Dialysis Stephanie Maillie, MSN, CCRN, CCNS OBJECTIVES ● At the conclusion of this educational session, the learner will be able to: ● ● ● ● ● Understand the process of Acute Renal Failure. Understand the principles of CRRT. Identify the types and management of CRRT. Identify the complications of CRRT. Manage and troubleshoot a Fresenius CRRT machine. KIDNEY FUNCTIONS ● Urine formation ● Excretion of waste ● Fluid regulation ● Electrolyte regulation ● Blood pressure control ● Red Blood Cell synthesis and maturation ● Acid Base Balance Acute Renal Failure Approximately 5% of all hospitalized patients will develop ARF during hospital stay Approximately 23% - 50% ICU patients develop AKI/ARF with an overall survival of 30% Uncomplicated ARF mortality = 8% Complicated by organ failure = 60% - 80% Usually older, in MODS, bariatric, unstable HD ACUTE RENAL FAILURE ● Rapid loss of renal function ● Damage to kidneys ● Retention of urea and creatinine and waste products – uremic syndromes, altered nutrition status (wasting) ● Metabolic acidosis ● Hyperkalemia ● Disturbances of fluid balance – fluid overload, F/E imbalance ● Affects other organs – infection, resp, GI/liver Basic Principles of Dialysis “no matter what the mode is” Resemble/restore kidney function Fluid balance & regulation Water consumption and disposal = 3L/day normally Restoration of electrolyte balance Na+, K+, Cl-, Ca+, PO4, Mg, bicarb, H2O, glucose Removal of toxins & metabolic waste - urea Regulation of pH – hydrogen & bicarb ions Success = constant refilling of intravascular volume ARF INTERVENTIONS ● Intermittent Hemodialysis – Traditional before 1970s ● 2-6 hours every other day performed by a dialysis nurse at the bedside. Access placed at bedside. Relatively inexpensive, efficient. No resemblance to a normal kidney function. Can cause hemodynamic instability and hypotension. Repeated episodes of hypotension can lead to ischemia of the nephrons, arrhythmias, cerebral edema ● Wide fluctuation in volume ● Dialysis Disequilibrium Syndrome – urea cross blood/brain barrier – increase ICP ● Coagulopathies, infection, air embolism, inadequate nutrition ● ● ● ● ● Peritoneal Dialysis – Traditional ● Abdominal viscera as semi permeable membrane to remove toxins. ● Gentle and slow. ● Contraindicated in peritonitis, abdominal surgery, adhesions, pregnancy. ARF INTERVENTIONS ● Continuous Renal Replacement Therapy ● Extracorporeal blood purification therapy intended to ● ● ● ● ● ● substitute for impaired renal function over an extended period of time. An extracorporeal blood flow from access blood to return blood through a hemofilter producing ultrafiltrate (effluent). Machine provides the pump Applied for 24 hours day / 7 days week. Slow and continuous with urea Clearance > 60 ml/min Fluid Management. Assists to maintain homeostatic mechanisms and hemodynamic stability Mimics normal kidney functions. CRRT OBJECTIVES ● Promote hemodynamic stability – prevent recurrent hypotension or ATN/MODS which leads to intolerance of IHD ● Nutritional Support ● Acid Base Balance ● Promote healing and recovery ● Maintain fluid balance ● Prevent further renal damage ● Increase chance of renal recovery ● Decrease LOS CRRT Objectives Fluid Management Solute Management – electrolyte & waste removal Slow, Continuous 24/7 – hemodynamic stability Best treatment for patients in catabolic states ICU only, start early the right treatment IMPROVE HEMODYNAMICS, MAINTAIN PH & FLUID BALANCE, PREVENT FURTHER RENAL DAMAGE & INCREASE CHANCE OF RENAL RECOVERY Advantages CRRT CV stability – decrease incidence of hypotension Safe, flexible F/E management – “sliding scales” Creates space/route for nutrition administration and fluids Minimizes rapid ICP changes Continuous removal mimics kidney function more closely PATIENTS Patient Management Solute Management MODS/Sepsis