CRRT in the ICU - Getting It Right
-
Upload
sweetcharmed-go -
Category
Documents
-
view
245 -
download
3
Transcript of CRRT in the ICU - Getting It Right
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
Effluent Pump Pre Blood Pump
BLD
Effluent Pressure
Hemofilter
Syringe pump
Filter Pressure
Blood Pump
Return Pressure Air Detector
Return Clamp
Patient
SCUF
Syringe Pump
Return Pressure Air Detector
Hemofilter
Filter Pressure
Effluent Pressure
Access Pressure
Return Clamp
Patient
Post
Post Pre
Replacement Pump Effluent Pump Replacement Pump Pre Blood Pump
CVVH
Dialysate Pump Effluent Pump
Hemofilter
BLD
Effluent Pressure
Filter Pressure
Syringe Pump
Return Pressure Air Detector
Blood Pump Return Clamp
Access Pressure
Patient
Pre Blood Pump
CVVHD
CVVHDF
Hemoperfusion
• Is an extracorporeal treatment that passes the patient’s 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
PrismaSate
BGK2/0
Calcium Ca2+ (mEq/L) 4.3 - 5.3 3.5 0
Magnesium Mg2+
(mEq/L) 1.5 - 2.5 1.0 1.0
Sodium Na+ (mEq/L) 135 - 145 140 140
Potassium K+ (mEq/L) 3.5 - 5.0 0 2.0
Chloride Cl- (mEq/L) 95 - 108 109.5 108
Lactate (mEq/L) 0.5 - 2.0 3 3
Bicarbonate HCO3-
(mEq/L) 22 - 26 32 32
Glucose (mg/dL) 65 - 110 0 110
Osmolarity (mOsm/L) 280 - 300 287 292
pH 7.35 - 7.45 ~ 7.40 ~ 7.40
LACTATE-BASED
• Metabolized into bicarbonate providing it’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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. Organize your CRRT competency assessment – Determine critical competencies to evaluate annually – Tie critical competencies to annual performance reviews
2. Understand JCAHO expectations – National Patient Safety Goals
3. Develop your CRRT competency assessment program – Design a compliant, consistent, and effective competency assessment
program
4. Validate CRRT competency – Validate clinical proficiency
5. Maintain a consistent CRRT validation system – Ensure that clinical proficiency is assessed and validated in a consistent
manner with our easy to implement skill sheets
6. Keep up with new CRRT competencies – Verify and document new—and existing—competencies, including those for
new equipment
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?