CRRT: I and O. I and O Sheet

Transcription

1 CRRT: I and O I and O Sheet The following slide outlines a 12 hour CRRT I and O record. The individual lines of the I and O portion of the record will be reviewed. At the end of each hour, the ICU nurse will input the values on the CRRT record. CRRT Flowsheet 1

2 Note 1A-1D are in their own section They are delivered by the machine and automatically removed by the software of the PrismaFlex You do not use these numbers to figure your I and O. 1A Effluent (Total of All Fluids) The content of the effluent will depend on the CRRT mode or therapy selected for the patient. Effluent is Ultra-filtrate (plasma water) being removed from the patient the used dialysate the used post -filter replacement fluid to the deareation chamber The used pre filter convective fluid i.e. everything that winds up in the collection bag. 2

3 1B: Dialysate Infused Enter the actual number from the history screen in Dialysate Used line. 1C: REPLACEMENT POST FILTER This volume is being delivered by the machine s integrated pumps to maintain the saline blood interface in the de-areation chamber. The integrated effluent pump adjusts to extract this additional fluid. 1D Pre Blood Pump (PBP) This fluid is pre filter dilution fluid delivered by the machine before the blood pump via the PBP. This fluid provides for convective solute clearances. 3

4 2: TOTAL INTAKE: IV, PO, (everything except replacement) Record all input from the previous hour and place on line 2. Line 2 will be the Input from the patient s IV, PO, NG etc that hour EVERYTHING (except replacement fluid) IS INCLUDED [Blood, albumin, FFP etc] 3A: Patient Fluid Removal Enter actual volume for Actual Patient Fluid Removed from the history screen. 3B: Additional Output (urine, NG, chest tubes, drains) Review patient output the previous hour and record it on line 3B. 4

5 3C (3A + 3B): Total Output Total volume removed from patient that hour via CRRT and all other sources. Hourly Fluid Balance The total output (3C) will be subtracted from the total input (2) for the hour. This will result in the Hourly Fluid Balance that hour. 5

6 Goal Section Choose your parameter for your goal. It may be a constant fluid goal per hour. Or a sliding scale based on the patient s CVP, PCWP, MAP. Input the desired outcome on line 5. Fluid Sliding Scale CVP REPLACEMENT > Target CVP even < Patient Fluid Replacement Given Your hourly fluid balance will display EPIC will calculate the replacement fluid to be given depending on the desired outcome you have entered The volume will be given at the distal stopcock on the venous return side of the vas cath. This fluid is given via an Infusion pump over the hour NOT as a bolus. 6

7 Type of Replacement fluid The next section is where you document the type of replacement fluid and the amount of each solution used. 7

8 Hourly Net Balance This will give us the actual hourly fluid balance. This takes into account the replacment fluid you are giving. This value should agree with Desired Outcome on line 5. Exceptions for not agreeing with line 5. Inaccurate I and O. 8

9 When they don t match Look at I and O sheet as final word. 9

10 CRRT: Fluid Boluses If a patient is hemodynamically unstable and the patient requires a bolus of fluid for support. (The intention is to give him volume) Make him positive the amount of the bolus for that hour. Enter the bolus amount only as the Desired Outcome for that hour Notify the Nephrologist. 10

11 Example of I s and O s with CRRT: Case Study From the hours of 6-7 AM: The effluent for each hour is 2700 ml each hour. The ultrafiltration rate is 1000 and the Dialysate rate is 1000 ml/hr and the pre blood pump dilution rate is set at 500 ml/ hr of NS and the post filter replacement pump is set at 200mls/hr. The patient receives 200 mls of input (iv, po, NG etc ) that hour and has 200 mls from his chest tube. His SBP IS 90/50, HR 110 and the CVP 7. How much Replacement do we give next hour? Fluid Sliding Scale CVP REPLACEMENT > Target CVP even < PRISMAFLEX TIME EFFLUENT (TOTAL OF ALL A FLUIDS) 1B DIALYSATE INFUSED C REPLACEMENT POST FILTER 200 Example of I and O using CRRT Flowsheet 1D PRE BLOOD PUMP) TOTAL INTAKE: IV PO, ETC. EXCEPT REPLACMENT 200 3A PATIENT FLUID REMOVAL ADDITIONAL OUTPUT (URINE, B NG, CHEST TUBES, DRAINS) 3C TOTAL OUTPUT (3A+3B) 4 HOURLY FLUID BALANCE (2-3c) DESIRED OUTCOME (+ OR -) MDORDER PATI ENT FLUID REPLACEMENT GIVEN 7 ACTUAL NET FLUID BALANCE +50 (4+6)) 11

