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Practical Considerations for CRRT

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

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Practical Considerations for CRRT

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  1. Practical Considerations for CRRT Helen Currier RN, BSN, CNN Nancy McAfee RN, BSN, CNN

  2. 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)

  3. CVVH SYSTEM Replacement fluid Heparin Drainage bag/UF Roller pump bm14 roller pump IV pump Venous chamber Roller pump Hemofilter From the patient Air detector To the patient

  4. CVVHD SYSTEM Replacement fluid Drainage bag/UF Heparin Dialysate Roller Pump IV pump bm14 roller pump IV pump Venous chamber Roller Pump Hemofilter From the patient Air detector To the patient

  5. Success with CRRT • Access • Equipment • Tubing/filter • Prime • Anticoagulation • Staffing

  6. 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

  7. Blood Pump Systems for CRRT

  8. CRRT Machines: Current Generation

  9. 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

  10. 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

  11. Blood Prime • Whole blood • PRBC + Albumin 5% • PRBC + NS • PRBC + FFP • Larger patients Albumin 5% • AN-69 filterrequires special considerations

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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 Anticoagulation

  17. 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

  18. 3rd International Conference on Pediatric Continuous Renal Replacement Therapy (PCRRT) June, 2004 Coronado Springs Disney Orlando, Fl www.pcrrt.com

  19. CRRT Modalities • CAVH: Continuous Arteriovenous Hemofiltration • SCUF: Slow Continuous Ultrafiltration • CVVH: Continuous Venovenous Hemofiltration • CVVHD: Continuous Venovenous Hemodialysis

  20. 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

  21. 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

  22. Baxter bm25™ • 2 integrated modules • Blood module (bm 11a™) • Balancing module / scales (bm14™)

  23. CRRT Modalities • CAVH: Continuous Arteriovenous Hemofiltration • SCUF: Slow Continuous Ultrafiltration • CVVH: Continuous Venovenous Hemofiltration • CVVHD: Continuous Venovenous Hemodialysis

  24. 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

  25. 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

  26. Baxter bm25™ • 2 integrated modules • Blood module (bm 11a™) • Balancing module / scales (bm14™)

  27. CVVH SYSTEM Replacement fluid Heparin Drainage bag/UF Roller pump bm14 roller pump IV pump Venous chamber Roller pump Hemofilter From the patient Air detector To the patient

  28. CVVHD SYSTEM Replacement fluid Drainage bag/UF Heparin Dialysate Roller Pump IV pump bm14 roller pump IV pump Venous chamber Roller Pump Hemofilter From the patient Air detector To the patient

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