Transcript CRRT in the PICU: Part 2

CRRT Therapy in the
Pediatric Critical Care Patient
An overview of common complications and solutions for
Pediatric Critical Care Patients undergoing CRRT Therapy
By Tom MacCrae RN, BSN
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Speaker Information
2 1/2 Years experience as EMT in Santa Clara County
Graduated with BSN from Azusa Pacific University 2004
PICU RN at Lucile Packard Children’s Hospital since 2004
CRRT Clinical Coordinator in PICU since 2006
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Hungry for Knowledge?
Lets Get Ready to Learn!!!!
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Objectives
Explanation of common catheter, filter, and pump
complications with CRRT in the Pediatric Patient
Examine specific patient related complications for
pediatric patients undergoing CRRT therapy.
Discuss the recommended solutions to common CRRT
complications in the Pediatric Patient
Review select case scenarios from the PICU at LPCH and
discuss how specific CRRT complications were addressed
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CRRT with Prisma Machine
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Catheter complications
Sluggish blood flow through the
catheter
Catheter entry site
complications
Patient position problems
Blood clotting complications
Blood Products / Drugs
affecting catheter function
Left Femoral Catheter
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Solutions To Catheter Complications
Re-positioning the patient
TPA for clotted catheters
Infuse blood products and
drugs as far away from the
CRRT catheter as possible
Reversing the catheter access
if necessary
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Example of Catheter Location
Tunneled Catheters
Non-tunneled Catheter
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CRRT Catheter with Pig-Tail Lumen
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Double Lumen Catheter with Dilator and Wire
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Filter / Pump Complications
Sluggish blood flow in the filter and
tubing
Failing or clotting filter
Cracked filter or ruptured tubing
Filter saturation, and short
filter life
Frequent air and blood leak alarms
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Filter Saturation
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Solutions To Filter / Pump Complications
Adjust blood flow rate to
accommodate for rising or falling
access and return pressures
Anticipate more frequent filter
changes for PT in DIC
Special attention to calcium and
citrate infusions can help to minimize
filter and pump complications
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Solutions To Filter / Pump Complications
Careful observation for clots in
the filter may warn of
impending failure
Keeping machine clean will also
eliminate potential alarms and
reduce pump complications
Trouble shooting alarms instead
of silencing them will decrease
associated complications.
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Pediatric Patient Complications
Blood Pressure instability
Electrolyte imbalance
Risk of Bleeding
Decreased HCT / HGB
Kids Don’t Hold Still
Smaller kids = smaller catheters = restricted blood flow
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Solutions To Pediatric Patient Complications
Blood Prime
Used for Small babies
and Patients with low HCT
**special considerations**
Albumin Prime
Used for Patients with B/P
instability
Saline Prime
Decreases exposure to blood
products in stable patients
Pre-Medication Administration
CACL, Albumin, isotonic volume
Frequent Lab and VS monitoring
Chem 10, CBC, Coags
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Case Scenarios
(1) Pt J.J., a morbidly obese teenager in renal failure,
fighting sepsis who is undergoing CRRT.
(2) Pt C.P., an active teenage patient undergoing CRRT
and plasmapheresis simultaneously using the same
catheter
(3) Pt A.M., a small infant with multi-system organ
failure waiting for a liver transplant
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Case Scenario #1 (Pt. J.J.)
In addition to his underlying metabolic disorder J.J.
experienced multi-system organ failure, severe
respiratory distress, and sepsis.
Making things even more complicated was the fact the
J.J. was morbidly obese.
J.J. experienced catheter and filter complications while
on CRRT. J.J. was also very unstable and frequently
dealt with B/P instability. He required multiple blood
transfusions while on CRRT.
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Case Scenario #1 (Pt. J.J.)
An Overview of Complications
Larger patients require much faster blood flow rates when
undergoing CRRT therapy. The faster rates increase the strain on
the HD catheter and generally lead to more complications with
CRRT therapy
Patients with large amounts of subcutaneous tissue generally have
more frequent complications with their HD Catheter
Patients who are unstable on CRRT may require multiple blood
transfusions and pharmacological interventions while undergoing
therapy. These additional therapies are problematic as they often
lead to clotted filters.
