CRRT Procedures. and Guidelines. CRRT: Guidelines

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1 CRRT Procedures 2013 and Guidelines Guidelines for the utilization of CRRT (Continuous Renal Replacement Therapies) at Monroe Carell Jr. Children s Hospital at Vanderbilt CRRT: Guidelines

2 CRRT Contacts: Monroe Carell Jr. Children s Hospital at Vanderbilt Name Title Address Phone Pager Kathy Jabs, M.D. Director Pediatric DOT Nephrology Tray Hunley, M.D. Pediatric Nephrology DOT Deborah Jones, M.D. Pediatric Nephrology DOT Brian Bridges, M.D. Pediatric Critical Care DOT Geoffrey Fleming, M.D. Pediatric Critical Care DOT John Pietsch, M.D. Pediatric Surgery DOT Daphne Hardison, RN ECMO and CRRT Mgr VCH Christy Worden, RN Lead ECMO Specialist VCH ECMO Team ECMO Team VCH Dialysis Storage 4 th Floor VUH VUH 4 th flr Code UHS Rental Rental PrismaFlex Nashville Gambro Intensive Care Hotline Troubleshooting Debi Camp RN Systems Support HED Wendy Williams RN Gambro Specialist Trainer

3 PROTOCOL FOR CRRT (CONTINUOUS RENAL REPLACEMENT THERAPY) I. Indications CRRT is used in critically ill patients to assist and replace normal renal function in the face of acute organ dysfunction. Additionally, the blood purification properties of the therapy may also be employed in certain situations. Indications for CRRT will be determined by the intensive care unit physician team caring for the patient. The usual clinical indications for CRRT in critically ill patients include (but are not limited to): 1. Acute renal failure 2. Treatment or prevention of diuretic-resistant fluid overload 3. Electrolyte or acid-base disturbances 4. Unstable chronic renal failure patients who cannot tolerate intermittent hemodialysis or peritoneal dialysis 5. Detoxification II. Modes of CRRT Modes of CRRT include SCUF (slow continuous ultrafiltration), continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD), and continuous veno-venous hemodiafiltration (CVVHDF). The most common form of CRRT most often used in the critical care setting at Monroe Carell Jr. Children s Hospital at Vanderbilt is CVVH. III. Policy CRRT will be ordered by the intensive care physician or nephrologist, and the initiation of CRRT will require subsequent consultation by pediatric nephrology. The ECMO Team will provide technical support including equipment set up, maintenance, and troubleshooting. The bedside RN will continuously monitor the CRRT delivered at the bedside and provide basic troubleshooting and adjustment of the therapy with the assistance of the ECMO Specialist as needed. IV. Equipment CRRT will be performed with the Prismaflex CRRT System. In general, the HF 1000 hemofilter set will be used on all patients. A blood prime should be provided for any patient less than 15 kilogram except in cases of life threatening emergency which do not allow for the time necessary for a blood prime. A blood prime should be considered for any patient 15 to 20 kilograms based on discussion with either the attending intensivists or nephrologists in relation to hemodynamic 3

4 instability. Procedure for blood priming the HF 1000 filter is listed under procedure and will require an ECMO medication kit to allow for buffering of the prime. The risk of a bradykinin release activation syndrome with blood priming of the circuit can result in potential tachycardia, hypotension, and vasodilation 1. This has been documented when the AN-69 (M60) hemofilter is used. 1 to 2 meq/kg of sodium bicarbonate should be administered prefilter, and a dose of intravenous calcium should be administered to the patient in the case of bradykinin release. Point of care testing by the ECMO Specialist with the approved instrument will be provided to measure activated clotting times (ACTs) if systemic heparinization is used or ionized calcium levels if regional anticoagulation with citrate is used. For patients who are not on ECMO, the initiation of CRRT will require the placement of a vascath. The chart below gives a guideline for the appropriate vascath size and location based on patient s age and weight. Suggested Size and Selection of CRRT Vascular Access for Pediatric Patients 2 Patient Size Catheter Size and Manufacturer Preferred Site of Insertion NEONATE Dual-Lumen 7.0 French (COOK/MEDCOMP) 3-6 KG Dual-Lumen 7.0 French (COOK/MEDCOMP) Triple-Lumen 7.0 Fr (MEDCOMP) 6-30 KG Dual-Lumen 8.0 French (KENDALL, ARROW) >15-KG Dual-Lumen 9.0 French (MEDCOMP) >30 KG Dual-Lumen 10.0 French (ARROW, KENDALL) >30 KG Triple-Lumen 12.5 French (ARROW, KENDALL) V. Procedure 1. Set up CRRT device per manufacturer recommendation. 4

