CRRT Din

CRRT
Procedures
and
Guidelines
2013
Guidelines for the utilization of CRRT (Continuous Renal

Replacement Therapies) at Monroe Carell Jr. Childrens Hospital at
Vanderbilt
CRRT:
Guidelines
CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU
Version: 03/18/2013
CRRT Contacts: Monroe Carell Jr. Childrens Hospital at Vanderbilt

Name
Kathy Jabs, M.D.
Title
Director Pediatric
Nephrology
Tray Hunley, M.D.
Pediatric Nephrology
Deborah Jones, M.D.
Pediatric Nephrology
Brian Bridges, M.D.
Pediatric Critical Care
Geoffrey Fleming, M.D. Pediatric Critical Care
John Pietsch, M.D.
Pediatric Surgery
Daphne Hardison, RN ECMO and CRRT Mgr
Christy Worden, RN
Lead ECMO Specialist
ECMO Team
ECMO Team
Dialysis Storage
4th Floor VUH
UHS Rental
Rental PrismaFlex
Gambro
Intensive Care Hotline
Debi Camp RN
Systems Support HED
Wendy Williams RN
Gambro Specialist
Address
Phone
Pager
DOT 10111
615-322-7416
615-835-0821
DOT 10111
DOT 10110
DOT 5121
DOT 5121
DOT 7100
VCH 4512
VCH 4414
VCH 4414
VUH 4th flr
Nashville
Troubleshooting
615-322-7416
615-322-7416
615-936-3698
615-936-1302
615-936-1050
615-322-0519
615-936-6562
615-775-5861
615-322-0912
615-367-4010
888-404-4266
615-936-0046
901-488-5564
615-835-0822
615-835-7233
615-835-1444
615-835-7228
615-835-7401
615-835-4049
615-835-4892
615-317-3266
Code 3-4-5
Trainer
615-477-2586
Authors: Brian Bridges M.D., Geoffrey Fleming M.D., Christy Worden, RN, Daphne Hardison RN, Deborah Jones
M.D., Kathy Jabs MD, Tray Hunley MD (Approved by group on March 18, 2013)
Version: 03/18/2013
PROTOCOL FOR CRRT (CONTINUOUS RENAL REPLACEMENT THERAPY)

I. Indications
CRRT is used in critically ill patients to assist and replace normal renal function
in the face of acute organ dysfunction. Additionally, the blood purification
properties of the therapy may also be employed in certain situations. Indications
for CRRT will be determined by the intensive care unit physician team caring for
the patient. The usual clinical indications for CRRT in critically ill patients
include (but are not limited to):
1.
2.
3.
4.
Acute renal failure

Treatment or prevention of diuretic-resistant fluid overload
Electrolyte or acid-base disturbances
Unstable chronic renal failure patients who cannot tolerate intermittent
hemodialysis or peritoneal dialysis
5. Detoxification
II. Modes of CRRT

Modes of CRRT include SCUF (slow continuous ultrafiltration), continuous
veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis
(CVVHD), and continuous veno-venous hemodiafiltration (CVVHDF). The most
common form of CRRT most often used in the critical care setting at Monroe Carell
Jr. Childrens Hospital at Vanderbilt is CVVH.
III. Policy
CRRT will be ordered by the intensive care physician or nephrologist, and the
initiation of CRRT will require subsequent consultation by pediatric nephrology.
The ECMO Team will provide technical support including equipment set up,
maintenance, and troubleshooting. The bedside RN will continuously monitor the
CRRT delivered at the bedside and provide basic troubleshooting and adjustment
of the therapy with the assistance of the ECMO Specialist as needed.
IV. Equipment
CRRT will be performed with the Prismaflex CRRT System. In general, the HF
1000 hemofilter set will be used on all patients. A blood prime should be provided
for any patient less than 15 kilogram except in cases of life threatening emergency
which do not allow for the time necessary for a blood prime. A blood prime
should be considered for any patient 15 to 20 kilograms based on discussion with
either the attending intensivists or nephrologists in relation to hemodynamic
Version: 03/18/2013
instability. Procedure for blood priming the HF 1000 filter is listed under
procedure and will require an ECMO medication kit to allow for buffering of the
prime.
The risk of a bradykinin release activation syndrome with blood priming of the
circuit can result in potential tachycardia, hypotension, and vasodilation1. This
has been documented when the AN-69 (M60) hemofilter is used. 1 to 2 meq/kg
of sodium bicarbonate should be administered prefilter, and a dose of intravenous
calcium should be administered to the patient in the case of bradykinin release.
Point of care testing by the ECMO Specialist with the approved instrument will
be provided to measure activated clotting times (ACTs) if systemic heparinization
is used or ionized calcium levels if regional anticoagulation with citrate is used.
For patients who are not on ECMO, the initiation of CRRT will require the
placement of a vascath. The chart below gives a guideline for the appropriate
vascath size and location based on patients age and weight.
Suggested Size and Selection of CRRT Vascular Access for Pediatric Patients2
Patient Size
Catheter Size and