Adsorption, removal of mediators & inflammatory cytokines Closer monitoring – SVO2 Restoring intravascular volume and perfusion ARF/ESRD Nutritional Support Trauma Fluid Management Unstable on IHD ARF/ESRD Organ Transplant Cardiac Surgery Diuretic Intolerance Burns Volume Overload CHF - SCUF Chemotherapy Why Use in Heart Failure? Decrease fluid overload Increase CI Decrease Vasculare Resistance Decrease Ascites/peripheral edema Normalize Filling Pressures Decrease Preload Bridge to Transplant Rids Myocardial Depressant Factor Why Use in Liver Failure? Reduce CNS Depression – dialysis to ammonia levels Improved Volume Management – with Ascites Improved Coagulation Profile Unlimited Nutrition Support Bridge to Transplant Rids Liver Failure Factor – middle molecule Why Use in Necrotizing Pancreatitis? Overwhelming inflammatory response that often leads to ARDS (pancreatic pleural effusions), MODS Rids mediators and cytokines Related encephalopathy can also be treated Why Use in Tumor Lysis Syndrome Promotes effective removal of serum uric acid Equilibrates K+, BUN, PO4 Very hyperkalemic & hypercalcemic – low K+ bath Promotes recovery from urate nephropathy Why Use in Burn Patients? 2% develop ARF Consistent fluid removal is adjunct to 1:1 replacement Better hemodynamic tolerance with BSA fluid loss Removal of inflammatory mediators Why Use in Sepsis/SIRS Patients? Modulates inflammatory mediators Fluid Balance (Euvolemia) Improves oxygenation Decreases fluid overload especially post aggressive FR Allows for nutrition Acid-Base Balance – early, corrects lactic acidosis Azotemia Control Rids Septic Mediators - cytokines, leukokines 2008 SCCM Guidelines on Sepsis & CRRT CRRT & IHD are equivalent in patients with severe sepsis and ARF – Grade 2B CRRT can be used to facilitate management of fluid balance in hemodynamically unstable septic patients – Grade 2D 2 meta-analyses report no difference in hospital mortality; to date 4 prospective, randomized trials found no significant difference in mortality No current evidence to support use of CRRT in Sepsis without ARF Only 2 prospective studies have reported better hemodynamic tolerance – no regional perfusion improvements or survival benefit 2 studies reported significant improvement with fluid management goals ATN Trial in US RENAL Trial in Australia and New Zealand TRANSPORT MECHANISMS ● Ultrafiltration ● Diffusion ● Osmosis ● Convection ● Adsorption ULTRAFILTRATION Movement of fluids through a membrane caused by a pressure gradient. Fluid Removal only from high to low pressure DIFFUSION Movement of solutes from an area of higher concentration to an area of lower concentration across a semipermeable membrane = the filter refers to small molecule movement Factors that affect diffusion: dialysate temp & flow rate, blood flow rate, solute size, concentration gradients, membrane permeability OSMOSIS Movement of water across a semi-permeable membrane. Like diffusion, osmosis is based on solute concentration. Reverse Osmosis with Fresinius CONVECTION The movement of solutes with a water flow – assists to get molecule across. The movement of membrane permeable solutes with ultrafiltrated water. “Solvent Drag” refers primarily to middle molecules FYI - Molecules Large, Middle Molecules Large = albumin Middle Liver failure factor Septic mediators Myocardial depressant factor Small Molecules Creatinine Phosphate Urea K+ PO4 Na+ Glucose, uric acid ADSORPTION Refers primarily to the middle molecules Substances adhere to the membraneas the blood moves through the membrane Certain membrane materials display adsorptions characteristics: Surface adsorption of solute onto the membrane Bulk adsorption within the membrane when the molecules can permeate it Components of the CRRT System Extracorpeal Lines Therapy Fluid – Dialysate Dialysate flow rate can be 3l/hr, depending on patient