1 / 36

Terminology and Common Issues in Pediatric CRRT

Terminology and Common Issues in Pediatric CRRT. John Gardner RN, BSN Nurse Manager Pediatric Nephrology & Transplant DeVos Children’s Hospital Grand Rapids Michigan. Over View. Terminology Common issues Access Anticoagulation Extracorporeal circuit size Blood priming Hypothermia

celinor
Download Presentation

Terminology and Common Issues in Pediatric CRRT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Terminology and Common Issues in Pediatric CRRT John Gardner RN, BSN Nurse Manager Pediatric Nephrology & Transplant DeVos Children’s Hospital Grand Rapids Michigan

  2. Over View • Terminology • Common issues • Access • Anticoagulation • Extracorporeal circuit size • Blood priming • Hypothermia • Staffing

  3. Terminology • SCUF slow continuous ultrafiltration • CAVH continuous arteriovenous hemofiltration • CAVHD continuous arteriovenous hemodialysis

  4. Terminology • CVVH continuous venovenous hemofiltration • CVVHD continuous venovenous hemodialysis • CVVHDF continuous venovenous hemodiafiltration

  5. CAVH/CVVH: Convective Clearance • CVVH/CAVH • Convective clearance • Replacement solutions • Physiologic sterile solution that is either infused pre filter (NA) or post filter (outside of NA) that infused at a set rate (Qr)

  6. CAVHD/CVVHDDiffusive Clearance • CVVHD/CAVHD • Diffusive clearance • Dialysate • Physiologic sterile solution that is infused countercurrent to the blood flow rate (Qd)

  7. CAVHDF/CVVHDFConvective and Diffusive Clearance • CVVHDF/CAVHDF • Convective clearance • Replacement solutions • Diffusive clearance • Dialysis solution

  8. Urea Clearance CVVH Vs CVVHD(Maxvold Et Al, Crit Care Med, April 2000) • Study design • Fixed blood flow rate-4 mls/kg/min • HF-400 (0.3 m2 polysulfone) • Cross over for 24 hrs each to FRF or Dx flow at 2000 mls/hr/1.73 m2 • TPN protein delivery at 1.5 gms/kg/day

  9. Comparison of Urea Clearance: CVVH Vs CVVHD(Maxvold Et Al, Crit Care Med April 2000) p = NS Urea Clearance (mls/min/1.73 m2) BFR = 4 mls/kg/min FRF/Dx FR = 2 l/1.73 m2/hr SAM = 0.3 m2

  10. Vascular Access • Properly functioning access is key to successful CRRT therapy Adequacy Filter life Decreased blood loss Staff satisfaction

  11. Ideal Catheter Characteristics • Easy insertion • Permits adequate blood flow without vessel damage, large diameter with shortest length • Low resistance, decreased arterial and venous pressures • Minimal technical flaws High recirculation rate Kinking

  12. Vascular Access Placement • Femoral • Internal jugular • Sub-clavian (avoid if possible) • Match catheter size to pt. Size and anotomical site • One dual- or triple-lumen or two single lumen uncuffed catheters

  13. Common Causes of Poor Catheter Flow Rates • Catheter tip position – is the tip in proper placement? • Kink • Tight suture • Clamp • Decreased intrvascular volume • Increased intrathoracic pressure • Thrombosis or fibrin sheath formation

  14. Comparison of Upper Vs. Lower Body Location Line Placement(Kendall 8 Fr 9 and 12 CmN = 20; 120 Treatments) P value NS NS NS NS Gardner et al, CRRT San Diego 1998

  15. Why Do We Need Triple Lumen Access?

  16. (Ca = 0.4 x citrate rate 60 mls/hr) (Citrate = 1.5 x BFR 150 mls/hr) Pediatr Neph 2002, 17:150-154 (BFR = 100 mls/min) Normal Saline Replacement Fluid Calcium can be infused in 3rd lumen of triple lumen access if available. Normocarb Dialysate • ACD-A/Normocarb Wt range 2.8 kg – 115 kg • Average life of circuit on citrate 72 hrs (range 24-143 hrs)

  17. Citrate ~ running it Arterial access Venous access Citrate infusion via “y” adaptor

  18. CaCl infusion line/or TPN/or Med line Venous line “arterial” line

  19. Anticoagulation • Heparin • Initial bolus 10 to 30 mg./ Kg • Continuous infusion of 10 to 30 mg./Kg • Maintain an activated clotting time (ACT) of 180-210 • Risks of heparin anticoagulation: Bleeding Thrombocytopenia

  20. Anticoagulation • Citrate • Citrate infusion to CRRT circuit • Calcium infusion to to patient via separate central line • Monitor post filter ionized calcium, adjust citrate infusion per protocol • Monitor systemic ionized calcium, adjust calcium infusion per protocol • Monitor for metabolic alkalosis and citrate loc

  21. Extracorporeal Circuit Volume • Circuit volumes should be < 10% of the patients intravascular blood volume • Human blood volume formula • < 10kg 80ml/kg • >10kg 70ml/kg • Removal of > 10% blood volume extracorporeal can result in hemodynamic instability (shock)

  22. Blood Priming • Indications Circuit volume >10% of the patients blood volume Hemodynamic instability

  23. Complications of Blood Priming • PRBC from the blood bank tend to have an increased potassium • The HCT of PRBC is around 80% • A 50% dilution with normal saline or 5% albumin should be performed prior to circuit prime • Bradykinin release syndrome may be seen with AN- 69 membranes (brophy,et al 2001ajkd) • System clotting

  24. Blood Priming Methods • More concerning with AN-69 or membranes, less concerns with polysulphone membranes • Zero balance ultrafiltration (Z-BUF) • Normalizes electrolytes and improves acid-base status of the prime prior to pt connection by performing CVVH, CVVHD or CVVHDF for 30 minutes • Hackbarth et al, Peds Neph, 2005 20:1328-33 • Bypass maneuver • The patient is transfused with the PRBC at the same time and rate as the circuit is primed with the patients blood. The NS prime is wasted • Brophy et al, am J kid Dis, 2001 Jul;38(1):173-8

  25. 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

  26. Hypothermia Nursing Intervention • External warming devices • Radiant warmers • Baer hugger • Heating mattress • Blood warmers • Solutions heaters • Monitoring • Skin breakdown and patient temperature

  27. Staffing • Staffing ratios • Education • System setup • Pump management • Program management

  28. A National Survey(April Tanner RN, Atlanta Ga, PCRRT 3, Orlando 2004) • An national review of current trends in CRRT • An 18 question survey sent to pediatric centers that offer CRRT • Free-standing or based in adult facility • 42 centers responded

  29. Staffing Ratios

  30. Education • Wide variety of teaching methods • Didactic/hands on skills lab training occurs in 69% of initial training sessions • 12% require mentoring shifts • 17% offer informal training • 7% utilize bedside training methods

  31. Education • Annual recertification - 43% • More frequent recertification occurs 26% • Smaller volume programs • 19% of programs have no formal annual competency or recertification programs • Many centers education programs are under review

  32. System Set-up

  33. Logistics and Coordination of System Set-up • 11 of 42 centers have no formal 24/7 coverage • In 93% of center’s RNs manage the pump • Dialysis, ECMO, and physicians make up the other % • Charge structure • The dept.That sets up equipment receives revenue in majority of centers • 21 of 42 centers also have daily charges • Varied response as to where revenue goes

  34. Conclusion • The education and competency of the bedside staff is essential for successful care of a child on CRRT • No better teacher than the child • Communication to colleagues throughout your program and throughout the world are critical in improvement in over all care

  35. Thank You

More Related