Manufacturer
Preferred Site of Insertion
NEONATE
Dual-Lumen 7.0 French

(COOK/MEDCOMP)
(COOK/MEDCOMP)
Triple-Lumen 7.0 Fr
(MEDCOMP)
(KENDALL, ARROW)
(MEDCOMP)
(ARROW, KENDALL)
Triple-Lumen 12.5 French
(ARROW, KENDALL)
Internal Jugular
3-6 KG
6-30 KG
>15-KG
>30 KG
>30 KG
Internal Jugular
Internal Jugular
Internal Jugular
Internal Jugular
Internal Jugular
Internal Jugular
V. Procedure
1. Set up CRRT device per manufacturer recommendation.
Version: 03/18/2013
2. The circuitry will be primed with heparin saline 2 to 5 units/ml per 1

ml saline. Reprime will be completed utilizing normal saline or blood.
3. Blood Prime procedure:
Step 1: Gather needed supplies

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Banked PRBCs Full Unit

100 units of Heparin Saline (ECMO Medication Kit)
10 meq 8.4% Sodium Bicarbonate (ECMO Medication Kit)
50 mls 25% Albumin (ECMO Medication Kit)
400 mg Calcium Chloride (bristojet) ECMO Medication Kit
1 L Heparin Normal Saline concentrated between 2 and 5 units heparin/ml
Emptied Liter bag from #4 post circuit prime
PrimsaFlex Ordered Circuitry
CRRT Order set
Step 2: Prime circuit with saline/heparin per institution protocols

Step 3: Prepare PRBCs by adding to the unit in the following order:
(1) 100 units heparin, 10 meq NAHCO3; 50 mls 25% Albumin; 400 mg Calcium Chloride
(2) Connect blood to a straight blood filter set
(3) Connect set to Access Port CRRT Circuit
(4) Leave Emptied 1 Liter Normal Saline bag attached to the Return Line CRRT Circuit
(5) Open all clamps and stopcocks on the CRRT Circuit
(6) Initiate Blood Flow at 100 ml/minute, displacing saline with PRBCs until fully primed
(7) Stop blood flow and clamp both access and return lines to CRRT Circuit
(8) Insert a 3-way high flow stopcock
(9) Open clamps and 3-way high flow stopcock
(10)Initiate Blood Flow at 50 ml/min
Step 4: Initiate CRRT to patient

(1)
(2)
(3)
(4)
(5)
(6)
Healthcare provider, nurse and ECMO Specialist all at bedside

Remove heparin from patient access line; flush assuring patency and clamp line
Stop blood flow on CRRT machine, clamp both access and return lines
Remove 3- way stopcock and attach access to access and return to return
Initiate blood flow at prescribed rate
Post initiation have Sodium Bicarbonate and Calcium Chloride available
3. If patient requires a blood warmer utilize the integrated blood warmer.

4. Notify physician when ready to begin CRRT. A member of the patient
care team (ICU or Nephrology) will be available at bedside during
initiation of therapy.
5. Access and Return ports can be switched to obtain functional blood
flow.
6. CRRT can be connected to the ECMO circuit directly for patients
requiring ECMO support (see ECMO protocol).
Version: 03/18/2013
7. Assess the patients hemodynamic status closely. Fluid boluses,