needs Saline Line Filter Dialysate and blood go in & out Outside filter fiber membrane = effluent Inside the filter fiber membrane = blood TYPES of CRRT ● Continuous Venovenous Hemofiltration (CVVH) ● Continuous Venovenous Hemodialysis (CVVHD) ● Continuous Venovenous Hemodiafiltration (CVVHDF) ● Slow Continuous Ultrafiltration (SCUF) ● Slow Low Effective/Efficient Daily Dialysis (SLEDD) CVVH ● Continuous Venovenous Hemofiltration (CVVH) ● Removal of large volumes of fluid by ultrafiltration and convection. Return = Venous ● Effluent includes patient volume removal and replacement solution. ● Moderate Solute clearance determined by rate. ● Adds replacement solution as convective fluid. ● Ultrafiltration & convection are primary mechanisms of removal CVVHD ● Continuous Venovenous Hemodialysis (CVVHD) ● Diffusion and ultrafiltration are used to remove waste products. ● Dialysate composition dramatically alters electrolytes exchange / transfer to effluent. ● Dialysate is altered to impact ● ● ● ● rate and amount of solute clearance for key electrolytes. Dialysate rate determines rate of clearance. Dialysate composition determines amount of clearance. Access – also venous via blood pump Return - venous CVVHDF ● Continuous Venovenous Hemodiafiltration (CVVHDF) ● All mechanisms in play (ultrafiltration, osmosis, diffusion, adsorption.) ● Effluent includes patient ● ● ● ● volume removal and all replacement solution and dialysate used. Used for convective (clearance of middle molecular weight) and diffusive (smaller molecules) therapy. Closest to conventional dialysis newer machines with high flow rates for blood /fluids may not have this mode Used to make up for slower rates of older CRRT machines SCUF ● Slow Continuous Ultrafiltration (SCUF) ● Effluent only, no dialysate or replacement fluids. Venous access and return ● Used for patients whom does not have a critical issue in wastes, electrolyte balance, and acid base balance. ● Uses ultrafiltration (pressure) for fluid removal. ● Convective loss. ● Used in fluid overload situation. ● Patients who are refractory to diuretics or need adjunctive fluid removal. ● Short term SLEDD/SHIFT SLEDD SHIFT Extended daily Hemodialysis or Hemofiltration ANTICOAGULATION ● Heparin – monitor PTT according to Renal/ICU MD ● ● ● ● ● Low risk for bleed – 45-80sec ● Higher risk for bleed – 45-60sec Argatroban – monitor PTT according to Pharmacy, ICU MD ● Low risk – 45-70 sec ● High risk-45-60 sec Lepirudin Citrate Sodium Chloride HEPARIN ● Least expensive and can be used systemically or regionally ● Short half life ● Requires frequent PTT monitor and adjustment dose ● Infused directly via syringe or an intravenous pump into the circuit blood prefilter or systemically via Alaris Pump ● Disadvantages: Increase bleeding risk. Thrombocytopenia ARGATROBAN ● Patients with HIT – usually hematology consult ● Direct Thrombin Inhibitors ● Eliminated by the liver ● Infused through intravenous pump into the arterial or access side of the CRRT system or systemic – Alaris pump periperally/centrally ● Determine low versus high risk for bleed LEPIRUDIN ● Patients with HIT ● Direct Thrombin Inhibitors ● Eliminated by the kidneys therefore do not use in ARF patients ● Infused through intravenous pump into the arterial or access side of the CRRT system CITRATE ● Prolong circuit life, good alternative for Heparin allergy ● Binds to calcium in patients blood within the CRRT system – regional anticoagulation ● Used in CVVH, CVVHD, CVVHDF, and SCUF. ● Can be used as replacement therapy ● Can be contraindicated in patients with hepatic failure or with lactic acidosis, although Univ.of Alabama has had success ● Monitor labs including ionized calcium and sodium and acid base status. ● Usually requires IV Calcium Gluconate administration won’t worsen metabolic acidosis ● Titrate IV citrate to system io