5 2. The circuitry will be primed with heparin saline 2 to 5 units/ml per 1 ml saline. Reprime will be completed utilizing normal saline or blood. 3. Blood Prime procedure: Step 1: Gather needed supplies (1) Banked PRBCs Full Unit (2) 100 units of Heparin Saline (ECMO Medication Kit) (3) 10 meq 8.4% Sodium Bicarbonate (ECMO Medication Kit) (4) 50 mls 25% Albumin (ECMO Medication Kit) (5) 400 mg Calcium Chloride (bristojet) ECMO Medication Kit (6) 1 L Heparin Normal Saline concentrated between 2 and 5 units heparin/ml (7) Emptied Liter bag from #4 post circuit prime (8) PrimsaFlex Ordered Circuitry (9) CRRT Order set Step 2: Prime circuit with saline/heparin per institution protocols Step 3: Prepare PRBCs by adding to the unit in the following order: (1) 100 units heparin, 10 meq NAHCO3; 50 mls 25% Albumin; 400 mg Calcium Chloride (2) Connect blood to a straight blood filter set (3) Connect set to Access Port CRRT Circuit (4) Leave Emptied 1 Liter Normal Saline bag attached to the Return Line CRRT Circuit (5) Open all clamps and stopcocks on the CRRT Circuit (6) Initiate Blood Flow at 100 ml/minute, displacing saline with PRBCs until fully primed (7) Stop blood flow and clamp both access and return lines to CRRT Circuit (8) Insert a 3-way high flow stopcock (9) Open clamps and 3-way high flow stopcock (10) Initiate Blood Flow at 50 ml/min Step 4: Initiate CRRT to patient (1) Healthcare provider, nurse and ECMO Specialist all at bedside (2) Remove heparin from patient access line; flush assuring patency and clamp line (3) Stop blood flow on CRRT machine, clamp both access and return lines (4) Remove 3- way stopcock and attach access to access and return to return (5) Initiate blood flow at prescribed rate (6) Post initiation have Sodium Bicarbonate and Calcium Chloride available 3. If patient requires a blood warmer utilize the integrated blood warmer. 4. Notify physician when ready to begin CRRT. A member of the patient care team (ICU or Nephrology) will be available at bedside during initiation of therapy. 5. Access and Return ports can be switched to obtain functional blood flow. 6. CRRT can be connected to the ECMO circuit directly for patients requiring ECMO support (see ECMO protocol). 5

6 7. Assess the patient s hemodynamic status closely. Fluid boluses, calcium chloride, and sodium bicarbonate will be available during the procedure and given under physician order. Be prepared to decrease or temporarily stop flow if patient shows signs of deterioration during initiation. 8. The ECMO specialist will document initiation of CRRT, patient s response, and initial settings in the HED note section CRRT flowsheet. 9. The bedside nurse will take over continuous monitoring and maintenance of CRRT. The bedside nurse will call the ECMO specialist as needed for general information and troubleshooting of the CRRT device. 10. In general, the standard BFR (blood flow rate) will be 3 to 5 ml/kg/min with a lower limit of 50 ml/min, this may be as much as 10 ml/kg/min. 11. FRF (filter replacement fluid) will run at 30 to 40 ml/kg/hr. For patients 10 kg or less, normal saline at 10% of the FRF rate will run post-filter. For patients greater than 10 kg, normal saline at 5% of the FRF rate will run post-filter. The FRF will be placed pre-filter. The FRF used with the Prismaflex will be the FDA approved PrismaSol. Exceptions can be made as per pediatric nephrology. 12. In general, the filtration fraction should be less than 30% in order to prevent hemofilter clotting. FF (%) = UFR X 100 BFR X (1 - HCT) 13. The Prismaflex excess fluid loss/gain settings should be set at 150 ml for patients less than 10 kg, 250 ml for patients 10 to 29 kg, and 400 ml for patients 30 kg or greater. Exceptions can be made by pediatric nephrology. 14. The Prismaflex circuit should be replaced every 72 hours. Exceptions can be made as per the critical care team. VI. Nursing Implications 1. Assess and document the venous catheter site. Notify the physician for signs of bleeding, infection, or any other concerns. 2. Monitor intake and output hourly. 3. Maintain device rates as ordered. 4. Except in rare circumstances, all patients on CRRT will require anticoagulation. 5. The ECMO specialist will monitor ACTs as ordered and titrate anticoagulation as needed. 6. If using citrate protocol, the ECMO Specialist will monitor and adjust anticoagulant per citrate protocol as ordered by the physician. See Citrate Protocol. 6

