Operation-Fluids-Electrolytes-Acid Base COMPLICATIONS OF DIALYSIS 2

Transcription

1 Operation-Fluids-Electrolytes-Acid Base COMPLICATIONS OF DIALYSIS 2

2 Maureen Craig, RN, MSN, CNN University of California Davis Medical Center Sacramento, California

3 Hospital Details Teaching Hospital Urban/ Rural mix 500 Bed Hospital 9 Intensive Care Units

4 Patient Treatment Details Adult Dialysis Treatments ~5000 / year Pediatric Dialysis Treatments ~200 / year

5 CRRT at UCDMC CRRT since 1995 Continuous Hemodialysis (CHD) 400 treatments / year

6 CVVHD: Hemodialysis Also known as Continuous Hemodialysis. CVVHD requires large volumes of dialysis solution. (100 ml/min) Heparin Dialysis Solution Electrolytes in the dialysate are adjusted to address the abnormalities in the patient s blood. Effluent

7 Slow Extended Daily Dialysis SLEDD since treatments/ year DFR 300 ml/min Fresenius K series

8 ICU - Dialysis Treatments ~1500 treatments / year ~ 1/3 of all treatments

9 Operation Goals for Dialysis Antibiotic choices Anticoagulation choices Pediatric Considerations

10 Goals for Dialysis Fluid Removal Waste Removal Uremic Toxins Electrolyte Balance Acid/Base Balance

11 Antibiotics during CRRT Published antibotic dosing recommendations may lead to underdosing! CRRT today is in many cases more efficient than those reported historic observations. This can lead to therapeutic failure and breakthrough resistance.

12 Antibiotic Dosing Ref Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Brett H. Heintz, Gary R. Matzke, William E. Dager Pharmacotherapy May; 29(5): doi: /phco

13 Factors affecting Dosing Treatment dependant Type of dialysis Patient dependant Intrinsic renal function Site of infection Patient size Immune function Drug Dependant Antimicrobial factors concentration dependent vs time-dependent killing, absorption, distribution, metabolism and elimination MIC data susceptibility patterns Drug - drug interactions

14 Recommended Adult Antimicrobial Dosages by Renal Replace Therapy. Brett H. Heintz, Gary R. Matzke, William E. Dager. Pharmacotherapy May; 29(5): doi: /phco

15 Anticoagulation Choices Heparin 1% of all treatments 15% of CHD and SLEDD Regional Citrate 1% of all treatments 15% of CHD and SLEDD Normal Saline Flushes (not an anticoagulant!) Flushing 100 ml/ 30 minutes Higher clotting rates

16 Clotting Rates Heparin 11% of all heparin treatments Regional Citrate 0% of all citrate treatments Normal Saline Flushes (not an anticoagulant!) 3.5% of all no anticoagulant treatments IHD ~ 3% clotting CHD~ 10% clotting

17 Pediatric Considerations Umbilical catheter Blood priming the circuit Anticoagulation for low blood flow Documentation for meaningful fluid balance

18 Neonatal Blood Flow Cardiac output ~ 200 ml/kg/min CRRT BFR ~ 5-10 ml/kg/min The net UFR ml/kg/min Regional Citrate Anticoagulation

19 Umbilical Vessels

20 NS PRBC NS Blood-prime of a Neonate Dialysis Circuit (recirculate x 2 minutes for citrate removal) AP A Three-way stopcock Dialysis Catheter V Y- connector Venous chamber V saline = V PRBC (HCT PRBC -HCT desired )= ml saline HCT desired Craig, 8-07

21 Blood Prime V saline = V PRBC (HCT PRBC -HCT desired )= ml saline HCT desired V PRBC = 24 HCT PRBC =74 HCT desired = 32 V saline = 24 (74-32) = 31.5 ml saline 32 Prime Volume prepared = 55.5 ml Circuit Volume = 47 ml Craig, 8-07

22 Citrate Anticoagulation Regional Citrate ACD-A Calcium Chloride BFR ml/min

23 Regional Citrate - Titration Adjust Citrate IV to achieve system ionized Calcium Adults: mmol/l Peds: mmol/l Adjust Calcium IV to achieve patient ionized Calcium mmol/l.

24 Citrate Toxicity Citrate returned to patient as Calcium-citrate complex Patient s liver capacity does not metabolize the citrate as fast as it is entering the patient. Labs: Total Calcium elevated Patient ionized Calcium any level Treatment: Increase dialysis solution flow to clear more calcium-citrate complex. Reduce ACD-A rate. Slow blood flow rate if tolerated.