calcium chloride, and sodium bicarbonate will be available during the
procedure and given under physician order. Be prepared to decrease or
temporarily stop flow if patient shows signs of deterioration during
initiation.
8. The ECMO specialist will document initiation of CRRT, patients
response, and initial settings in the HED note section CRRT
flowsheet.
9. The bedside nurse will take over continuous monitoring and
maintenance of CRRT. The bedside nurse will call the ECMO
specialist as needed for general information and troubleshooting of the
CRRT device.
10. In general, the standard BFR (blood flow rate) will be 3 to 5
ml/kg/min with a lower limit of 50 ml/min, this may be as much as
10 ml/kg/min.
11. FRF (filter replacement fluid) will run at 30 to 40 ml/kg/hr. For
patients 10 kg or less, normal saline at 10% of the FRF rate will run
post-filter. For patients greater than 10 kg, normal saline at 5% of the
FRF rate will run post-filter. The FRF will be placed pre-filter.
The FRF used with the Prismaflex will be the FDA approved
PrismaSol. Exceptions can be made as per pediatric nephrology.
12. In general, the filtration fraction should be less than 30% in order to
prevent hemofilter clotting.
FF (%) = UFR X 100
BFR X (1 - HCT)
13. The Prismaflex excess fluid loss/gain settings should be set at 150 ml
for patients less than 10 kg, 250 ml for patients 10 to 29 kg, and 400
ml for patients 30 kg or greater. Exceptions can be made by pediatric
nephrology.
14. The Prismaflex circuit should be replaced every 72
hours. Exceptions can be made as per the critical care team.
VI. Nursing Implications

1. Assess and document the venous catheter site. Notify the physician for
signs of bleeding, infection, or any other concerns.
2. Monitor intake and output hourly.
3. Maintain device rates as ordered.
4. Except in rare circumstances, all patients on CRRT will require
anticoagulation.
5. The ECMO specialist will monitor ACTs as ordered and titrate
anticoagulation as needed.
6. If using citrate protocol, the ECMO Specialist will monitor and adjust
anticoagulant per citrate protocol as ordered by the physician. See
Citrate Protocol.
Version: 03/18/2013
7. Use heparin 100 units/ml to heparin lock catheters for temporary

disconnect. Use only volume needed to fill catheter. Mark the catheter
to notify it is heparin locked.
8. Venous access dressing should be changed by bedside nurse according
to the PCCU/NICU protocol for central line dressing changes.
VII. Documentation
1. The ECMO specialist will document initiation and any troubleshooting
or changing of the circuit on the CRRT flowsheet in HED.
2. Bedside nurse will be responsible for hourly documentation on the
CRRT flowsheet (HED) and any troubleshooting or adjustments made
in therapy.
3. Physician orders will be complete, reviewed, and in the electronic
medical record.
4. Documentation is the responsibility of the ECMO Specialist and
bedside nurse in the electronic documention record hourly including
removal, bag changes, co signs, verifications and set rates or when
change is made.
VIII. Complications
Complications that may result from the use of CVVH may include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hypovolemia
Hypotension
Thrombosis
Bleeding
Infection
Electrolyte imbalance
Clot formation/emboli
Hemolysis
Filter rupture/blood loss from circuit
IX. Contraindications
The contraindications to hemofiltration include:
1. Inability to obtain vascular access
2. Life threatening risks from anticoagulation.
Version: 03/18/2013
X. Fluid Management
CRRT is utilized for its capabilities of gentle fluid management. Wide
vacillations in hour-to-hour fluid goals should be avoided, and if noted, indicates
a problem. The goal in hemofiltration should be fluid regulation. Aiming for a
zero balance or even a slightly negative balance is optimal. Usual fluid removal
rates range 0-2 ml/kg/hour net fluid removal. Hourly intake and output are
calculated to determine the needed removal to meet the prescribed fluid balance.
Some common scenarios that may occur:
1. When administering blood products for the correction of lab results
(i.e., hematocrit, platelets, etc.) try to minimize the confusion of the
hemofiltration calculations by:
Scheduling the administration to begin at the beginning of the hour or
half hour (give products immediately in life threatening situations);
Extending the length of time the transfusion will infuse over (1 hour for
platelets, 2 to 4 hours for other blood products)
2. When administering volume for hypotension/hypovolemia:
What is the etiology of hypotension? (Fluid loss, pressor
manipulations, acute event)
Is the fluid removal rate to high for the patient hemodynamics?
Attempt to treat with fluid aliquots smaller than a standard 10 or 20
ml/kg (treat to effect rather than by dose).
After resuscitation for hypotension secondary to hypovolemia (absolute
or relative) reduce fluid removal rate to net even for 2-4 hours. Do not
remove the fluid immediately given in resuscitation.
XI.
Nutrition
1. Whenever possible, enteral nutrition is preferred in critically ill
patients. However, if TPN is used for patients on CRRT, they should
receive at least 2g/kg/day protein.
XII.
ECMO Specialist Considerations

