Session Number 122 AS ABC AND 123

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
maillies@einstein.edu
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
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●
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● 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
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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

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
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
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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
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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
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● 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
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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
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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
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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)
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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
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● 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
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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
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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
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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
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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
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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
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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
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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
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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
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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