Download Term: Definition: The Prismaflex® 5.1 System is a fully integrated

Policy Name: Continuous Renal Replacement Therapy via the Prismaflex® 5.1 System Procedure
Effective Date: 03/29/13
Policy Primary:
Status: Published
Final Approval:
Approved by: DUH Critical Care Standards Committee Date:
Glossary:
Term:
Definition:
Definitions:
The Prismaflex® 5.1 System is a fully integrated system for automated CRRT and continuous fluid
management. The Prismaflex® 5.1 System provides four therapy options:
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Slow Continuous Ultrafiltration (SCUF) provides fluid removal by ultrafiltration only. No
replacement or dialysis fluid is used. The maximum patient fluid removal rate in SCUF is 2000
ml/hr.
Continuous Veno-Venous Hemofiltration (CVVH) is a process of hemofiltration which is
designed primarily to remove fluid, but also removes some solutes by convection as the
patient's blood moves across a semi-permeable membrane. Convection is the process which
uses the force of fluid to remove solutes and is optimized by infusing replacement fluid. It offers
high volume ultrafiltration using replacement fluid which can be given pre-filter (pre-dilution)
and/or post-filter (post-dilution). The maximum patient fluid volume removal in CVVH is 2000
ml/hr.
Continuous Veno-Venous Hemodialysis (CVVHD) provides solute removal by diffusion. Solutes
pass from the patient's blood across the semi- permeable membrane into the dialysate flowing
through the fluid compartment of the filter. Diffusion is the process by which ions move from an
area of higher to lower concentration. The concentration of solutes is higher in the blood than it
is in the dialysate. This results in the solutes moving from the blood to the dialysate. Maximum
patient fluid removal is 2000 ml/hr.
Continuous Veno-Venous Hemodiafiltration with Fluid Replacement (CVVHDF) is the same
process as noted in #2 and #3 above utilizing both ultrafiltration, convection and diffusion.
Definitions
1. Pressures
o
o
o
o
Access - coming from the patient, always a negative number
Filter- reflects amount of difficulty for PRISMAFLEX system to get blood into the filter, as
this number increases there may be increased incidence of clotting
Effluent- amount of pressure on the kidney membrane, increases as opportunity to clot
increases
Return - amount of pressure to return blood to the patient
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o
Transmembrane Pressure- amount of pressure within the filter
NOTE: These pressures should be monitored on a routine basis for trending. As the trend
pressure increases, the opportunity for clotting increases. It is preferred that the system be
changed prior to a clotting event so the patient experiences minimal to no blood loss (cannot
return blood if the kidney clots).
2. Filtration Fraction – A Filtration Fraction > 25%, enhances the "protein cake" on the surface of
the inner filter membrane, increasing pore clogging and clotting. This will lead to the need for early
replacement of the hemofilter set.
To decrease the Filtration Fraction percentage, prescribed fluid delivery strategies may need to be
initiated such as a mix of pre- and post-dilution.
NOTE: For accurate Filtration Fraction percentage monitoring, the patient’s hematocrit should
be updated once a day.
Indications: Patients experiencing acute renal failure who require
fluid removal,control of azotemia in hyper-catabolic states and have
electrolyte imbalances. A nephrology consult is necessary prior to
establishing the need for treatment. This therapy is not recommended
for "No Heparin" treatment unless the patient is systemically
heparinized or has a coagulopathy that prevents normal clotting.
Contraindications: Any patient receiving ace – inhibitors has a
high incidence of anaphylaxis.
The Prismaflex® machine does NOT have a battery back up; therefore, the therapy will need to be
discontinued to travel for any diagnostic testing or procedure.
RESPONSIBILITIES
Nephrology team (Attendings, Fellows, Residents) A consult will include:
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Type or mode of therapy to be used
Completing the dialysis order set
Baseline and ongoing lab studies, with parameters
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



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Ultrafiltration rate
Composition of replacement fluid and rate (pre and/or post replacement)
Composition of dialysate fluid and rate
Pre-blood pump fluid and rate
Blood pump speed
Net fluid balance
Anticoagulation circuit orders and parameters
Vascular access in conjunction with the ICU team.
Hemodialysis or other competent staff responsibilities:
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Verifies physician orders
Initiates system setup
Sets up the dialysis machine, delivers to ICU and initiates therapy
Changes (resets) circuit every 72 hours or as indicated
Evaluates patient's response to therapy and documents daily on progress note
Serves as a consultant and resource to the ICU staff.
ICU staff responsibilities:
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Verifies physician orders
Assists with vascular access placement
Patient assessment
Documents q 2 hrs net fluid removal and pressure values on flowsheet or electronic health
record
Maintains the Prismaflex system
*Discontinues system and return blood as ordered – See "NOTE" below.
