Transcript Practical Considerations for CRRT in

Practical Considerations
for CRRT
Helen Currier RN, BSN, CNN
Nancy McAfee RN, BSN, CNN
Advantages of CRRT
• SLOW: Hemodynamically unstable patients
may not tolerate the rapid ultrafiltration
of intermittent hemodialysis
• CONTINUOUS: Can help preserve
metabolic stability in critically ill patients;
can maintain fluid balance for oliguric
patients who require high daily input (IV
medications, parenteral nutrition)
CVVH SYSTEM
Replacement
fluid
bm14
roller
pump
Heparin
IV pump
Roller
pump
Roller
pump
Hemofilter
From the
patient
Drainage
bag/UF
Venous
chamber
Air
detector
To the patient
CVVHD SYSTEM
Replacement
fluid
bm14
roller
pump
From the
patient
Heparin
IV pump
Roller
Pump
Roller
Pump
Drainage
bag/UF
Dialysate
IV pump
Hemofilter
Venous
chamber
Air detector
To the patient
Success with CRRT
•
•
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•
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•
Access
Equipment
Tubing/filter
Prime
Anticoagulation
Staffing
Access-What Works?
• Hemodialysis /Pheresis Line
• Shortest, fattest catheter possible
(highest flows with least resistance)
• May need two single lumen lines
• Leg position-be creative
• Tape on the skin-may need to get creative
Blood Pump
Systems for CRRT
CRRT Machines:
Current Generation
Tubing and Equipment
• Tubing volume ranges from 44-110 ml
• Filter volume ranges from 28 – 83 ml
• Hotline volume 18.5 ml
• Blood volume of patient (~70 ml/kg)
• PRISMA – 108 ml
• BM-25 -Smallest filter + tubing + hotline =
90.5 ml
Extracorporeal Volume
• Blood volume in extracorporeal
circuit is very large compared
to a small infant or child
• Patients require a blood prime
if the circuit >10% of their
blood volume
Blood Prime
•
•
•
•
•
•
Whole blood
PRBC + Albumin 5%
PRBC + NS
PRBC + FFP
Larger patients Albumin 5%
AN-69 filter requires special
considerations
Bradykinin Release
Syndrome
(Brophy et al Am J Kidney Dis. 2001 Jul;38(1):173-8
)
• What is the link
– Blood bank blood has
• ICa of 0.04 mmol/l
• K+ of 40-60 mEq/l
• pH of 6.4
• Reaction can be mitigated by
buffering the blood and giving IV
calcium at initiation
Buffered System
• ECMO circuits are commonly primed
with a cocktail to correct the pH,
Hct, and K of banked blood
– Addition of THAM
–
–
–
–
calcium chloride
Heparin
Sterile Water
Sodium bicarb
Bypass System
• Transfuse the PRBC post-filter directly
into the patient
• The patient is then connected to the
circuit
• Using the same rate for priming on and
infusing the PRBC (mixed with NS or Alb)
• Thus the patient’s blood can be used as a
“bradykinin filter” (Brophy,et al 2001AJKD)
Thermal Regulation
• Hotline® Blood warming tubing
• Place at venous return to patient
• Leave on at constant temperature
of 39o C
• Treat temp elevations if they occur
Anticoagulation
Heparin
• Heparin bolus
then continuous
infusion
• Maintain
activated clotting
time (ACT) ~200
• Risk of bleeding,
thrombocytopenia
Citrate
• Citrate infusion
to CRRT circuit
• Calcium infusion
to patient at
separate site
• Monitor for
metabolic
alkalosis
CRRT Staffing in
PICU/IICU
• Nephrology/Dialysis RN sets-up &
initiates therapy
• PICU/IICU RN manages patient
• Nephrology/Dialysis RN on call 24/7
• Acuity assigned to pump as if a separate
patient
• Staffing determined by acuity
3rd International Conference on
Pediatric Continuous Renal Replacement
Therapy
(PCRRT)
June, 2004
Coronado Springs Disney Orlando, Fl
www.pcrrt.com
CRRT Modalities
• CAVH:
Continuous Arteriovenous
Hemofiltration
• SCUF:
Slow Continuous
Ultrafiltration
• CVVH:
Continuous Venovenous
Hemofiltration
• CVVHD:
Continuous Venovenous
Hemodialysis
bm25™: Blood Pump Module
• Blood monitor
– Blood flow rate:
 30-350 mL / min
-- Safety features:
 pressure monitors
 air detector
 clot trap
 venous clamp
 blood leak detector
bm25™: Fluid Control Module
• Balancing monitor
– Substitution pump / filtrate
pump
– Integrated scales
– Fluid heater
– TMP monitor
– Operational ranges
• Replacement fluid 300- 9000
mL/hr
• Filtrate pump 100 - 11,000
mL/hr
• Net UFR 0.1 – 2000 mL/hr
Baxter bm25™
• 2 integrated
modules
– Blood module (bm
11a™)
– Balancing module /
scales (bm14™)
CRRT Modalities
• CAVH:
Continuous Arteriovenous
Hemofiltration
• SCUF:
Slow Continuous
Ultrafiltration
• CVVH:
Continuous Venovenous
Hemofiltration
• CVVHD:
Continuous Venovenous
Hemodialysis
bm25™: Blood Pump Module
• Blood monitor
– Blood flow rate:
 30-350 mL / min
-- Safety features:
 pressure monitors
 air detector
 clot trap
 venous clamp
 blood leak detector
bm25™: Fluid Control Module
• Balancing monitor
– Substitution pump / filtrate
pump
– Integrated scales
– Fluid heater
– TMP monitor
– Operational ranges
• Replacement fluid 300- 9000
mL/hr
• Filtrate pump 100 - 11,000
mL/hr
• Net UFR 0.1 – 2000 mL/hr
Baxter bm25™
• 2 integrated
modules
– Blood module (bm
11a™)
– Balancing module /
scales (bm14™)
CVVH SYSTEM
Replacement
fluid
bm14
roller
pump
Heparin
IV pump
Roller
pump
Roller
pump
Hemofilter
From the
patient
Drainage
bag/UF
Venous
chamber
Air
detector
To the patient
CVVHD SYSTEM
Replacement
fluid
bm14
roller
pump
From the
patient
Heparin
IV pump
Roller
Pump
Roller
Pump
Drainage
bag/UF
Dialysate
IV pump
Hemofilter
Venous
chamber
Air detector
To the patient