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Case Scenario #1 (Pt. J.J.)
An Overview of Solutions
If possible, using the largest size HD catheter in the obese
patients will allow for optimum blood flow rates which will enable
the CRRT therapy to be most effective
By adjusting the blood flow rates as soon as catheter blood flow
becomes a problem, the associated catheter complications may be
avoided
Infusing the necessary blood transfusions and drug products as far
away from the CRRT catheter can minimize complications with the
catheter and the filter. (opposite side of body and diaphragm)
TPA and heparin are useful tools to maintain a patent catheter.
When used to lock the catheter during circuit changes TPA or
heparin can un-clot an occluded catheter
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Case Scenario #2 (Pt. C.P.)
C.P. was a very unique patient in the PICU because of
her mobility.
C.P. was one of the very few patients to undergo CRRT
and was stable enough to sit up in bed and interact as a
relatively normal teenage girl.
During the course of her CRRT it was determined that
C.P. would benefit from plasma pheresis. The decision
was made to run plasma pheresis and CRRT on the same
catheter, thereby increasing the amount of strain on
the CRRT catheter
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Case Scenario #2 (Pt. C.P.)
An Overview of Complications
Active children and teenagers can often complicate
CRRT therapy with frequent and unpredictable
movement which can clamp off the HD catheter both
internally and externally
Children with medical conditions which require additional
intravenous therapies may increase the likelihood of
complications with their CRRT therapy
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Case Scenario #2 (Pt. C.P.)
An Overview of Solutions
Encourage the medical / surgical team to place the HD
catheter in a location which will be minimally kinked with
patient movement
Proper dressing and arm board placement to extremities
with HD catheters in place can minimize complications
Adjusting the blood flow rate of the CRRT during any
additional intravenous therapies will help minimize any
potential complications
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Case Scenario #3 (Pt. A.M.)
A.M. was one of the smallest patients that we have
placed on CRRT in the PICU
While waiting for a liver transplant this patient
developed renal failure
Without a functioning liver or kidney the patients body
began retaining fluid and toxins
The benefit of CRRT for this patient outweighed the
risks associated with using CRRT on such a small patient
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Case Scenario #3 (Pt. A.M.)
An Overview of Complications
Babies often encounter unique complications with CRRT
therapy because of their small size
Complications can include blood pressure instability,
electrolyte imbalances, and catheter complications
Small patients require extra special attention to fluid
and electrolyte removal when receiving CRRT therapy
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Case Scenario #3 (Pt. A.M.)
An Overview of Solutions
The smaller the patient the smaller the amount of fluid that can be
safely removed at a given time
(smaller patients = slower pump speed)
Special attention must be taken not to drop the blood pressure or
blood volume of the small CRRT patients
When changing the CRRT machine every 3 days a “circuit to circuit
prime” can lower the risk of blood pressure instability and lower the
amount of exposure to additional blood products.
By administering certain medications such as CACL or albumin prior
to initiating CRRT therapy, specific complications can be minimized
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Circuit to Circuit Prime
This priming process takes advantage of the circulating
blood volume in the existing CRRT circuit
The dialysis RN can connect the new filter and tubing to
the old filter and tubing and by running the circuits
together, can use the blood from the existing circuit to
prime the new one
This process benefits the patient by not requiring any
exposure to new blood products. In addition the patient
is benefited by lowering the potential for a drop in
circulating blood volume (blood pressure)
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Conclusion
Knowing what complications to expect when running CRRT and
anticipating their solutions has many benefits.
These benefits include:
● Decreasing the stresses associated with maintaining
CRRT
● Providing the most efficient and effective treatment for
patients undergoing CRRT
● Decreasing the amount of circuit changes due to circuit
failure
● Minimizing the need for blood and electrolyte replacement
during CRRT therapy
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