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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 • 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) CVVH SYSTEM Replacement fluid bm14 roller pump Heparin IV pump Roller pump Roller pump Hemofilter From the patient Drainage bag/UF Venous chamber Air detector To the patient CVVHD SYSTEM Replacement fluid bm14 roller pump From the patient Heparin IV pump Roller Pump Roller Pump Drainage bag/UF Dialysate IV pump Hemofilter Venous chamber Air detector To the patient Success with CRRT • • • • • • Access Equipment Tubing/filter Prime Anticoagulation Staffing 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 Blood Pump Systems for CRRT CRRT Machines: Current Generation 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 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 Blood Prime • • • • • • Whole blood PRBC + Albumin 5% PRBC + NS PRBC + FFP Larger patients Albumin 5% AN-69 filter requires special considerations 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 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 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) 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 Anticoagulation 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 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 3rd International Conference on Pediatric Continuous Renal Replacement Therapy (PCRRT) June, 2004 Coronado Springs Disney Orlando, Fl www.pcrrt.com CRRT Modalities • CAVH: Continuous Arteriovenous Hemofiltration • SCUF: Slow Continuous Ultrafiltration • CVVH: Continuous Venovenous Hemofiltration • CVVHD: Continuous Venovenous Hemodialysis 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 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 Baxter bm25™ • 2 integrated modules – Blood module (bm 11a™) – Balancing module / scales (bm14™) CRRT Modalities • CAVH: Continuous Arteriovenous Hemofiltration • SCUF: Slow Continuous Ultrafiltration • CVVH: Continuous Venovenous Hemofiltration • CVVHD: Continuous Venovenous Hemodialysis 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 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 Baxter bm25™ • 2 integrated modules – Blood module (bm 11a™) – Balancing module / scales (bm14™) CVVH SYSTEM Replacement fluid bm14 roller pump Heparin IV pump Roller pump Roller pump Hemofilter From the patient Drainage bag/UF Venous chamber Air detector To the patient CVVHD SYSTEM Replacement fluid bm14 roller pump From the patient Heparin IV pump Roller Pump Roller Pump Drainage bag/UF Dialysate IV pump Hemofilter Venous chamber Air detector To the patient
