CRRT in the ICU : Getting it Right

Annabelle Sy-Lim,MD May 22, 2012

Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies

Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies

Lecture Outline
Evolution of CRRT Principles involved in CRRT Different modalities of CRRT Dialysate Fluids Principle of Clearance in CRRT

1977 : First CRRT by Kramer

CONVECTION

PRINCIPLE : ULTRAFILTRATION ULTRAFILTRATION

PRINCIPLE OF DIFFUSION DIFFUSION

PRINCIPLE OF ADSORPTION ADSORPTION

SCUF
Hemofilter Effluent Pressure

Return Pressure

Air Detector Return Clamp Patient

Syringe pump

Blood Pump

Filter Pressure

BLD

Effluent Pump

Pre Blood Pump

CVVH
Hemofilter

Return Pressure

Air Detector

Syringe Pump

Return Clamp Patient

Filter Pressure Effluent Pressure Post Post Pre

Access Pressure

Replacement Pump

Effluent Pump

Replacement Pump

Pre Blood Pump

CVVHD
Syringe Pump Hemofilter

Return Pressure

Air Detector Return Clamp Patient

Blood Pump

Filter Pressure
Effluent Pressure BLD

Access Pressure

Dialysate Pump

Effluent Pump

Pre Blood Pump

CVVHDF

Hemoperfusion
Is an extracorporeal treatment that passes the patients blood through a filter impregnated with anabsorptive substance, for example, charcoal. This is able to bind to certain toxins in the bloodstream which removes them, returning the cleaned blood to the patient (Kellum, Mehta, Angus,Palevskey, & Ronco, 2002). It has been shown to be effective against drugs like digoxin,glutethimide, phenobarbital theophiline and paraquat among others, and allowed patients tomaintain normal levels of essential molecules (Ponikvar, 2003)

Dialysate Fluids : Differences

2 types : lactate based solution and a bicarbonate based fluid. Are pre-prepared and packaged ready to use typically in 5 litre bags which are hung below the machine .

BICARBONATE BASED
Bicarbonate based solutions are physiologic and replace lost bicarbonate immediately. Effective tool to correct acidosis Concentration of 30-35mEq/L corrects acidosis in 24 to 48 hours.

BICARBONATE BASED
Preferred buffer for patients with compromised liver function. Mean arterial pressure remains stable Superior buffer in normalizing acidosis without the risk of alkalosis Improved hemodynamic stability, and fewer cardiovascular events.

Plasma

PrismaSate BK0/3.5
3.5 1.0 140 0 109.5

PrismaSate BGK2/0
0 1.0 140 2.0 108

Calcium Ca2+ (mEq/L)

4.3 - 5.3 1.5 - 2.5 135 - 145 3.5 - 5.0 95 - 108

Magnesium Mg2+ (mEq/L)

Sodium Na+ (mEq/L) Potassium K+ (mEq/L) Chloride Cl- (mEq/L)

Lactate (mEq/L)
Bicarbonate HCO3(mEq/L) Glucose (mg/dL) Osmolarity (mOsm/L) pH

0.5 - 2.0
22 - 26 65 - 110 280 - 300 7.35 - 7.45

3
32 0 287 ~ 7.40

3
32 110 292 ~ 7.40

LACTATE-BASED
Metabolized into bicarbonate providing its under normal conditions. Lactate is converted in the liver on a 1:1 basis to bicarbonate and can sufficiently correct acidemia.

LACTATE-BASED
Non physiologic pH value of 5.4 Is a powerful peripheral vasodilator Further acidemia for patients in:
Hypoxia Liver impairment Pre-existing lactic acidemia can result in worsening of lactic acidemia

PRINCIPLES OF CRRT CLEARANCE

CRRT clearance of solute is dependent on the following: The molecule size of the solute The pore size of the semi-permeable membrane The higher the ultrafiltration rate (UFR), the greater the solute clearance.

MOLECULAR SIZES

PRINCIPLE OF CRRT CLEARANCE

Sieving Coefficient
The ability of a substance to pass through a membrane from the blood compartment of the hemofilter to the fluid compartment. A sieving coefficient of 1 will allow free passage of a substance; but at a coefficient of 0, the substance is unable to pass. .94 Na+ 1.0 K+ 1.0 Cr 0 albumin will not pass

Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies

CRRT Nursing Competency

What knowledge and skills are essential? What resources are needed to support the program? Staff?
Print, on-line, personnel, 24/7 on-call or on-site

Collaboration

Nephrology Nurse
How CRRT works Reason for treatment When and how to terminate treatment Equipment operation Most common alarms When and how to reach the nephrology team Fluid balance calculations Assessment of clotting How to adjust AP/VP limits, BFR, or UFR How to verify dialysis fluid or replacement fluid and/or rate changes

Bedside Nurse: Competencies

Verbalize
How CRRT works (fluid and solute balance, changes in nutrition and medications) Reason for treatment When and how to terminate treatment How to troubleshoot alarms (AP, VP, blood leak, error codes, air detector) When and how to recirculate the system How to care for catheter and catheter exit site When and how to contact nephrologist or nephrology nurse How to operate extracorporeal circuit warmer

