power plans for crrt - london health sciences centre heparin via crrt • prior to ordering crrt,...

Power Plans for CRRT

Objectives

By the end of the presentation the CRRT-trained RN will

be able to:

1. Recall how electronic CRRT orders are placed

2. View or print a CRRT prescription

Starting April 10th, orders for CRRT will be provided

electronically. To enter an order, from the patient’s home

page the provider will:

• Select “Add order” &

• Search “CRRT”

• 3 ordersets will appear (they will select the

appropriate orderset):

1. NEPH- CRRT Heparin

2. NEPH- CRRT No anticoagulation or other

anticoagulation

3. NEPH- CRRT Citrate (VH)

Entering Electronic Orders

In this example, the physician orders

the NEPH- CRRT Heparin orderset

Ordering Heparin via CRRT

• Prior to ordering CRRT, there needs to be communication

between the Nephrology and CCTC physicians:

– To determine whether heparin can be used

– To review fluid removal goals

• If heparin cannot be used, orders for “no anticoagulation”

should be initiated

• Continue with subcutaneous VTE prophylaxis during

CRRT heparin to ensure that VTE prophylaxis is

maintained during CRRT downtime

Recommended Orders: NEPH- CRRT Heparin

• Solution is PrismaSoL 4

• Flow rates

– Dialysate 1,000 mL/hr

– Predilultion hemofiltration (PBP) 1,000 mL/hr

– Postdilution hemofiltration (POST replacement pump) 200

mL/hr

• Prime with heparin 5,000 units then reprime with saline

• Potassium replacement protocol enabled

• Electrolyte replacement orders activated

• Heparin titration protocol enabled

** Higher flow rates may be required if there is inadequate

clearance or extreme acidosis, but we should start at these rates

for most patients.

Once selected, the Power Plan loads

NEPH- CRRT Heparin

• Note: most orders are preselected

• When “initiate” is selected, the Powerform with the

CRRT prescription appears for the physician to

complete.

Blank Powerform for CRRT Prescription

Note dropdown menus:

• Can only select ST150 filter & can only select CVVHDF

• Can only select blood flow rate to start at 150 mL/min & increase to 250 mL/min

Recommended Prescription for Heparin via

CRRT (alternate orders if desired, can be typed

into the box)

Note dropdown menus:

• 2 priming options: (1) 2 liters of plain saline or (2) 1 liter saline with heparin & 2nd liter plain saline

• Dialysate solution & PBP solution: can only choose PrismaSol 0 or PrismaSol 4

• Post Replacement solution: can select PrismaSol 0, PrismaSol 4 or normal saline (although it is

preferred to use either PrismaSol 0 or PrismaSol 4)

Once complete, physician needs to click

green check mark top left hand corner

Clicking the green check mark takes us back to this screen where the

physician needs to click the “orders for signature” and then “sign”

• Note there is a missing detail

(top left hand corner)

Clicking on the missing detail (the blue

circle with an “X”) takes the physician

to the following screen…..

• What is missing is the Reason/Clinical History

• Once the Reason/Clinical History is completed the

physician will be prompted to “sign” and “refresh”

• How the orders will appear

What will be the biggest practice change in

CCTC?

Potassium Titration Change

Effective April 10, 2017, the potassium titration protocol

will be used to maintain the same potassium

concentration in ALL dialysis and hemofiltration

solutions.

This change will reduce the risk for error through

standardized practice.

So how do I see my PRISMA prescription once the order is placed?!?

Go to “Results Review” Menu and find the tab

along the top menu for Dialysis Treatment.

You can print this screen.

Hover over the line between the date columns and drag to widen you can read all of the information

How can I print a copy of the potassium,

heparin and/or citrate titration orders?

Go to the CCTC Website and Choose CRRT from the What’s New page.

Go to What’s New Page

Click on the link shown and print a copy.

You can also view your prescription from

Form’s Browser.

