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Nursing pt.1

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  • 1. Nursing Issues in Pediatric CRRT Helen Currier BSN, RN, CNN Assistant Director – Renal, Pheresis Scholar – Center for Clinical Research
  • 2. CRRT Treatment Responsibilities: Points 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
  • 3. Before Treatment Equipment/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
  • 4. Before Treatment Equipment/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
  • 5. 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 21%
      • Length
        • 19% ↑ in diameter will compensate for doubling of length
    • Placement
      • Site *RIJ (LIJ, IVC, Subclavian)
      • Tip *well within the atrium
  • 6. 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
  • 7. 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
  • 8. Treatment Initiation
    • Nephrology Nurse
      • Assess patient’s 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 patient’s 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. CRRT Treatment Responsibilities: q 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
  • 13. CRRT Treatment Responsibilities: q 2 hr into treatment/ q 6 hr thereafter
    • Bedside Nurse
      • Check circuit ionized Ca ++ (sample from venous port) and patient’s 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
  • 14. CRRT Treatment Responsibilities: q 24 hr
    • Bedside Nurse
      • Assess patient’s 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 patient’s nutritional status – daily weight, albumin, bowel patterns, skin turgor, muscle wasting
      • Monitor the integrity of the access dressing – change per protocol
  • 15.  
  • 16. Potential Complications with Pediatric Hemofiltration
    • Circuit Volumes
    • Hypothermia
    • Anticoagulation
    • Fluid Management
    • Blood Flow Rates
    • Nutrition
    • Solutions
  • 17. Circuit Volumes
    • Significant when dealing with pediatrics
    • General Guidelines
      • Circuit volumes should be < 10% of the patients intravascular blood volume
  • 18. Blood Priming
    • Indications
      • Circuit volume > 10% of the patients blood volume
      • Hemodynamic instability
      • Infants
  • 19. Complications of Blood Priming
    • Blood Bank pRBC tend to be high in K+
      • Close K+ monitoring needed at initiation
    • pRBC HCT are approximately 80%
      • 1:1 dilution with normal saline
      • Blood prime need to be done at time of initiation.
      • Citrate binds calcium
        • hypotension
  • 20. 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
  • 21. Hypothermia Nursing intervention
    • External warming devices
      • Radiant warmers
      • Baer hugger
      • Heating mattress
      • Blood warmers
      • Solutions heaters
    • Monitoring
      • Skin breakdown and patient temperature
  • 22. 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
  • 23. 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
  • 24. Fluid Management Nursing
    • 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
  • 25. Access Difficulties
    • What is the correct access?
    • ? Best placement
    • In flow vs out flow difficulties
  • 26. 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
  • 27. 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

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