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Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies
Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies
Lecture Outline
Evolution of CRRT Principles involved in CRRT Different modalities of CRRT Dialysate Fluids Principle of Clearance in CRRT
CONVECTION
SCUF
Hemofilter Effluent Pressure
Return Pressure
Syringe pump
Blood Pump
Filter Pressure
BLD
Effluent Pump
CVVH
Hemofilter
Return Pressure
Air Detector
Syringe Pump
Access Pressure
Replacement Pump
Effluent Pump
Replacement Pump
CVVHD
Syringe Pump Hemofilter
Return Pressure
Blood Pump
Filter Pressure
Effluent Pressure BLD
Access Pressure
Dialysate Pump
Effluent Pump
CVVHDF
Hemoperfusion
Is an extracorporeal treatment that passes the patients blood through a filter impregnated with anabsorptive substance, for example, charcoal. This is able to bind to certain toxins in the bloodstream which removes them, returning the cleaned blood to the patient (Kellum, Mehta, Angus,Palevskey, & Ronco, 2002). It has been shown to be effective against drugs like digoxin,glutethimide, phenobarbital theophiline and paraquat among others, and allowed patients tomaintain normal levels of essential molecules (Ponikvar, 2003)
BICARBONATE BASED
Bicarbonate based solutions are physiologic and replace lost bicarbonate immediately. Effective tool to correct acidosis Concentration of 30-35mEq/L corrects acidosis in 24 to 48 hours.
BICARBONATE BASED
Preferred buffer for patients with compromised liver function. Mean arterial pressure remains stable Superior buffer in normalizing acidosis without the risk of alkalosis Improved hemodynamic stability, and fewer cardiovascular events.
Plasma
PrismaSate BK0/3.5
3.5 1.0 140 0 109.5
PrismaSate BGK2/0
0 1.0 140 2.0 108
Lactate (mEq/L)
Bicarbonate HCO3(mEq/L) Glucose (mg/dL) Osmolarity (mOsm/L) pH
0.5 - 2.0
22 - 26 65 - 110 280 - 300 7.35 - 7.45
3
32 0 287 ~ 7.40
3
32 110 292 ~ 7.40
LACTATE-BASED
Metabolized into bicarbonate providing its under normal conditions. Lactate is converted in the liver on a 1:1 basis to bicarbonate and can sufficiently correct acidemia.
LACTATE-BASED
Non physiologic pH value of 5.4 Is a powerful peripheral vasodilator Further acidemia for patients in:
Hypoxia Liver impairment Pre-existing lactic acidemia can result in worsening of lactic acidemia
MOLECULAR SIZES
Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies
Collaboration
Nephrology Nurse
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
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
Bedside Nurse
Review, clarify, and note CRRT Draw baseline labs per CRRT orders Explain procedure and answer questions as needed Check cannulated limb for circulation
Bedside Nurse
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
Treatment Initiation
Nephrology Nurse
Assess patients 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
Bedside Nurse
Assess patients 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
Bedside Nurse
Check circuit ionized Ca++ (sample from venous port) and patients 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
I AND O FORMULA
Net fluid removal hourly (physician order)
+
Nonprisma intake (IV, TPN, etc.)
=
Patient Fluid Removal Rate (set in prisma)
Learning Objectives
To discuss the fundamentals of CRRT To enumerate the required nursing competencies to perform CRRT To present the latest recommendations to improve nursing competencies
Understand JCAHO expectations Develop your CRRT competency assessment program Validate CRRT competency Maintain a consistent CRRT validation system Keep up with new CRRT competencies
Predictions
FTEs by shift Budgeting FTEs
Shortages Effects
Clinical Outcomes Therapy Choice
Safety/Quality
Protocols Order sets Solutions
Stability, expirations, FRF/dialysate, medication management, compounding