Bedside Nurse: Competencies

Demonstrate
How to calculate fluid balance How to assess clotting in the system How to adjust AP and VP limits, BFR, UFR How to verify dialysis and replacement fluid solution and rates Document continuing care in nursing notes and flow sheet

Before Treatment Equipment/Supplies

Nephrology Nurse
CRRT Equipment/Circuit

Bedside Nurse
Order dialysis fluid; citrate and any replacement solutions IV tubing for each infusion pump 3-way stopcocks Extracorporeal circuit warmer Extracorporeal circuit prime Telephone at bedside

Before Treatment Equipment/Supplies

Nephrology Nurse
Review and note CRRT orders Verify consent Notify bedside nurse of treatment orders and initiation time Set-up and prime CRRT circuit with heparinized normal saline Prime other lines in CRRT circuit Verify catheter placement

Bedside Nurse
Review, clarify, and note CRRT Draw baseline labs per CRRT orders Explain procedure and answer questions as needed Check cannulated limb for circulation

CRRT Treatment Responsibilities: Points to Remember

Nephrology Nurse
Initiate treatment based on individual patient needs as assessed by the nephrologist

Bedside Nurse
Do not infuse other medications or blood products directly into the CRRT system Cooling effects of CRRT may prevent temperature elevation Adjust patient fluid removal rate hourly to maintain net UFR Changes in net URF

Treatment Initiation
Nephrology Nurse
Assess patients condition *fluid and electrolyte Prep catheter ports Aspirate appropriate blood volume from catheter and flush w/saline Prime CRRT circuit w/priming solution and attach blood lines of equipment to catheter(s) Start citrate drip After 5 w/stable VS, start replacement fluid and ultrafiltration Change catheter site dressing if needed

Bedside Nurse
Assess patients condition *fluid and electrolyte Baseline VS, Wt, PAWP (if applicable), CVP, BP, edema, lung/heart sounds, lab values VS q 30 x 2 then q 1 h Monitor and document starting AP, VP, DFR, RFR, BFR, URF and infusion pump rates

CRRT Treatment Responsibilities: q 1 hour

Bedside Nurse
Monitor system for kinks, loose connections, patient bleeding Evaluate changes in pressure reading VP or AP Evaluate hemofilter and venous chamber for clotting or fibrin Evaluate color of ultrafiltrate (no pink-tinged fluid) Document arterial pressure (AP), venous pressure, BFR, and intake/output

CRRT Treatment Responsibilities: q 2 hr into treatment/ q 6 hr thereafter

Bedside Nurse
Check circuit ionized Ca++ (sample from venous port) and patients ionized Ca++ (sample from site other than CRRT circuit) Recheck CRRT circuit/patient ionized Ca++ after any changes in anticoagulation reference optimal ranges specified Notify nephrology nurse if circuit clots

CRRT Treatment Responsibilities: q 24 hr

Bedside Nurse
Assess patients fluid/electrolyte balance and overall condition, PAWP (if applicable), CVP, edema, lungs, heart Evaluate serum chemistry for changes Monitor serum calcium and pH for signs of citrate toxicity Monitor for s/s of sepsis or local infection Monitor for s/s of hypothermia Assess and monitor patients nutritional status daily weight, albumin, bowel patterns, skin turgor, muscle wasting Monitor the integrity of the access dressing change per protocol

FLUID MANAGEMENT IN CRRT

Goal of Fluid Management The patient will achieve and maintain fluid volume balance within planned or anticipated goals (ANNA Standards of Clinical Practice for Continuous Renal Replacement Therapy) Considerations Intakes and outputs (I&O)

I AND O FORMULA
Net fluid removal hourly (physician order)

+
Nonprisma intake (IV, TPN, etc.)

Nonprisma output (urine, etc.)

=
Patient Fluid Removal Rate (set in prisma)

Typical Calculation of Fluid Balance

Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies

CRRT Competency Management

1. 2. 3. 4. 5. 6. Organize your CRRT competency assessment
Determine critical competencies to evaluate annually Tie critical competencies to annual performance reviews National Patient Safety Goals Design a compliant, consistent, and effective competency assessment program Validate clinical proficiency Ensure that clinical proficiency is assessed and validated in a consistent manner with our easy to implement skill sheets Verify and document newand existingcompetencies, including those for new equipment

Understand JCAHO expectations Develop your CRRT competency assessment program Validate CRRT competency Maintain a consistent CRRT validation system Keep up with new CRRT competencies

Staffing Nurses for CRRT

Variations
Skill mix Opened vs. Closed Responsibilities
Dialysis Critical Care

Predictions
FTEs by shift Budgeting FTEs

Shortages Effects
Clinical Outcomes Therapy Choice

Safety/Quality
Protocols Order sets Solutions
Stability, expirations, FRF/dialysate, medication management, compounding

Managing complications Anticoagulation Access (where, size) Time out?