12 CRRT I and O Scenarios Example Hepatorenal patient that is now requiring CRRT to maintain fluid, electrolytes and acid-base balance. Hourly Settings: CVVHDF Effluent- 2700mls Dialysate- 1000mls Replacement post filter- 200mls Pre Blood Pump- 500mls Patient Fluid Removal- 1000mls AM Patient s input that hour was 300 mls that hour and had 200 mls output. The patient s CVP had dropped to 5 mm Hg, the Hct dropped to 23 and the patient had a SBP of 70 mm Hg. The MD orders one unit of prbc s (300mls) stat for hypotension. 12

13 Fluid Sliding Scale CVP REPLACEMENT > Target CVP even < PRISMAFLEX TIME EFFLUENT (TOTAL OF ALL 1A 2700 FLUIDS) 1B DIALYSATE INFUSED C REPLACEMENT POST FILTER 200 1D PRE BLOOD PUMP) 500 TOTAL INTAKE: IV PO, ETC. 300 EXCEPT REPLACMENT This patient is hypotensive and needs volume. How do you record this? 3A PATIENT FLUID REMOVAL ADDITIONAL OUTPUT (URINE, B NG, CHEST TUBES, DRAINS) 3C TOTAL OUTPUT (3A+3B) 4 HOURLY FLUID BALANCE -600 (2-3c) 5 DESIRED OUTCOME (+ OR -) MDORDER PATI ENT FLUID REPLACEMENT 6- GIVEN 7 ACTUAL NET FLUID BALANCE (4+6)) What is the desired Fluid goal? Do we follow the Fluid Sliding Scale if we give a bolus of fluid to the patient? 13

14 PRISMAFLEX TIME EFFLUENT (TOTAL OF ALL A FLUIDS) 1B DIALYSATE INFUSED C REPLACEMENT POST FILTER 200 1D PRE BLOOD PUMP) TOTAL INTAKE: IV PO, ETC. EXCEPT REPLACMENT A PATIENT FLUID REMOVAL ADDITIONAL OUTPUT (URINE, B NG, CHEST TUBES, DRAINS) 3C TOTAL OUTPUT (3A+3B) 4 HOURLY FLUID BALANCE -600 (2-3c) MDORDER DESIRED OUTCOME (+ OR -) (4+6)) PATI ENT FLUID REPLACEMENT GIVEN 900 ACTUAL NET FLUID BALANCE +300 Use the Bolus rule and make him positive the amount of the bolus AM There have been no changes in the flow rates. That next hour the input was 350 mls and output was 50 mls. The SBP was 95 mm Hg and the CVP climbed to 8. Fluid Sliding Scale CVP REPLACEMENT > Target CVP even <

15 PRISMAFLEX TIME EFFLUENT (TOTAL OF ALL A FLUIDS) 1B DIALYSATE INFUSED C REPLACEMENT POST FILTER D PRE BLOOD PUMP) TOTAL INTAKE: IV PO, ETC EXCEPT REPLACMENT A PATIENT FLUID REMOVAL ADDITIONAL OUTPUT (URINE, B NG, CHEST TUBES, DRAINS) 3C TOTAL OUTPUT (3A+3B) 4 HOURLY FLUID BALANCE (2-3c) MDORDER DESIRED OUTCOME (+ OR -) PATI ENT FLUID REPLACEMENT GIVEN 7 ACTUAL NET FLUID BALANCE (4+6)) The patient is hemodynamically stable. The R.N. now follows the Fluid Sliding Scale ordered by the Nephrologist. Brief Words Regarding I s and O s At the end of the hour, the ICU nurse will fillout the CRRT Doc Flowsheet The ICU nurse will document the Patient Fluid Replacement Given calculated by EPIC. The Patient Fluid Replacement Given will be given over the next hour. If given over less time (as a bolus), the CVP or PCWP may be artificially elevated and the volume replacement next hour will be insufficient. dâxáà ÉÇá 15