25 CVVHDF with Citrate Treatment 24 hrs/ day BFR 200 ml/min DFR ml/min Dialysate K+ 3-4 meq/l Ca++ 0 meq/l Na+ 135 meq/l HCO meq/l PO mg/dl UFR ml/hr

26 icalcium Monitoring and Drip Titration Citrate solution ( - pressure) NS Patient ionized- Calcium sample A Citrate > Bicarbonate Calcium solution V Zero Calcium Dialysate System ionized- Calcium sample

27 Patient icalcium Best Option: Draw Patient icalcium from a separate A-line. Alternate Option: 1. Draw System icalcium first 2. Stop ACD-A infusion. 3. Reduce or maintain BFR at < 50 ml/min 4. Clamp venous port (& 3 rd port if present) of central catheter 5. Await increased VP alarm (15-20 seconds) 6. Scrub the stopcock hub with alcohol, turn the stopcock off to the machine, draw ½-1 ml blood to waste and then draw patient icalcium sample from the stopcock of the Arterial port of the central catheter. 7. Flush stopcock with 1 ml of normal saline to clear. Return system to standard position by turning stopcock off to syringe and unclamping all used ports of the catheter 8. Resume BFR 9. Resume ACD-A infusion. 10. Send samples to Stat Lab x33200 Neonate Dialysis or CRRT Circ with Regional Citrate Anticoagulation ACD-A NS AP A V Three-way stopcock Dialysis Catheter Craig, 8-07 Calcium Best Option: Infuse Calcium drip into a separate central line. Alternate Option: Infuse Calcium drip into the Y- connector on the venous return line or 3 rd limb of dialysis catheter. System icalcium Draw System icalcium before Patient icalcium. Draw from venous sample port. Maintain BFR during sampling. Y- connector Venous chamber

28 Symptoms of Calcium Abnormalities Hypercalcemia. Increased heart rate, vaso-constriction. Shorten QT interval, first degree heart block. Lethargy, muscle weakness. Headache, nausea/vomiting. Hypocalcemia. Circumoral tingling. Muscle cramps. Tetany and seizures. Chvostek s or Trousseau s sign. Hypotension due to vaso-dilation. Prolonged QT interval, decreased heart rate, arrhythmias.

29 Fluids UFR Calculation Documentation Meaningful fluid balance

30 Calculating UFR for Adults Keep it simple! UFR = Pt UFR + intake rate Perform calculation at any time Ignore small quantities of I/O s Set the UFR as patient tolerates! Total I/O s once/shift

31 Calculating UFR - Pediatrics Keep it simple! UFR = Pt UFR + intake rate + prior hr (boluses output) Perform calculation at any time Include all I/O s Set the UFR as patient tolerates! Total I/O s hourly

32 Documentation Time UF Calculator Total current intake rate Total previous hour boluses Total Intake Total previous hour output Patient fluid removal rate Calculated goal UF rate Continuous Dialysis Actual UF rate UF removed (charts in I/O s) Arterial Pressure Venous Pressure Transmembrane Pressure Blood flow rate Dialysis flow rate Comments Initials MC MC MC MC

33 Electrolytes - Phosphorus

34 Phosphorus Balance Phosphorus removal Serum Phosphorus may fall below desired levels on day 2 or 3 of CHD or SLEDD IV phosphorus replacement or Phosphorus Additive in dialysis solution

35 Phosphorus Additive Sodium Phosphate Solution Same concentrations as Fleet Phospho Soda Sodium 1660 mg/15 ml Phosphorus 62.4 mmol/15 ml More specifically 480 mg/ml Monobasic sodium phosphate, monohydrate (CAS no ) 180 mg/ml Dibasic Sodium Phosphate, heptahydrate (CAS no )

36 Phosphorus Additive 45X Dialysis Solution preparation Fresenius NatruaLyte 4000 Series ( LB) Bicarbonate 6.4 liter container size Add Phosphorus Additive to Bicarbonate Concentrate 45 ml Phosphorus Additive to 6.4 L Bicarbonate Concentrate End dialysis solution Phosphorus concentration =

37 AGITATE gently End dialysis solution Phosphorus = 3.0 mg/dl Prevent patient hypophosphatemia