NOTE:
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If the machine has alarmed and the screen states "FILTER CLOTTED", DO NOT RETURN the
blood.
If the machine had given the advisory alarm "FILTER IS CLOTTING", return blood and notify
Hemodialysis staff.
If a clot is noted in the Deaeration Chamber, the blood in the circuit can still be returned
because the clot will not go through the tubing. If the clot did go to the tubing, the pressure in
the system would be too high and the machine would say "RETURN EXTREMELY POSITIVE" and
the machine would not allow the blood to be returned.
Assesses circuit integrity for leaks, loose connections, clots
*Changes anticoagulant every 24 hours and prn
*Notify pharmacy when additional potassium or other additive bags or syringes are needed
Provides and documents patient/family education.
Pharmacy will prepare and provide WITH SPECIAL LABELING per order:


*Anticoagulant Syringe (must be in a 20ml leur-lock syringe) or infusion bag
*Potassium or other additives for the system.
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Level: Interdependent - asterisked [*] items require an order from a health care practitioner licensed to
prescribe medical therapy.
Personnel:
CRRT procedures will be performed by RNs and LPNs that have demonstrated competency.
CRRT is available in Critical Care Units only
Competencies/Skills:
Required Resources:
Provided by the Renal Team
Prismaflex System 5.1 Unit
Prismaflex Set (M100 or M60)
Effluent bag
20 ml syringe filled with Normal Saline
Therapy:
Effluent bag replacements
Replacement syringes (if medication ordered)
Electrolyte additives (if ordered)
Replacement solutions
Adapter, Spike Accessory SAP# 344839
Policy Statement:
Purpose:To outline the responsibilities of the RN, and Nephrology Team in the care of the adult and
pediatric patient receiving continuous renal replacement therapy (CRRT), set-up, maintenance and
discontinuation of the Prismaflex® 5.1 System.
Content:
A. Setup:
1. Reinforce physician's explanation and provide reassurance to the patient during the
procedure.
2. The Renal Fellow or Dialysis nurse will set up the Prismaflex control unit, prime the
tubing, connect to the patient, and set the initial flow rates, anticoagulant therapy
dosing, and alarms.
3. The Renal fellow or Dialysis nurse will have 24 hour responsibility for all Prismaflex set
changes.
4. The Renal attending/fellow is responsible for writing orders to include:
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a.
b.
c.
d.
e.
f.
Mode of therapy
Goal for fluid therapy
Flow rates
Anticoagulant doses, parameters, and routine aPTTs
Monitoring labs
Response to unplanned emergent situations, i.e. filter membrane rupture,
anaphylaxis
g.
Emergency beeper number for 24-hour on-call renal fellow.
B. Maintenance of System:
1. Verify that all connections are secure to the patient to prevent leakage, blood loss, air
embolism and clots. CLAMP any lines that are not in use or have a flow rate of ZERO.
2. Verify that Prismaflex tubing is inserted into the air detector.
3. Record date and time CRRT is initiated.
4. After initiation of therapy, monitor net fluid removal and pressures values and flow
settings. Document pressures at least q 2 hrs and flow settings q shift and with any
changes.NOTE: A Filtration Fraction of Greater than 25% indicates that the blood may
become too hemoconcentrated as it moves through the hemofilter and require early
changing of the hemofilter set.
5. Monitor the blood leak detector. The machine will alarm and stop when the color
changes from amber to pink.
6. Alarm conditions should be promptly addressed to prevent hemostasis, clotting of the
filter, and patient complications.
7. *If Citrate used for anticoagulation, a calcium drip must be infused through a central
line, not the access port of the hemodialysis catheter. The circuit will be monitored by
drawing ionized calcium from the post-filter port (blue).
8. *Coagulation studies will be monitored as ordered when heparin is used for system
anticoagulation.
9. *Machine aPTTs will be obtained from the post-filter port (blue).
10. Change dialysis solution bags when prompted to do so by Prismaflex machine's
calculation time or prn by using change bag feature on machine.
11. Empty effluent bag when full and alarm sounds (recalibrates simultaneously at change).
12. Confirm that circuit is changed at least q 72 hrs or if indicated.
13. Use a 22-gauge needle to obtain blood or fluid samples (from blue port), or remove air
trapped in the Prismaflex set.
C. Patient Assessment:
1. Circulatory assessment of the extremity every 2 hours if femoral vein is used for
catheter insertion site.
2. Obtain baseline assessment data, VS, I & O, daily weight*.
3. After initiation of therapy, monitor hemodynamic, respiratory and neurologic status
every two hours.
4. Monitor for signs of acute allergic reaction.
5. Monitor acid/base balance and electrolytes.
6. Assess fluid status for signs of dehydration.
7. Monitor for hypothermia – use warming device on Prismaflex or another external device
(warm air unit or Bair Hugger®).
