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Continuous Renal
Replacement Therapy
GAMBRO
Emily Castro, BSN, MSN, CCRN
Critical Care Nurse Educator
1
Objectives
• To review the different modalities of CRRT
therapy
• To understand the concept of changing the
modality of CRRT therapy (for example:
switching from CVVHDF to SCUF mode)
• To understand the different alarms in CRRT
therapy and corresponding troubleshooting
techniques
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SCUF Modality
Slow Continuous UltraFiltration
Return
Blood Pump
Effluent
Pump
Effluent
Access
PBP
Pump
Infusion or
Anticoagulant
SCUF Modality
Slow Continuous UltraFiltration
• Primary therapeutic goal:
–Safe and effective management of
fluid removal from the patient
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CVVHD Modality
Continuous VV HemoDialysis
• Primary therapeutic goal:
– Small solute removal by diffusion
– Safe fluid volume management
• Dialysate volume automatically removed through
the Effluent pump
Solute removal determined by Dialysate Flow Rate.
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CVVHD Modality
Continuous VV HemoDialysis
Return
Hemofilter
Dialysate
Pump
Dialysate
Fluid
Effluent
Blood
Pump
Effluent
Pump
Access
PBP
Pump
Infusion or
Anticoagulant
Dialysate Solutions
• Flows counter-current to blood flow
• Remains separated by a semi-permeable membrane
• Drives diffusive transport
– dependent on concentration gradient and flow rate
• Facilitates removal of small solutes
• Physician prescribed
• Contains physiologic electrolyte levels
• Components adjusted to meet patient needs
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CVVH Modality
(Continuous VV Hemofiltration)
• Primary Therapeutic Goal:
•
•
Removal of small, middle and large sized solutes
Safe fluid volume management
• Replacement solution is infused into blood
compartment pre or post filter
• Drives convective transport
• Replacement fluid volume automatically
removed by effluent pump
Solute removal determined by Replacement Flow Rate.
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CVVH Modality
Continuous VV Hemofiltration
Return
Blood
Pump
Replacement
Pump 2
Replacement 2
Effluent
Pump
Effluent
Replacement
Pump 1
Replacement 1
Access
PBP
Pump
Infusion or
Anticoagulant
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Pre-Dilution Replacement Solution
Return
Access
Hemofilter
•Decreases risk of
clotting
Blood
Pump
Effluent
Pump
Replacement
Pump
PBP
Pump
•Higher UF
capabilities
•Decreases Hct.
In filter
Effluent
Replacement
Fluid
Infusion or
Anticoagulant
Post-Dilution (Post- Filter)
Replacement Solution
Return
•Consider lowering
replacement rates
(filtration %)
Access
Hemofilter
Blood
Pump
•Higher BFR
(filtration %)
•Higher
anticoagulation
Replacement
Pump
Effluent
Pump
Replacement
Pump
PBP
Pump
•More efficient
clearance (>15%)
Replacement
Fluid
Effluent
Replacement
Fluid
Infusion or
Anticoagulant
Replacement Solutions
• Infused directly into the blood at points along the
blood pathway
• Drives convective transport
• Facilitates the removal of small middle and large
solutes
• Physician Prescribed
• Contains electrolytes at physiological levels
• Components adjusted to meet patient needs
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CVVHDF Modality
Continuous VV Hemodiafiltration
Primary therapeutic goal:
– Solute removal by diffusion and convection
– Safe fluid volume management
– Efficient removal of small, middle and large molecules
• Replacement and dialysate fluid volume
automatically removed by effluent pump
Solute removal determined by
Replacement + Dialysate Flow Rates.
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CVVHDF Modality
Continuous VV HemoDiaFiltration
Return
Blood
Pump
Dialysate
Pump
Dialysate
Fluid
Effluent
Effluent
Pump
Replacement
Pump
Replacement
Fluid
Access
PBP
Pump
Infusion or
Anticoagulant
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Switching CRRT Modality
• We always prime the machine in CVVDHF
mode.
• In CVVHDF mode all pumps can be
activated. The dialysate pump functions the
same as in CVVHD mode. The PBP pump
functions the same as in the other modes.
The replacement pump functions the same
as in CVVH mode.
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Switching CRRT Modality
• CVVHDF mode allows the user to switch from
one therapy mode to another by simply
deactivating one or more solution pumps. For
example: deactivating the dialysate pump
would deliver CVVH; deactivating the
replacement pump delivers CVVHD;
deactivating both dialysate and replacement
solution pumps deliver the SCUF mode.
However, there will be an increased chance of
clotting in the deaeration chamber and filter
when post filter replacement and PBP solution
pumps are deactivated.
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Switching CRRT Modality
• In practice, SCUF can also be delivered safely by
maintaining PBP rate and Post filter replacement rate at
less than 8m/kg/hr dosage; consult the attending
nephrologist. In other words, we can still run treatment in
the SCUF mode using low PBP and Post Filter replacement
solution rates; discuss with the attending nephrologist.