7 7. Use heparin 100 units/ml to heparin lock catheters for temporary disconnect. Use only volume needed to fill catheter. Mark the catheter to notify it is heparin locked. 8. Venous access dressing should be changed by bedside nurse according to the PCCU/NICU protocol for central line dressing changes. VII. Documentation 1. The ECMO specialist will document initiation and any troubleshooting or changing of the circuit on the CRRT flowsheet in HED. 2. Bedside nurse will be responsible for hourly documentation on the CRRT flowsheet (HED) and any troubleshooting or adjustments made in therapy. 3. Physician orders will be complete, reviewed, and in the electronic medical record. 4. Documentation is the responsibility of the ECMO Specialist and bedside nurse in the electronic documention record hourly including removal, bag changes, co signs, verifications and set rates or when change is made. VIII. Complications Complications that may result from the use of CVVH may include: 1. Hypovolemia 2. Hypotension 3. Thrombosis 4. Bleeding 5. Infection 6. Electrolyte imbalance 7. Clot formation/emboli 8. Hemolysis 9. Filter rupture/blood loss from circuit IX. Contraindications The contraindications to hemofiltration include: 1. Inability to obtain vascular access 2. Life threatening risks from anticoagulation. 7

8 X. Fluid Management CRRT is utilized for its capabilities of gentle fluid management. Wide vacillations in hour-to-hour fluid goals should be avoided, and if noted, indicates a problem. The goal in hemofiltration should be fluid regulation. Aiming for a zero balance or even a slightly negative balance is optimal. Usual fluid removal rates range 0-2 ml/kg/hour net fluid removal. Hourly intake and output are calculated to determine the needed removal to meet the prescribed fluid balance. Some common scenarios that may occur: 1. When administering blood products for the correction of lab results (i.e., hematocrit, platelets, etc.) try to minimize the confusion of the hemofiltration calculations by: Scheduling the administration to begin at the beginning of the hour or half hour (give products immediately in life threatening situations); Extending the length of time the transfusion will infuse over (1 hour for platelets, 2 to 4 hours for other blood products) 2. When administering volume for hypotension/hypovolemia: What is the etiology of hypotension? (Fluid loss, pressor manipulations, acute event) Is the fluid removal rate to high for the patient hemodynamics? Attempt to treat with fluid aliquots smaller than a standard 10 or 20 ml/kg (treat to effect rather than by dose). After resuscitation for hypotension secondary to hypovolemia (absolute or relative) reduce fluid removal rate to net even for 2-4 hours. Do not remove the fluid immediately given in resuscitation. XI. Nutrition 1. Whenever possible, enteral nutrition is preferred in critically ill patients. However, if TPN is used for patients on CRRT, they should receive at least 2g/kg/day protein. XII. ECMO Specialist Considerations 1. The CRRT circuit check will be completed every 4 hours and documented per the electronic documentation record. This includes close observation for clots, air, leaks and connections in the blood path as well as the color of the fluid in the ultrafiltrate space. 8

9 2. If the blood leak detector alarms or frank blood is noted in the ultrafiltrate space, therapy should be stopped. Contact the ECMO Specialist in house via or pager and send plasma free hemoglobin from the ultrafiltrate to determine if blood is present. If blood is detected, the hemofilter should be replaced. 3. A decrease in the ability of the UF pump to remove the set amount of ultrafiltrate usually indicates a filter that is clotting or becoming sluggish. Interventions include: Assure that the blood flow shunted through the hemofilter is at least 100cc/min. (Set flow - Delivered flow = Shunt) Reduce the rate of ultrafiltrate (to decrease the alarm) and prepare to have the ECMO team member change the hemofilter. 4. Close monitoring of vital signs will be maintained. In the event the patient blood pressure drops and frequent volume repletion is required to maintain, the ultrafiltrate rate per hour will be decreased. 5. ACTs are monitored closely after connection of the system. Because of the hemofilter s action, heparin is filtered or removed along with electrolytes and free water. Therefore, heparin consumption may increase. 6. Electrolytes are monitored closely. Basic chemistries, including sodium, potassium, chloride, bicarbonate, blood urea nitrogen, calcium, and creatinine, should be followed a minimum of every 12 hours. A level of magnesium, phosphorus, and a blood gas with ionized calcium, will be followed daily in the AM. XIII. Removal of the Prismaflex circuit: 1. CRRT will be discontinued per physician order. The Prismaflex will be removed by a member of the ECMO team. Volume is not returned to the patient without an attending or nephrology order. References 1. Brophy PD, Mottes TA, Kudelka TL, et al. AN-69 membrane reactions are ph-dependent and preventable. Am J Kidney Dis Jul;38(1): Brophy P, Bunchman, TE. References and Overview for Hemofiltration in Pediatrics and Adolescents < Accessed 2011 Feb. 9

