Practical Considerations for CRRT

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

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CVVH SYSTEM
Replacement fluid
Heparin
Drainage bag/UF
Roller pump

IV pump
bm14 roller pump
Venous chamber
Roller pump
Hemofilter

From the patient
Air detector
To the patient
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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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Success with CRRT

• Access
• Equipment
• Tubing/filter
• Prime
• Anticoagulation
• Staffing

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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

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Blood Pump Systems for CRRT
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CRRT Machines Current Generation
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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

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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
  gt10 of their blood volume

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Blood Prime

• Whole blood
• PRBC Albumin 5
• PRBC NS
• PRBC FFP
• Larger patients Albumin 5
• AN-69 filter requires special considerations

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Bradykinin Release Syndrome(Brophy et al Am J
Kidney Dis. 2001 Jul38(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

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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

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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 patients blood can be used as a
  bradykinin filter (Brophy,et al 2001AJKD)

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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

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Anticoagulation

• Citrate
• Citrate infusion to CRRT circuit
• Calcium infusion to patient at separate site
• Monitor for metabolic alkalosis

• Heparin
• Heparin bolus then continuous infusion
• Maintain activated clotting time (ACT) 200
• Risk of bleeding, thrombocytopenia

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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

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3rd International Conference on Pediatric
Continuous Renal Replacement Therapy (PCRRT)

• June, 2004
• Coronado Springs Disney Orlando, Fl
• www.pcrrt.com

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CRRT Modalities

• CAVH Continuous Arteriovenous
  Hemofiltration
• SCUF Slow Continuous Ultrafiltration
  
• CVVH Continuous Venovenous
  Hemofiltration
• CVVHD Continuous Venovenous
• Hemodialysis

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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

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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

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Baxter bm25

• 2 integrated modules
• Blood module (bm 11a)
• Balancing module / scales (bm14)

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CRRT Modalities

• CAVH Continuous Arteriovenous
  Hemofiltration
• SCUF Slow Continuous Ultrafiltration
  
• CVVH Continuous Venovenous
  Hemofiltration
• CVVHD Continuous Venovenous
• Hemodialysis

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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

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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

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Baxter bm25

• 2 integrated modules
• Blood module (bm 11a)
• Balancing module / scales (bm14)

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CVVH SYSTEM
Replacement fluid
Heparin
Drainage bag/UF
Roller pump

IV pump
bm14 roller pump
Venous chamber
Roller pump
Hemofilter

From the patient
Air detector
To the patient
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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