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
 Nephrology Nurse  Bedside Nurse

 Initiate treatment based on  Do not infuse other

individual patient needs as medications or blood
assessed by the products directly into the
nephrologist 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
 Nephrology Nurse
 Prisma/Prisma tubing
 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
Before Treatment
Equipment/Supplies
 Nephrology Nurse
 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
 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
Catheter Issues
 Design *largest diameter w/shortest length
 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
 Site *RIJ (LIJ, IVC, Subclavian)
 Tip *well within the atrium
Catheter Issues
 Catheter flow
 Early – malposition
 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
 Catheter related infection
 Local
 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
 Catheter related bacteremia
Treatment Initiation

 Nephrology Nurse  Bedside Nurse

 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
 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
 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
 Verbalize
 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
 Demonstrate
 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
 Bedside Nurse
 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

 Bedside Nurse
 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
 Bedside Nurse
 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
 Circuit Volumes
 Hypothermia
 Anticoagulation
 Fluid Management
 Blood Flow Rates
 Nutrition
 Solutions
Circuit Volumes
 Significant when dealing with pediatrics
 General Guidelines
 Circuit volumes should be < 10% of the patients
intravascular blood volume
Blood Priming

 Indications
 Circuit volume > 10% of the patients blood
volume
 Hemodynamic instability
 Infants
Complications of Blood
Priming
 Blood Bank pRBC tend to be high in K+
 Close K+ monitoring needed at initiation
 pRBC HCT are approximately 80%
 1:1 dilution with normal saline
 Blood prime need to be done at time of initiation.
 Citrate binds calcium
 hypotension
Hypothermia
 Significant in pediatrics
 The smaller the more difficult
 Heat loss related to rate of blood flow and
volume of blood in circuit
 Blood flow rate
 Higher blood flow rate decrease heat loss due to
less time outside of the body
Hypothermia
Nursing intervention
 External warming devices
 Radiant warmers
 Baer hugger
 Heating mattress
 Blood warmers
 Solutions heaters
 Monitoring
 Skin breakdown and patient temperature
Anticoagulation
 Nursing assessment
 Monitor ACT q 1-2 hours
 via Hemochron®
 Maintain ACT range 150-200”
 Monitor for active bleeding
 Monitor circuit for cracks and clotting
Fluid Management
 Ultrafiltration controller necessary
 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
 Accurate Intake and Output assessments
 Hourly ultrafiltration calculations
 Monitoring vital signs
 Heart Rate, CVP, Blood pressures
 Patient Weights
 q 12 hours or daily
 IMPORTANT - Look at your patient
Access Difficulties
 What is the correct access?
 ? Best placement
 In flow vs out flow difficulties
In Flow Difficulties
 Obstruction or clot “upstream” of inflow
 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
 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
 reverse flow, change access, decrease blood flow
rates