10 Pediatric CRRT Order Sheet Type of therapy: Hemofilter: Prismaflex (Polysulfone HF) HF 1000 [1.1 m 2, 165 ml in circuit] Hemofiltration solutions: SCUF Priming solution: NS U/L heparin followed by NS CVVH with Filter Replacement Fluid (FRF) CVVHD with Dialysate CVVHDF (Filter Replacement Fluid & Dialysate) Filter replacement solutions: PrismaSol BGK 4/2.5 [4 meq/l K, 2.5 meq/l Ca, 1.5 meq/l Mg, 100mg/dL dextrose] PrismaSol BGK 2/3.5 [2 meq/l K, 3.5 meq/l Ca, 1.0 meq/l Mg, 100mg/dL dextrose] PrismaSate BGK 0/2.5 [0 K, 2.5 meq/l Ca, 1.5 meq/l Mg, 100mg/dL dextrose] PrismaSol BGK 4/0/1.2 [4 meq/l K, 0 Ca, 1.2 meq/l Mg, 100mg/dL dextrose] PrismaSol BGK 2/0 [2 meq/l K, 0 Ca, 1.0 meq/l Mg, 100mg/dL dextrose] PrismaSate BK 0/0/1.2 [0 meq/l K, 0 Ca, 1.2 meq/l Mg, 0 mg/dl dextrose] Additional additives: Na K meq/l meq/l Post-filter Infusion: Normal saline to be infused post filter at 10% of the FRF rate (for patients 10 kg or less) Normal saline to be infused post filter at 5% of the FRF rate (for patients greater than 10 kg) Treatment orders: RECOMMENDED Prismaflex Blood flow rate ml/min (3-5 ml/kg/min) (10) FRF rate ml/hr (30-40 ml/kg/hr) (50) Dialysate rate ml/hr (30-40 ml/kg/hr) (50) NET UF rate ml/hr (net loss 0-2 ml/kg/hr) Filtration fraction (goal<30%) = UFR X 100 BFR X (1 - HCT) 10

11 Prismaflex excess fluid loss/gain settings as below: 150 ml (for patients less than 10 kg) 250 ml (for patients 10 to 29 kg) 400 ml (for patients 30 kg or greater) Laboratory monitoring: Patient and circuit ica within 15 minutes after initiation, every 1 hour X 4 hours or until stable, then every 4 hours. BMP every 12 hours; Phosphorus and Magnesium every AM Anticoagulation: Heparin based: Heparin infusion: 1 ml/hr = 10 units/kg/hr Titrate heparin to maintain an ACT of seconds (180 to 200 seconds, unless bleeding) Heparin bolus: units (10-20 units/kg) Heparin infusion: units (5-20 units/kg/hour) Citrate based: Citrate ACD-A Solution-infused into the Access side of the circuit. Citrate infusion rate: ml/hr (start at 1.5 times the BFR). RECOMMENDED ADJUSTMENTS TO CITRATE INFUSION BASED UPON Cai AND PATIENT S WEIGHT: Post-filter ionized calcium (mg/dl) Citrate infusion adjustment > 20 kg < 20 kg <1.4 rate by 10 ml/hr rate by 5 ml/hr (optimal range) No adjustment rate by 10 ml/hr rate by 5 ml/hr > 2.4 rate by 20 ml/hr rate by 10 ml/hr Notify MD if citrate infusion rate > 200 ml/hr Calcium chloride solution (8 grams/liter NS)-infused into separate central line. Calcium chloride infusion: ml/hr (start at 40% of the citrate rate). RECOMMENDED ADJUSTMENTS TO Calcium INFUSION BASED UPON Cai AND PATIENT S WEIGHT: Patient ionized calcium (mg/dl) Calcium infusion adjustment > 20 kg < 20 kg >5.2 rate by 10 ml/hr rate by 5 ml/hr (optimal range) No adjustment rate by 10 ml/hr rate by 5 ml/hr < 3.6 rate by 20 ml/hr rate by 10 ml/hr Notify MD if calcium infusion rate > 200 ml/hr 11

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