Ca+ = 0.5 mmol ● Titrate IV calcium to patient io Ca= 1.11 – 1.31mmol/L SODIUM CHLORIDE ● Patients whom cannot have any anticoagulation ● Flushed at intervals with small boluses of sodium chloride to reduce stagnation of blood in the hemofilter ● Keep circuit free of clots ● Increase volume intake ● 100-200 ml every 30-60 minutes – remember I&Os ● NOTE: XIGRIS – no other anticoagulant should be used FLUID MANAGEMENT ● Patients are usually oliguric, anuric, and possibly overloaded. ● Hourly ultrafiltrate removed depends on hourly fluid balance calculation. ● Fluid balance system needs to be calculated hourly. ● Goal is to reduced fluid overload. ● Reduce intake to minimal volumes of fluids. ● Hourly calculation of patient’s non-CRRT intake ● Infusions, medications, feedings ● Plus fluid loss ordered by MD minus non-CRRT output ● Urine, drainage fluid, blood loss ● Excess fluid volume to be removed in a patient with fluid overload “net loss” and is ordered by MD. COMPLICATIONS ● ● ● ● ● ● ● ● ● ● Hypothermia Air Embolus Hypotension/Dehydration Electrolyte/Acid Base Imbalance Hyperglycemia Dialyzer Reaction Clotted Filters/Circuits Catheter Problems Blood Leaks Infections HYPOTHERMIA ● Adsorption of inflammatory (septic) mediators decrease the inflammatory response. ● Replacement fluid and dialysate are at room temperature. ● Cooling of the blood as it moves through the circuit. ● Extracorporeal circuit volume can quickly lower patient’s temperature if the fluids are are not warmed. ● Causes dysfunction of clotting factors and platelets, activating fibrinolysis and cardiac dysrhythmias. ● Monitor patient’s temperature and warmer temperature and also WBC - Temperature masked by cooling effects of circuit. ● Use blood warmers, warming blankets, tuck tubing under warming blanket AIR EMBOLUS ● Receives air in blood return. ● Alarm and air not properly removed from the blood circuit during priming or it port is loose or open. ● Bags run dry. ● Circuit should be checked to ensure all air has been removed. ● Verify arterial and venous access side of access tubing is securely connected. HYPOTENSION/DEHYDRATION ● ● ● ● ● Incorrect intake and output calculation Inadequate fluid replacement Fluid shifts Interstitial edema Excessive fluid removal - could be technical ● Volume Depletion Rule – Remember if you are replacing fluid, stop removing fluid ● Assess is it volume depletion or something else? ● Vasodilation from sepsis, anaphylaxis, neurogenic shock, anesthesia ● Contractility issues? Pump issues? ● Look to SVO2, CVP, PAs ELECTROLYTE/ACID BASE BALANCE ● Inadequate monitor of blood values – before; Q 8 hr ● Inadequate infusion of suitable replacement solution for volume ● Incorrect dialysate ● Lactate intolerance ● Citrate Shifts – Ca+, Na+, pH ● Usually requires changes to diasylate and or replacement fluids ● Remember true correction can take up to 24 hours ● Some nephrologists prefer to leave solutions alone and balance electrolytes with minibags/riders – sliding scales HYPERGLYCEMIA ● Stress response ● Molecule too large to filter ● Dialysate solutions DIALYZER REACTION ● Allergic ● Anaphylactic syndrome ● Type A ● Code, usually within 5 minutes of exposure to filter ● Type B ● Less severe ● ● ● ● Stop treatment Antihistamines Epinephrines Support blood pressure CLOTTED FILTERS/CIRCUITS ● Recirculation Problems is the leading cause of filter clots ● Low MAP (50s), hemodynamic instability, length of catheter, location of catheter tip ( reverse ports) ● ● ● ● ● Hypotensive episodes Kinked lines and blood stops Poor flow through catheter Concentration of blood Do not flush blood back into patient ● Clots can dislodge ● Visual clots in circuit ● Visual color changes ● Reprime and restart ● Be aware of high filter pressures ● TMP is indicative of pressure of blood as it passes through the filter CATHETER PROBLEMS ● Kinking and Clotting ● Access side – High negative pressure indicates its working hard to pull blood in order to maintain flow ● Return side – High positive pressure indicates its working hard to push blood back to patient ● Reposition patient ● Flip catheter ● Switch access and return to opposite ports of catheter. BLOOD LEAKS ● Blood Leak Detector – most alarms are false ● Check for microscopic blood in effluent ● Blood in effluent indicate microscopic tears of filter membranes ● Blood should not be present in effluent ● ● ● ● ● ● Myoglobin with trauma, burns rhabdo gives pink appearance ● Bilirubin noted with liver pt. – yellow/orange Defective membrane – improper handling Filter membrane leak Air in effluent line or UF at zero High pressure in the circuit Change the set INFECTIONS ● Dialysis Catheters ● Important that sterile technique be maintained ● Ports reserved for dialysis only ● Sampling in line via sample ports ● Fluids with dextrose – minimize if possible ● System integrity breached for bag change ● Break in skin integrity NURSING ASSESSMENT/MANAGEMENT ● ● ● ● ● ● ● ● ● ● ● ● ● Overall Assessment Cardiovascular Assessment Respiratory Assessment Gastrointestinal Assessment Renal/Fluid Volume Assessment Neurological Assessment CRRT Fluid Balance Calculation Ongoing Circuit Monitoring Body Temperature Dialysis Catheter Care and Patency Monitoring of Electrolyte Balance and Dialysis Solution CRRT Circuit Care and Management Alarms OVERALL ● ● ● ● ● ● PMH Current diagnosis Current therapies Medications Laboratory values Allergies ● Information obtained can provide information about the effects of therapy ● Knowledge of patient normal values help follow trends CARDIOVASCULAR ● BP, HR, Rhythm ● CVP, PAP, Stroke volume, CI/CO ● Peripheral pulses ● Cardiac status and pulmonary pressure indicate the effect of fluid removal and patient’s tolerance of the therapy. ● Too much fluid removed can decrease blood pressure RESPIRATORY ● ● ● ● ● ● Oxygen saturation Carbon dioxide levels Pao2 Vent settings RR and effort ABG ● Respiratory status can parameters can indicate positive effects of therapy ● Unwanted changed in ABG, ARDS, increase PAP indicate adverse effects of overhydration GASTROINTESTINAL ● GI function ● Nutritional status ● Adequate nutrition is important to promote wound healing and provide proper metabolic function RENAL/FLUID VOLUME ● ● ● ● ● Edema Body weight I&O Fluid losses Calculate CRRT fluid balance ● Determine the effect of the therapy and patient’s tolerance ● Fluid balance goal compare with achieved goals ● MD notified of cannot achieve fluid goal because of patient’s condition NEUROLOGICAL ● ● ● ● Mentation GCS Pain Medication effects ● Sedatives, Paralytics ● Patients can become confused during dialytic therapies ● Serum urea nitrogen level ● Osmolarity of cerebral spinal fluid decreases more slowly than osmolarity of blood CRRT FLUID BALANCE ● Calculate fluid balance once an hour ● Fluid gain indicated by ● ● ● ● increase in BP, PAWP, CVP, and decrease in arterial oxygen saturation Fluid loss may indicate decrease in BP, CVP, PAWP Weight increases as fluid is gain and edema occurs Fluid balance calculations are a potential source of error in CRRT Some do not tolerate prescribed fluid removal CIRCUIT MONITOR ● ● ● ● ● ● ● ● Blood flow rate Venous or return pressure Arterial or access pressures Filter pressures Balance pressures Effluent pressures Color of blood in the circuit Presence of air ● Documentation in CRRT ● Changes in pressure can indicate clotting ● Pressure can alert nurses of disconnection BODY TEMPERATURE ● Hypothermia and hyperthermia ● Use warmer for fluid or blood in indicated ● Patient’s blood is outside body in a circuit ● Hypothermia common complication of CRRT ● Maintain body temperature promote healing and help maintain normal coagulation and normal