1. The CRRT circuit check will be completed every 4 hours and
documented per the electronic documentation record. This includes close
observation for clots, air, leaks and connections in the blood path as well
as the color of the fluid in the ultrafiltrate space.
Version: 03/18/2013
2. If the blood leak detector alarms or frank blood is noted in the

ultrafiltrate space, therapy should be stopped. Contact the ECMO
Specialist in house via 775-5861 or pager 317-3266 and send plasma free
hemoglobin from the ultrafiltrate to determine if blood is present. If blood
is detected, the hemofilter should be replaced.
3. A decrease in the ability of the UF pump to remove the set amount of
ultrafiltrate usually indicates a filter that is clotting or becoming sluggish.
Interventions include:
Assure that the blood flow shunted through the hemofilter is at least
100cc/min. (Set flow - Delivered flow = Shunt)
Reduce the rate of ultrafiltrate (to decrease the alarm) and prepare to
have the ECMO team member change the hemofilter.
4. Close monitoring of vital signs will be maintained. In the event the
patient blood pressure drops and frequent volume repletion is required to
maintain, the ultrafiltrate rate per hour will be decreased.
5. ACTs are monitored closely after connection of the system. Because of
the hemofilters action, heparin is filtered or removed along with
electrolytes and free water. Therefore, heparin consumption may increase.
6. Electrolytes are monitored closely. Basic chemistries, including sodium,
potassium, chloride, bicarbonate, blood urea nitrogen, calcium, and
creatinine, should be followed a minimum of every 12 hours. A level of
magnesium, phosphorus, and a blood gas with ionized calcium, will be
followed daily in the AM.
XIII. Removal of the Prismaflex circuit:

1. CRRT will be discontinued per physician order. The Prismaflex will
be removed by a member of the ECMO team. Volume is not returned
to the patient without an attending or nephrology order.
References
1. Brophy PD, Mottes TA, Kudelka TL, et al. AN-69 membrane
reactions are pH-dependent and preventable. Am J Kidney Dis.
2001 Jul;38(1):173-8.
2. Brophy P, Bunchman, TE. References and Overview for Hemofiltration
in Pediatrics and Adolescents <http://pcrrt.com/>. Accessed 2011 Feb.
Version: 03/18/2013
Pediatric CRRT Order Sheet

Type of therapy:
SCUF
CVVH with Filter Replacement Fluid (FRF)
CVVHD with Dialysate
CVVHDF (Filter Replacement Fluid & Dialysate)
Hemofilter:
Prismaflex (Polysulfone HF)
HF 1000 [1.1 m2, 165 ml in circuit]
Hemofiltration solutions:
Priming solution:
NS + 5000 U/L heparin followed by NS
Filter replacement solutions:

PrismaSol BGK 4/2.5
PrismaSol BGK 2/3.5
PrismaSate BGK 0/2.5
PrismaSol BGK 4/0/1.2
PrismaSol BGK 2/0
PrismaSate BK 0/0/1.2
Additional additives:
Na phosphate @
K phosphate @
[4 mEq/L K, 2.5 mEq/L Ca, 1.5 mEq/L Mg, 100mg/dL dextrose]

[2 mEq/L K, 3.5 mEq/L Ca, 1.0 mEq/L Mg, 100mg/dL dextrose]
[0 K, 2.5 mEq/L Ca, 1.5 mEq/L Mg, 100mg/dL dextrose]
[4 mEq/L K, 0 Ca, 1.2 mEq/L Mg, 100mg/dL dextrose]
[2 mEq/L K, 0 Ca, 1.0 mEq/L Mg, 100mg/dL dextrose]
[0 mEq/L K, 0 Ca, 1.2 mEq/L Mg, 0 mg/dL dextrose]
mEq/L
mEq/L
Post-filter Infusion:
Normal saline to be infused post filter at 10% of the FRF rate (for patients 10 kg or less)
Normal saline to be infused post filter at 5% of the FRF rate (for patients greater than 10 kg)
Treatment orders:
Blood flow rate
FRF rate
Dialysate rate
NET UF rate
ml/min
ml/hr
ml/hr
ml/hr
Filtration fraction (goal<30%) =
RECOMMENDED
(3-5 ml/kg/min)
(30-40 ml/kg/hr)
(30-40 ml/kg/hr)
(net loss 0-2 ml/kg/hr)
Prismaflex
10-450 (10)
0-8000 (50)
0-8000 (50)
UFR X
100
BFR X (1 - HCT)
10
Version: 03/18/2013
Prismaflex excess fluid loss/gain settings as below:

