Nursing Issues in Pediatric CRRT Helen Currier BSN, RN, CNN Assistant Director – Renal, Pheresis Scholar – Center for Clinical Research
Nursing Issues in Pediatric CRRT
Helen Currier BSN, RN, CNNAssistant Director – Renal, Pheresis
Scholar – Center for Clinical Research
CRRT Treatment Responsibilities:Points to Remember
Nephrology Nurse
Initiate treatment based on individual patient needs as assessed by the nephrologist
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
Before TreatmentEquipment/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 TreatmentEquipment/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 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
Bedside Nurse 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 ManagementNursing
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