• Any powerforms completed for the patient

will be found here

• This patient only has the CRRT Heparin

Prescription VH

• Double clicking over the prescription will

open the prescription in a new window

Unfortunately we cannot

print from this screen. You

can print from the Dialysis

Treatment Tab (slide 23-

26).

To print- Right click over the

prescription to get the “print” option

Select the appropriate printer from the drop

down menu & click ok (RP 863 is at the front

desk & RP 864 prints to the RT area)

• Right click over the prescription to

get the “print” option

Printing the Prescription

Other CRRT Ordersets

• For a physician to place an order for CRRT using citrate or

no/other anticoagulant, the process is the same

• The steps for printing the prescription are also the same

• The electronic

prescription is your

source of truth

• If there is a printed

prescription at your

bedside, make sure it

matches the electronic

version before using it

Remember:

Summary of Recommended Orders:

Patient on Systemic Anticoagulation

• If a patient is receiving systemic anticoagulation at a therapeutic rate, they do not require additional filter anticoagulation

• Use the same flow rates as Heparin but without any filter anticoagulation

• If the systemic anticoagulation is going to be stopped electively, start filter anticoagulation with heparin or high flow prior to discontinuing systemic anticoagulation

• If the systemic anticoagulation is stopped urgently, immediately increase the PBP to high flow rates and stop dialysate (switch to NEPH- CRRT no anticoagulation protocol)

Summary of Recommended Orders: No

Anticoagulation

• Solution is PrismaSoL 4

• Flow rates – Dialysate 0 mL/hr (if dialysate is zero you can prime with saline

as flow rate will be turned to off)

– Predilultion hemofiltration (PBP) 2,000 to 2,500 mL/hr

– Postdilution hemofiltration (POST replacement pump) 500 mL/hr

• Prime with heparin 5,000 U and reprime with saline if no HITT



• AIM TO INCREASE BLOOD FLOW RATE AS HIGH AS 250 mL/min or as tolerated

**Higher flow rates may be required if there is inadequate clearance but the default should be these flow rates

Summary of Recommended Orders: Citrate

• Solution is Prism0CAL

• Prism0CAL has zero potassium, therefore, potassium must be added to all bags

• Prism0CAL also has zero calcium

• Flow rates – Dialysate 1,000 mL/hr

– Predilultion hemofiltration (PBP) is the citrate solution

– Postdilution hemofiltration (POST replacement pump) 1000 mL/hr

• Prime with heparin 5,000 (if no HITT) and reprime with saline; or saline without heparin if HITT



• Citrate titration orders enabled

• Calcium chloride titration protocol enabled

Additional Reminders

• CRRT orders should be made collaboratively between

Nephrology and CCTC medical teams

• It is important that CCTC physicians know the treatments (e.g.,

heparin or citrate use) as this has implications for care

• If a patient has persistent hyperkalemia, CCTC physicians

must be made aware to evaluate possible reasons for the

hyperkalemia (e.g., rhabdo, bowel infarction)

• Critical Care Electrolyte orders should also be ordered for

patients on CRRT

• We use the same Prisma solutions on all pumps for safety


• Any situation that causes a red alarm will cause blood

flow through the filter to stop. Each time blood flow stops

(even if only for a few seconds) the likelihood of filter

clotting increases

• Filter clotting will occur regardless of anticoagulation if

there are frequent high pressure alarms. Line issues

should always be addressed as a priority

– High pressure alarms can occur if there is catheter

thrombosis, kinks or flow problems

– Frequent coughing with frequent high pressure backup to IJ

or SC lines can also lead to increased filter clotting


• High flow PBP of at least 2,000 – 2,500 mL/hr is

recommended when no anticoagulation is being used

• When high flow PBP is being used, dialysate is not

required (clearance will be provided by the predilution

hemofiltration)

• CCTC nurses continue to have an automatic order to

switch back and forth between PrismaSoL 4 and 0 to

achieve desired potassium (or if you run out of stock at

night)

power plans for crrt - london health sciences centre heparin via crrt • prior to ordering crrt,...

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