Download Nursing Workshop 1 - Pediatric Continuous Renal Replacement

Nursing Issues in Pediatric
CRRT
Helen Currier BSN, RN, CNN
Assistant Director – Renal, Pheresis
Scholar – Center for Clinical Research
CRRT Treatment Responsibilities:
Points to Remember
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Nephrology Nurse
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Initiate treatment based on
individual patient needs as
assessed by the
nephrologist
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Bedside Nurse
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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
Before Treatment
Equipment/Supplies
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Nephrology Nurse
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Prisma/Prisma tubing
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Bedside Nurse
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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
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Nephrology Nurse
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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
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Bedside Nurse
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Review, clarify, and note
CRRT
Draw baseline labs per
CRRT orders
Explain procedure and
answer questions as
needed
Check cannulated limb for
circulation
Catheter Issues
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Design *largest diameter w/shortest length
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Diameter
 19% ↑ = flow 2x
 50% ↑ = flow 5x
 Increasing from 2.0mm to 2.1 mm increases flow 21%
Length
 19% ↑ in diameter will compensate for doubling of length
Placement
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Site *RIJ (LIJ, IVC, Subclavian)
Tip *well within the atrium
Catheter Issues
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Catheter flow
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Early – malposition
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Kink
Tip malposition – too high/low
Tip malposition – arterial against the wall
Tight suture
Tip in wrong vessel
Late – thrombosis or fibrin sheath formation
Catheter Issues
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Catheter related infection
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Local
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Exit site – s/s redness, drainage, crusting, swelling,
odor, or pain
Tunnel – s/s swelling, pain, redness or ability to
express draining down the tunnel track to the exit site
Systemic
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Catheter related bacteremia
Treatment Initiation
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Nephrology Nurse
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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
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Bedside Nurse
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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
Nephrology Nurse
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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
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Verbalize
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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
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Demonstrate
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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
CRRT Treatment Responsibilities:
q 1 hour
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Bedside Nurse
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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
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Bedside Nurse
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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
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Bedside Nurse
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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
Potential Complications with
Pediatric Hemofiltration
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Circuit Volumes
Hypothermia
Anticoagulation
Fluid Management
Blood Flow Rates
Nutrition
Solutions
Circuit Volumes
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Significant when dealing with pediatrics
General Guidelines
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Circuit volumes should be < 10% of the patients
intravascular blood volume
Blood Priming
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Indications
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Circuit volume > 10% of the patients blood
volume
Hemodynamic instability
Infants
Complications of Blood
Priming
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Blood Bank pRBC tend to be high in K+
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Close K+ monitoring needed at initiation
pRBC HCT are approximately 80%
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1:1 dilution with normal saline
Blood prime need to be done at time of initiation.
Citrate binds calcium
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hypotension
Hypothermia
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Significant in pediatrics
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The smaller the more difficult
Heat loss related to rate of blood flow and
volume of blood in circuit
Blood flow rate
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Higher blood flow rate decrease heat loss due to
less time outside of the body
Hypothermia
Nursing intervention
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External warming devices
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Radiant warmers
Baer hugger
Heating mattress
Blood warmers
Solutions heaters
Monitoring
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Skin breakdown and patient temperature
Anticoagulation
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Nursing assessment
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Monitor ACT q 1-2 hours
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via Hemochron®
Maintain ACT range 150-200”
Monitor for active bleeding
Monitor circuit for cracks and clotting
Fluid Management
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Ultrafiltration controller necessary
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Pumps up to 30% inaccurate
Ultrafiltration rate 0.5-1ml/kg/hr
Difficulty in accurate assessment of
measurement of u/f with less room for error in
small children
Fluid Management
Nursing
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Accurate Intake and Output assessments
Hourly ultrafiltration calculations
Monitoring vital signs
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Patient Weights
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Heart Rate, CVP, Blood pressures
q 12 hours or daily
IMPORTANT - Look at your patient
Access Difficulties
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What is the correct access?
? Best placement
In flow vs out flow difficulties
In Flow Difficulties
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Obstruction or clot “upstream” of inflow
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high intrathoracic pressure with HIFI
up against the vessel wall
Clamp on inflow
Access kinked at skin site
Consider reversing or changing access
Out Flow Difficulties
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Clamp on access/”arterial” line
Inflow port up against vessel wall
Patient “dry” e.g. with femoral site
High of blood flow requirements based upon
flow ability of access
Consider
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reverse flow, change access, decrease blood flow
rates