150 ml (for patients less than 10 kg)
250 ml (for patients 10 to 29 kg)
400 ml (for patients 30 kg or greater)
Laboratory monitoring:
Patient and circuit iCa within 15 minutes after initiation, every 1 hour X 4 hours or until stable,
then every 4 hours.
BMP every 12 hours; Phosphorus and Magnesium every AM
Anticoagulation:
Heparin based:
Heparin infusion: 1 ml/hr = 10 units/kg/hr
Titrate heparin to maintain an ACT of
seconds (180 to 200 seconds, unless bleeding)
Heparin bolus:
units (10-20 units/kg)
Heparin infusion:
units (5-20 units/kg/hour)
Citrate based:
Citrate ACD-A Solution-infused into the Access side of the circuit.
Citrate infusion rate:
ml/hr (start at 1.5 times the BFR).
RECOMMENDED ADJUSTMENTS TO CITRATE INFUSION BASED UPON Cai AND PATIENTS
WEIGHT:
Post-filter ionized calcium (mg/dl)
Citrate infusion adjustment
> 20 kg
<1.4
rate by 10 ml/hr
1.4-2.0 (optimal range)
No adjustment
2.0-2.4
rate by 10 ml/hr
> 2.4
rate by 20 ml/hr
Notify MD if citrate infusion rate > 200 ml/hr
< 20 kg
rate by 5 ml/hr
rate by 5 ml/hr
rate by 10 ml/hr
Calcium chloride solution (8 grams/liter NS)-infused into separate central line.

Calcium chloride infusion:
ml/hr
(start at 40% of the citrate rate).
RECOMMENDED ADJUSTMENTS TO Calcium INFUSION BASED UPON Cai AND PATIENTS WEIGHT:
Patient ionized calcium (mg/dl)
Calcium infusion adjustment
> 20 kg
>5.2
rate by 10 ml/hr
4.4-5.2 (optimal range)
No adjustment
3.6-4.4
rate by 10 ml/hr
< 3.6
rate by 20 ml/hr
Notify MD if calcium infusion rate > 200 ml/hr
< 20 kg
rate by 5 ml/hr
rate by 5 ml/hr
rate by 10 ml/hr
11

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CRRT

Guidelines for the utilization of CRRT (Continuous Renal

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

CRRT Contacts: Monroe Carell Jr. Childrens Hospital at Vanderbilt

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

PROTOCOL FOR CRRT (CONTINUOUS RENAL REPLACEMENT THERAPY)

Acute renal failure

II. Modes of CRRT

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

Catheter Size and

Preferred Site of Insertion

Dual-Lumen 7.0 French

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

2. The circuitry will be primed with heparin saline 2 to 5 units/ml per 1

Step 1: Gather needed supplies

Banked PRBCs Full Unit

Step 2: Prime circuit with saline/heparin per institution protocols

Step 4: Initiate CRRT to patient

Healthcare provider, nurse and ECMO Specialist all at bedside

3. If patient requires a blood warmer utilize the integrated blood warmer.

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

7. Assess the patients hemodynamic status closely. Fluid boluses,

VI. Nursing Implications

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

7. Use heparin 100 units/ml to heparin lock catheters for temporary

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

ECMO Specialist Considerations

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

2. If the blood leak detector alarms or frank blood is noted in the

XIII. Removal of the Prismaflex circuit:

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

Pediatric CRRT Order Sheet

Filter replacement solutions:

[4 mEq/L K, 2.5 mEq/L Ca, 1.5 mEq/L Mg, 100mg/dL dextrose]

Filtration fraction (goal<30%) =

CRRT Protocol: Pediatric ICU, Pediatric Cardiac ICU, Neonatal ICU

Prismaflex excess fluid loss/gain settings as below:

Calcium chloride solution (8 grams/liter NS)-infused into separate central line.

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