Title/Description: Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT)

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1 University of Kentucky / UK HealthCare Policy and Procedure Policy # NE08-06 Title/Description: Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) Purpose: To provide direction to nursing staff for safe and effective care of patients on CRRT. Policy Definitions Continuous Renal Replacement Therapy (CRRT) Dialysate Filter or Dialyzer Ultrafiltrate (UF) Effluent Procedure Types of CRRT Caring for Patient on CRRT Nephrology Consult ICU Nursing Responsibilities Troubleshooting Disconnecting from CRRT Machine Evidence-Best Practice References Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates Policy Providing safe and effective nursing care to patients on CRRT requires verifying that the patient s fluids and toxins are removed through a special central venous access site. CRRT is indicated in critically ill patients who often cannot tolerate intermittent hemodialysis due to hemodynamic instability. Nursing staff who care for patients on CRRT shall follow the standards and procedures detailed in this policy and procedure. Definitions Continuous Renal Replacement Therapy (CRRT) CRRT is a general term that refers to any extra-corporeal blood purification therapy which is intended to substitute impaired renal function over an extended period of time and applied (or aimed at being applied) for 24 hours per day. Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 1

2 Dialysate A fluid containing electrolytes and buffers given to provide a concentration gradient across the filter membrane to enable diffusive solute clearance; can also be used as replacement fluid. Filter or Dialyzer A tubular-shaped device made up of a plastic casing and the capillary fibers of the semipermeable membrane inside it. Ultrafiltrate (UF) The net volume of fluid removed from the patient's vascular system by the dialysate (essentially functions and looks like urine). Effluent Total volume of fluid ultrafiltrate, dialysate, solutes of electrolytes and toxins such as excess creatinine; in effect, waste products from patient. Procedure Types of CRRT CRRT includes the following variations 1. CVVH (continuous veno-venous hemofiltration), 2. CVVHD (continuous veno-venous hemodialysis), 3. CVVHDF (continuous veno-venous hemodiafiltration), 4. SCUF (slow continuous ultrafiltration) 5. SLEDD (slow extended daily dialysis). Each type of CRRT utilizes an extracorporeal circuit consisting of one double lumen catheter in a large vein (either jugular or femoral), blood tubing, a hemofilter, and a blood pump. Caring for Patient on CRRT 1. Patients requiring CRRT shall be in the Intensive Care Unit (ICU). 2. Nursing shall only accept orders from a nephrologist (includes Pediatric Nephrologists in the Pediatric Intensive Care Unit [PICU]). 3. Dialysis nursing personnel shall: (a) Set up and initiate the system upon order of a nephrologist. (b) Be responsible for charges. (c) Be on-call through the nephrologist for troubleshooting. (d) Change the set-up cassette as needed. 4. In the PICU, if ordered, RN staff who have demonstrated competency shall be responsible for drawing and running activated clotting times (ACTs). Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 2

3 5. ICU RN staff who have demonstrated competency as super-users can initiate and set-up the CRRT system. Nursing personnel shall perform the following functions related to the delivery of CRRT: (a) Change dialysate and/or replacement fluid bags when nearly empty, as indicated on CRRT machine screen. (i) All bags shall be labeled with the patient s name, date, additives, and the nurses initials. (ii) Pharmacy shall add and verify any additives ordered. (b) Change citrate bags if used, as needed, per Citrate Protocol. (c) Document appropriate inputs and outputs (I&Os), vital signs (VS), labs and patient s response on the flow sheet hourly. Document hourly the CRRT machine blood flow rate, arterial & venous pressures, filter & other pressures as displayed on CRRT machine screen. (d) Perform basic monitoring of the patient and system by: (i) Appropriate anticoagulant administration according to orders; (ii) Appropriate administration of replacement fluids according to orders; (iii)accurate I&Os with appropriate documentation of net fluid loss if ultrafiltration is used; and (iv) Electrolyte monitoring. (e) Order dialysate and/or replacement fluids from Pharmacy. (f) Check patency of the system. (g) Initiate troubleshooting interventions as indicated on CRRT machine alarm screen. (h) Call the nephrologist for any complications. (i) Follow appropriate procedure for disconnecting, reinfusing and reconnecting to venous access as needed for transporting or clotting of system. (j) Terminate treatment upon a physician s order or for complications outlined in the guide. Nephrology Consult 1. A nephrology consult shall be obtained prior to initiation of a CRRT. If CRRT is indicated, the nephrologist shall be responsible for vascular access placement and notifying the dialysis staff. 2. Baseline information shall be obtained by the ICU nurse, including: (a) Weight and VS; (b) Labs as ordered; and (c) Hemodynamic measurements 3. CRRT orders shall be made by the nephrologist. Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 3

