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