Nursing Issues in Pediatric CRRT

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Nursing Issues in Pediatric CRRT

• Helen Currier BSN, RN, CNN
• Assistant Director Renal, Pheresis
• Scholar Center for Clinical Research

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CRRT Treatment ResponsibilitiesPoints 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

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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

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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

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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
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• Length
• 19 ? in diameter will compensate for doubling of
  length
• Placement
• Site RIJ (LIJ, IVC, Subclavian)
• Tip well within the atrium

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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

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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

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Treatment Initiation

• Nephrology Nurse
• Assess patients 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 patients 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

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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

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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

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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

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CRRT Treatment Responsibilitiesq 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

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CRRT Treatment Responsibilitiesq 2 hr into
treatment/ q 6 hr thereafter

• Bedside Nurse
• Check circuit ionized Ca (sample from venous
  port) and patients 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

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CRRT Treatment Responsibilitiesq 24 hr

• Bedside Nurse
• Assess patients 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 patients nutritional status
  daily weight, albumin, bowel patterns, skin
  turgor, muscle wasting
• Monitor the integrity of the access dressing
  change per protocol

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Potential Complications with Pediatric
Hemofiltration

• Circuit Volumes
• Hypothermia
• Anticoagulation
• Fluid Management
• Blood Flow Rates
• Nutrition
• Solutions

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Circuit Volumes

• Significant when dealing with pediatrics
• General Guidelines
• Circuit volumes should be lt 10 of the patients
  intravascular blood volume

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Blood Priming

• Indications
• Circuit volume gt 10 of the patients blood volume
• Hemodynamic instability
• Infants

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Complications of Blood Priming

• Blood Bank pRBC tend to be high in K
• Close K monitoring needed at initiation
• pRBC HCT are approximately 80
• 11 dilution with normal saline
• Blood prime need to be done at time of
  initiation.
• Citrate binds calcium
• hypotension

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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

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Hypothermia Nursing intervention

• External warming devices
• Radiant warmers
• Baer hugger
• Heating mattress
• Blood warmers
• Solutions heaters
• Monitoring
• Skin breakdown and patient temperature

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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

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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

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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

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Access Difficulties

• What is the correct access?
• ? Best placement
• In flow vs out flow difficulties

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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

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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