4 4. The CRRT machine shall be lined, primed and connected to patient by a dialysis nurse, or ICU super-users who have demonstrated competency. CRRT filter and set-up will be changed every 72 hours. ICU Nursing Responsibilities 1. Inform patient and family of treatment. 2. Strict I&Os. 3. Document hourly as indicated on CRRT flowsheet. 4. Administer replacement fluids at ordered rate. 5. Change dialysate and/or replacement fluid bags, citrate bags if used, and empty effluent bags as indicated on CRRT machine screen. 6. Always ensure connection between catheter ports and CRRT lines are taped with clear surgical tape (never white adhesive tape) for safety. 7. CRRT lines are not to be used for infusing IV fluids or blood products. Troubleshooting 1. Bleeding from body orifices: (a) Stop anticoagulant infusion. (b) If citrate is being used, also immediately stop calcium chloride infusion in the peripheral line. (c) Check labs. (d) Notify nephrologist and the house officer. 2. Severe hypotension: notify the physician. 3. High or low pressures on the CRRT machine: (a) Follow guide on screen to clear alarms. (b) Check patency of lines and catheter by pausing machine and quickly flushing each port of catheter with 10 ml of normal saline. (c) Reverse catheter ports if necessary. Nurse, patient and all others in room to wear mask whenever catheter is opened. 4. All other CRRT machine alarms: follow screen prompts. CAUTION: patient safety may be compromised if alarms are repeatedly 'overridden' for a lengthy period. If the same frequent alarms occur, consult the nephrologists on call. 5. Filters: It is best practice and manufacturer s recommendations to only use filters for 72 hours. Filters should not run until clotting occurs. The efficiency of the filter is no longer optimal after this point. Also, there are several risks associated with allowing the system to clot: (a) Blood loss: If the machine is telling you that the filter is clotted then you should not return blood, and this leads to blood loss. Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 4

5 (b) Emboli: Using a clotted filter increases the risk of clot formation in the system. Remember the blood lines that are attached to your patient are an extension of their blood stream and is in direct contact with the patient s circulatory system. (c) Catheter malfunctions: Clotting the dialysis circuit can lead to clotting of the catheter as well. This leads to replacement of the catheter, increased risk for infection, stenosis of venous blood vessels, and delays in patient therapy. (d) Fluid and electrolyte imbalances: As the TMP increases on your machine, the pressure inside the dialyzer increases which can lead to an increase in fluid and solute exchange and imbalance. TMP will increase as your system clots. Disconnecting from CRRT Machine 1. Equipment: (a) Masks for nurse, patient (if not on respirator) and all in room. (b) Gloves (c) Two 10 cc syringes filled with 0.9% normal saline (d) Two syringes of sodium citrate 4% or other anticoagulant as ordered, obtained from pharmacy (e) Chux (f) Two alcohol swabs (g) Two male luer locks 2. Procedure: (a) Wash hands. Put on gloves and mask. Place chux under connection of lines to access. (b) Follow CRRT screen prompts to stop treatment and reinfuse the patient's blood remaining in the CRRT lines. (i) When disconnecting arterial (red) line, attach 10 ml normal saline syringe to the catheter end until reinfusion complete. (ii) Connect red CRRT line to normal saline bag via 'Y' connection. (iii)begin reinfusion by following CRRT screen instructions. (iv) When reinfusion is complete, disconnect venous (blue) line from patient and attach 10 ml normal saline syringe to blue catheter port. (c) Flush both catheter ports with the 10 ml of normal saline. (d) Note volume of each lumen of the access catheter (it shall be written on each port). This volume may vary. Instill the exact volume of sodium citrate 4% into each catheter port. Clamp ports. (e) Swab ends of ports with alcohol. (f) Cap ends of catheter ports with male luer locks and tape. Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 5

6 (g) Unload CRRT filter/line cassette per screen instructions and toss into red hazardous waste bin. Leave CRRT machine in forward 'unload' position, turn off machine and warmer, if used. Notify dialysis unit. Evidence-Best Practice References 1. Continuous Renal Replacement Therapy, John A. Kellum, Rinaldo Bellomo & Claudio Ronco, editors, Core Curriculum for Nephrology Nursing, American Nephrology Nursing Association, 5th edition, American Nephrology Nurses' Association: Nephrology Nursing Standards of Practice and Guidelines for Care, 7th edition, Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children s Ambulatory Department Nursing Policies Replaced Chandler HP Good Samaritan Kentucky Children s CH Ambulatory KC Other Effective Date: 01/16/2014 Review/Revision Dates: 08/1989, 01/16/2014 Approval by and date: Name Laura Bruin, Dialysis Nurse Manager, Review Team Leader Name Richard Zerbee, Chair, Nursing Professional Practice Council Name E. Darlene Spalding, Senior Nurse Administrator, UK HealthCare Good Samaritan Hospital Name Kathleen Kopser, Senior Nurse Administrator, Chandler Hospital Name Colleen Swartz, Chief Nurse Executive Policy # NE08-06 Nursing Care of the Patient on Continuous Renal Replacement Therapy (CRRT) 6

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