• When post-filter replacement rate is set at 200 ml/hr, the
CVVH mode shows on the screen of Prismaflexx machine.
• Remember: a minimum of 200 ml per hour of post-filter
replacement pump rate is highly recommend to create a
buffer between blood and air to prevent clotting in the
dearation chamber and blood return line, as well as
prevent air bubble formation.
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Goal of Treatment
• To remove 35ml/kg/hr of effluent to optimize
therapy benefits; consult with the attending
nephrologist.
• Always enter patient weight when initiating
therapy.
• If 35ml/kg/hr is not being achieved (this number is
found on status screen), reassess the goal of
treatment; consult the attending nephrologist.
• If the goal of treatment is to remove small
molecules (thru diffusion) then increase the
dialysate solution flow rate.
• If the goal of the treatment is to remove more
middle molecules (convective clearance/solute
drag) then increase the replacement solution flow
rate (such as to remove the proteins seen in sepsis).
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Access Alarms
ACCESS ALARMS- ACCESS TOO POSITIVE
• (access pressures should be negative)
• Cause: Machine cannot detect your access
because because the blood flow rate is
probably too low (100-150ml/min).
• Action to take: Increase your blood flow rate
to at least 180ml/min.
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Access Alarms
ACCESS ALARMS- ACCESS TOO NEGATIVE
• Cause: Machine is having to pull too hard to get
blood out of access catheter. THEREFORE, it is not a
machine problem…it is a vascular access problem.
Nurse needs to troubleshoot vascular access.
• Actions to take:
• Draw up 10mls of blood using a 20-30ml syringe
from the access catheter. If this cannot be easily
done over 6 seconds, THE MACHINE WILL NOT BE
ABLE TO PULL OFF blood from access catheter.
• Flip ports (connect blue return line to red port and
red access line to blue port), or call surgeon to
reposition line (could be up against a valve). If
nothing works, line will need to be replaced.
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Access Alarms
****beware of “flipping of ports” on vascular
access because it will cause some degree of
recirculation of the same blood, decrease
filter clearance of the blood and increased
clotting of filter…..it is only a temporary
solution…line will probably need to be
changed****
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Set Up Alarms
BLOOD DETECTED
• Cause: This alarm occurs during the priming
mode when the tubing has been improperly
inserted into the blood leak detector or the
blood leak detector is dirty.
• Action to take: Re-seat the tubing or clean the
blood leak detector with alcohol and then
push “NO BLOOD” on the screen.
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Set Up Alarms
ALARM: “WRONG SET HAS BEEN LOADED”
• Action to take: Clean bar code reader with
alcohol.
ALARM: “BLOOD IN SET”
• Action to take: Must make sure that there
this a secure fitting on the return line of the
dearation chamber.
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Run Alarms
NET FLUID LOSS ALARMS (-33OML)
• Action to take: Make sure the “pin” is completely
cracked when hanging a new bag and no lines are
left clamped, otherwise, fluid flow will be impeded
and cause net fluid loss alarms.
NET FLUID GAIN ALARMS (+33OML)
• Action to take: Always remember to hook effluent
line into tubing guide on machine, otherwise, over
time the effluent tubing will naturally kink and
impede drainage into the effluent bag and cause
excess fluid gain alarms.
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Run Alarms
FILTER
• Actions to take:
• To avoid multiple blood transfusions, always try to
return blood to patient before disconnecting
patient or patient will lose 160mls of blood. If it
says “filter is clotting”…be proactive: stop
treatment and return blood.
• Septic patients have a tendency to clot off filters
frequently due to increased circulating proteins
(TNF/cytokines) which will clog up the intimal lining
of the filter. There is no treatment other than to
treat the sepsis. As the sepsis improves….so will the
lifespan of your filter!
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Run Alarms
HIGH TMP ALARMS (transmembrane
pressure)
• This is tracked on the green graph on the
status screen and represents the pressure
across the filter from the pushing and
pulling action across the membrane.
• Actions to take:
• Decrease the blood flow rate (only a
temporary solution).
• Be proactive: stop the treatment and return
the blood and initiate a new filter.
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Run Alarms
PRESSURE ALARMS
• Actions to take: Go into SYSTEM TOOLS and
force a self-test. This will reposition the
pressure pods and hopefully resolve the
pressure alarm. If the pressure alarm
persists, the nurse will need to do a manual
DRP-diaphragm reposition procedure, by
following the directions on the screen,
referring to your owner’s manual or calling
GAMBRO 24hr support at 800-525-2623.
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Reminder
***Reminder: after priming the
machine, must reprime machine
with a one liter bag of 0.9% NS if
machine sits idle for more than 15
minutes without initiating
therapy***
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Equipment Malfunction Report
• Call BIOMED at ext# 4241 and provide the following
information:
–
–
–
–
–
–
Your unit
Your name
Machine serial number
Problem (describe)
Alarm (error message)
Biomed number
• For technical support or any clinical questions call
GAMBRO at 800-525-2623 (which is located at the
back of the CRRT machine)
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