lab values ● Cold patients may experience cardiac arrthymias and use more energy in addition to increase CO DIALYSIS CATHETER ● Monitor catheter patency before and during CRRT and at disconnection of CRRT ● Monitor access pressure hourly to assess catheter flow and detect access problems ● Manage catheter dressing changes ● Patency of catheter can affect the effectiveness of CRRT ● Flush with NS to evaluate patency Best CRRT Catheter Choice Insertion Sites – Good Flow is Key = 300ml/min, Double Lumen: Femoral – 19 cm or longer Advantages – safest and easiest insertion, short-term Disadvantages – highest infection rates, recirculation issues Subclavian – 15 to 20 cm catheter length Advantages – decreased recirculation, stenosis, long term, easy to dress and keep clean Disadvantages – difficult insertion, risk of subclavian arterial stick, pneumothorax, subclavian stenosis Internal Jugular – 19cm on the right; 23 cm left (Gold Standard) Advantages – decreased recirculation, stenosis, long term Disadvantages – difficult insertion, risk of carotid arterial stick, proximity to mouth and trachea, difficult to bandage and dress(infection) ELECTROLYTE BALANCE ● Proper solution, dialysate, replacement fluid and proper infusion site. ● Type of CRRT solution have a significant effect on electrolytes levels ● Lab works per protocol ● Replace electrolytes per order CIRCUIT CARE ● Proper circuit care and interventions to prevent nosocomial infection ● Gloves, masks, aseptic or sterile techniques to protect patient ● CRRT patient higher risk of BSI than other patients Monitoring Checklist – “To Do List” Assess all Alarms & respond promptly Assess Lines Vital Signs, I&Os on CRRT flowsheet, labs, ptt Monitor and adjust flow rate as Rx for BP and Rx arterial and venous pressures Typical Pressures during treatment Saline is primed, double clamped – no infusion, no air Observe Blood Circuit for clotting Manual fluid bolus with arterial access (red) clamped ALARMS ● Respond Promptly to All Alarms ● Ensure patient lines are ● ● ● ● visible & securely attached to vascular access Determine all cause of alarms Be able to troubleshoot alarms Overriding alarms without investigation is a safety hazard Alarms should be distinct and loud from other alarms in the room Documentation CRRT Flow Sheet ● ● ● ● ● ● ● ● Vital signs and HD profile every hour Fill out flow sheet before RMVD is cleared every hour Date, time, blood pump speed as Rx = rate, Dialysate Flow rate, UF rate, TMP, venous pressure, RMVD, flush amount, cumulative balance, BP ?Clear all pumps and record volume on CRRT flow sheet hourly Calculate and record hourly intake and output Calculate and record cumulative intake and output Calculate and record ongoing balance POLICY ● Purpose: ● To establish a CRRT program in the critical care unit ● Definition: ● CRRT is the filtration of blood through a hollow fiber semipermeable membrane. It is slow continuous therapy which is managed by critical care and nephrology nurses in a critical care setting ● Goals: ● To provide CRRT for critically ill patients ● To delineate areas on hospital where CRRT will be performed ● To establish responsibility of setting up, initiating, maintaining, and monitoring of patients on CRRT. POLICY ● General Description and Scope of Process: ● The nephrology fellow and or the attending will evaluate and decide of a patient is a candidate for CRRT ● All patients requiring CRRT will be in ICU or CCU. ● Nephrology nurse will be responsible for setting up the machine and initiating CRRT. Once patient is connected and treatment is running stable, the nephrology nurse will transfer the monitoring of treatment to the critical care nurse. The nurse in the unit will be responsible to maintain and discontinue treatment of it becomes necessary. ● The critical care nurse will monitor the patient’s vital signs, I &O as well as CRRT machine. ● Any change in patient's hemodynamic status and if treatments discontinues will be reported to the fellow and or attending nephrologists by the critical care nurse. POLICY ● The nephrology nurses are available for problem solving. The nephrology nurse will return to the unit to check the ongoing treatment every 12 hours or when notified by critical care nurse if any problems in the procedure. ● The nephrology nurse will change the extracorporeal circuit as needed, minimal every 48 hours. ● Use of an AVF/graft should be used as a last resort and only when the dialysis RN is in the hospital. If CRRT is to occur overnight – then temporary catheter needs to be placed. ● The CRRT machine will be cleaned by the nephrology nurse or competent staff. So Who is Responsible for What? ICU MD Renal MD Obtain Renal Consult Write all CRRT orders Order, monitor, treat labs Consent, time out – insert with HD & ICU RN Consent, Time Out, Insert vascular line and remove line Order, monitor & treat labs with ICU team So Who Is Responsible for What? ICU RN Explain procedure to pt/family Obtain Daily weight Review Orders including lab draws Verify line placement & check cannulated limb for circulation Collaborate with Renal/HD RN when suspect filter is clotting Receive bedside in-service Supplies on Standby: 1L NSS Saline Flushes 100 units/ml Heparin FRESINIUS H/K •CCRT Mode •On-Line dialysis solution production with reverse osmosis RO water •Recirculate PRBC-saline mix for 2 minutes prior to initiating treatment •Return Blood with Specific Volume upon d/c •Dialysate & Reverse Osmosis Water 36-37 c •Acid and bicarb concentrates •Oral Fleet Phospho-soda solution can be added to bicarb concentrate Dialysis RN Review Orders as well Notify ICU RN of Treatment plan – time line Verify Confirmation of Line Placement Pre-Assess for tolerance Prep machine, prime lines, set –up and initiate CRRT Make sure all supplies are available Provide bedside in-service and on-call & pager number FRESINIUS K •Hourly •Turn off UF light = green light •Touch “UF Removed” button until background turns yellow •Touch zero •Touch confirm •Turn UF Light on = green light Procedure for Fresenius Clearing RMVD Changing UF Rate Remember noting pt response – HR/UO/CVP/BP Flushing CRRT System Termination of CRRT Care of CCRT Machine after Treatment Termination TroubleShooting Air Detector Alarm See What Alarm is Highlighted, Press Reset X2 2 sec Check bloodlines for kinks Flush blood lines with 100 ml NSS & check for clotting Press & Hold Reset Pad and check for wet transducer Conductivity Alarm Press Reset Increased Venous Pressure If drip chamber levels are low, increase fluid levels slightly with arrow pad Blood Pump Stop Check for air in bloodlines and drip chambers Check Fluid level in jugs and that hoses are in fluid TMP Touch Reset pad & press again for 2 sec Touch override pad to spread limits Check Jugs – if too low TMP will alarm until conductivity rises – 5 to 10 minutes You need to keep resetting to keep pump running. Press mute to silence Flush with 100 ml NSS and observe for clotting RETURN OF BLOOD & ENDING CRRT Termination Make sure there is at least 500 ml NSS in flush bag attached to blood tubing Record RMVD Press Override Unclamp line to NSS bag Clamp Arterial bloodline and arterial side of pt’s access Continue retransfusion until venous line is cleared Turn blood pump off Clamp Venous Blood Line and Venous side of pt’saccess Follow procedure for Dialysis Line Care # CODE Set fluid removal at 0cc, clamp arterial line, allow for venous return Follow Procedure to Return Blood as CODE is being called and ACLS is being implemented QUESTIONS ● Dialysis RN ● Office: ● Pager: ● On Call: ● Your ICU CNS ● Unit “SuperUsers” ● RRT/MICU Charge RN ● Not emergent page
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