8. *Monitor patient ionized calcium if citrate is being used for system (machine)
anticoagulation.
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D. Changing Anticoagulant Dose:
1. *Monitor frequency of aPTT or ionized calcium and titration as ordered.
2. Change anticoagulant every 24 hours and prn. NOTE: Advisory Alarm: "Syringe Almost
Empty" indicates the syringe will be empty in 5 minutes.
E. Adding Potassium (KCI) to Dialysate:
1. Obtain correct dose minibag from Omnicell.
2. Perform hand hygiene.
3. Using secondary IV tubing set, spike the potassium (KCI) minibag.
4. Break BLUE pin as instructed on bag of dialysate.
5. Attach secondary tubing to BLUE port on dialysate bag.
6. Squeeze contents of potassium (KCI) minibag into dialysate bag.
7. Remove secondary tubing and minibag from dialysiate bag.
8. Label dialysate bag with medication and dose added, date, time and initials.
F. Discontinue Treatment:
1. To terminate treatment, press "End Treatment."
2. *Press "Return Blood" soft key only if blood is to be returned to the patient at the end
of treatment.
3. *Enter desired return blood rate (10 – 100 ml/min, physician order).
4. Hang 250 - 500ml NS on upper left side hook.
5. Clamp red access line and disconnect line from patient.
6. Connect red access line to the "accessory spike" and spike into the saline flush bag and
unclamp access line.
7. Hold down "Start Return" key. (Return desired amount of blood, approximately 100 ml
of saline is required to flush line.)
8. Press "Continue" to disconnect patient.
9. Clamp all lines in set.
10. Disconnect return line from the patient.
11. Disconnect anti-coagulant line from anticoagulant syringe.
12. Press "Unload" key to unload set. The control panel automatically unloads lines from
raceways.
13. *Attach continuous flush system to both ports of the hemodialysis catheter. (Refer to:
Permcath and Vascath Access Protocol) unless otherwise ordered. (*PICU instill heparin
1000units/ml, priming volume of each lumen as printed on each catheter port).
G. Troubleshooting:
1. For an alarm secondary to an occlusion, reposition the patient, check patency of access,
and/or switch lines to see if this relieves the occlusion.
2. After alarm has been "corrected", continue, if alarm reoccurs, then original problem has
not been corrected. Notify HD nurse.
3. The filter and effluent pressures increase as clotting potential increases.
4. Any blood products or medications should be administered via a non-Prismaflex line
with the exception of citrate.
H. Documentation:
1. Document the following:
a.
Prismaflex pressures at least q 2hrs and flow settings q shift and with any
changes.
b.
Access site
I. Critical Events – RN to Notify Provider Immediately
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1. Discontinue CRRT immediately if profuse bleeding occurs.
2. If tubing disconnection occurs, clamp blood tubing and vascular access immediately.
3. If using Citrate for anticoagulation and calcium drip stops, immediately STOP Citrate
infusion by going to FLOW RATE screen and change pre-blood pump (PBP) rate to
ZERO until calcium is infusing. NOTE: If citrate therapy is stopped, immediately STOP
calcium drip.
4. If air embolism is suspected, provide emergency interventions:
a.
Discontinue CRRT system and DO NOT RETURN BLOOD.
b.
Position patient on left side with head lower than chest (Trendelenburg)
c.
Administer oxygen as ordered
d.
Assess for changes in vital signs
e.
Notify provider.
Reportable Conditions – RN to Notify Provider Immediately
1.
2.
3.
4.
5.
Clotted circuit, line leakage, rupture of filter membrane
Abnormal VS or lab results
Signs of bleeding
Signs of anaphylaxis
Significant changes in assessment, i.e. AMS (altered mental status), dysrhythmias or
ectopy, increased SOB, drop in SBP > 20 mmHG in ADULTS and > 10 mmHG in
PEDIATRICS
6. Increased trending of filter or effluent pressures. Notify dialysis nurse ASAP.
7. Signs of dehydration
Resources:
Renal Team (0700-2100) 681-7880.
Page 970-7701 or 970-8461 between 2100-0700
REFERENCES
Citations:
ANNA standards of clinical practice for Continuous Renal Replacement Therapy, 2000
Augustine JJ, Sandy D, Seifert TH, Paganini EP. (2004). A randomized controlled trial comparing
intermittent with continuous dialysis in patients with ARF. American Journal of Kidney Diseases. 44(6):
1000-7.
Small KR, McMullen M. (2005). When clear becomes cloudy: a review of acute tubular necrosis, a form
of renal failure. American Journal of Nursing. 105(1): Critical Care Extra: 72AA-BB, 72EE, 72GG.
Prismaflex® 5.1 Operator’s Manual, Gambro Dasco S.p.A. 2005
Policies:
Authoritative Source:
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Additional References:
Attachment Names:
Company:
Entities:
DUH
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