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PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
PEDIATRIC GUIDELINES AND PROTOCOLS
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PEDIATRIC GUIDELINES AND PROTOCOLS

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  • 1. PAGE: 1 of 2 General Pediatric Guidelines for CLM Hct–Based Blood Volume Monitoring Note: Blood Volume Monitoring (BVM) must always be used in conjunction with the clinical assessment and existing medical history before altering a dialysis treatment • The following guidelines are for ultrafiltration using the Crit-Line Monitor (CLM). Always check with the pediatric nephrologist for more specific orders. • A pediatric patient is defined as an individual younger than 18 years of age. By weight: Neonatal patient = 3 to 6 kg; Pediatric patient = 12 to 48 kg. • BVM is mandatory for the pediatric patient weighing < 35 kg. • Pediatric patients will have their growth (height and weight) reassessed monthly. Dry weight changes are needed more frequently r/t growth. Pts may be on growth hormones. • Blood volume of a child is approximately 80 ml per kg. • Smaller infants are especially prone to hypotension r/t their small blood volume. • Small errors in UFR can easily cause hypotension or overload. • Acidosis is more common in children. • Assess 24 hour residual urinary output prior to proceeding and monthly thereafter. • Review clinical assessment, patient’s medical history, last dialysis treatment data, last BVM profile, and amount of plasma refill to determine initial UF goal. (See Table I) • Outcome goal for predialysis B/P is lower of 90% of normal for age/ht/wt or 130/80. • Dry weight will be challenged by 50 – 200 ml if the patient is hypertensive pre or post dialysis, irrespective of the presence or absence of post dialysis edema. • A size appropriate B/P cuff will be used to check blood pressure measurements. • Age Specific Vital Signs: Age B/P Pulse Infant 20-60/30 120-150 irregular 4 yrs 85/60 90-110 8yrs 95/62 85- 100 12yrs 108/67 85-100 16yrs 118/75 80- 100 20yrs 120/75 80-100 • Infants and small children are prone to precipitous falls in Blood Pressure with no warning. BP is a post-facto indicator of a problem. • Patients will be instructed to hold their antihypertensive medications till after dialysis unless otherwise directed by their physician, and be given parameters as to when to take / hold them post treatment. • Medication lists need to be reviewed at least monthly, after any intradialytic morbidity (IDM) for continued need, and possible treatment related side effects. • No UF modeling will be used during BVM. • Per KDOQI guidelines, sodium modeling is not generally recommended. • Thermal control (Dialysate temperatures between 35-36 Celsius) is recommended. EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 2. PAGE: 2 of 2 • Patients will be instructed not to eat on hemodialysis; small meals prior to and for one hour after the treatment are also recommended • Verify Accuracy of CLM every day of patient use. • Each patient’s blood volume change will be monitored during the entire treatment. • When attempting to decrease dry weight, consult with pediatrician for maximum goal / UFR allowance. Goal of < 5% of body wt is generally recommended. • The amount of increase or decrease in the patient’s UF Goal will be patient-specific, but generally, after the first 10 minutes of dialysis, incremental adjustments of the Goal by 50 to 200 ml every 20-30 minutes until the BVΔ is at least -3% per hour are appropriate; the total change and maximum UF Goal will be based on the physician orders. • A physician order will be obtained for the amount of saline/ replacement fluids to be used for bolus during pediatric dialysis when IDMs occur. • Identify and report the Hct Threshold: The critical blood volume level in a patient, identified by the Hct at which the patient experiences an IDM. The Hct Threshold will remain unchanged as long as the patients RBC mass remains unchanged. It is reassessed every treatment by a dry weight (plasma refill) check.(See method below) • All interventions / dry weight checks will be marked with assessment arrows by pressing the up or down arrow on the CLM key pad. Arrows can be inserted every 5 minutes. • Root cause analysis will be done after an IDM to assess possible causes and preventative measures. • Set the Hct Limit, or CLM alarm line: -The initial Hct Limit will be set to reflect an approximate - 5% BVΔ and may be increased by 1 Hct point at a time after assessing the patient’s response to fluid removal. The Hct Limit should not exceed a total of -15% BVΔ by treatment end; -8% for patients that are acute, compromised, or that have high residual urine output. (See exceptions under Recommended CLM Protocol). - If the Hct Threshold was identified during current or previous treatments, the final Hct Limit will be set at 1-2 Hct points below this identified Hct Threshold. • Identify and Treat Hypoxemia prior to symptomology: Hypoxemia may begin with an arterial sat (SaO²) from a fistula or graft below 90% or a Venous Sat (SvO²) from a CVC line below 60%. The anaerobic threshold is identified by a venous sat (SvO²) of <30%. Hypoxemia may also occur with an acceptable saturation in the presence of cardiac dysfunction, a low Hct/Hgb (Hgb <10 gm/dL / Hct < 30%) or Oxygen carrying capacity < 19ml/dL (1.39 x Hgb x arterial sat). • Assess dry weight (plasma refill) check every treatment: Turn the UFR to minimum for 10 minutes. If plasma refill is observed (BVΔ does not level off and continues to increase by ≥ 1.5%, and HCT decreases by ≥ 0.5) true ideal dry weight has not yet been achieved. If noted at the end of the treatment, 50-200ml will be added to the patient’s UF goal the next treatment. (See Table I) Table I EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 3. Reduction in Plasma Refill Intra/ Interdialytic Symptoms/ Dry Weight Change BV Post Dialysis Fatigue Yes No No No Yes No Yes Revise Up Yes Yes No Revise Down Yes Yes Yes Revise Down – assess other causes No Not checked No Revise Down PAGE: 1 of 5 Recommended CLM Protocol for the Pediatric Patient on Hemodialysis Assess patient’s blood volume (BV) profile type and BV change (Δ) to identify appropriate interventions thru the Crit-line Monitor (CLM). a. Follow the General Guidelines for CLM Hct–Based Blood Volume Monitoring (BVM). b. Adjust UFR to obtain a B profile thru Linear or Fly the Curve methodologies below. c. Observe Hct to avoid Hct Threshold (Crash Crit): The critical blood volume level in a patient, identified by the Hct at which the patient experiences an intradialytic morbidity d. All interventions / dry weight checks will be marked with assessment arrows by pressing the up or down arrow on the CLM key pad. Arrows can be inserted every 5 minutes. A. The A Profile: Represents fluid overload in the absence of Residual Renal Function 1. The plasma refill rate (PRR) is equal to, greater than, or near ultrafiltration rate (UFR) and appears as a flat, positive, or less than -3% BVΔ per hour with the UFR above minimum. . This can occur in spite of considerable amounts of fluid removal. The patient is at risk of developing pulmonary edema/CHF during or after treatment. 2. Exceptions: a BV profile that is flat, or < -3% per hour is acceptable if after a fluid removal challenge, a dry weight (plasma refill) check is conducted by reducing the UFR to minimum for 10 minutes and the BV increases by < 1.5% whilst the Hct decreases by < 0.5 Hct points. There is no vascular compartment refill if Hct does not decrease by 0.5 or more in 10 minutes or less. These patients are unable to significantly refill into the vascular compartment as they are already near their Hct Threshold (Crash Crit) and dry weight related to conditions such as but not limited to: small weight gain, high residual urine output, high output renal failure, dehydration, ileostomy, pregnancy, leg amputation, acute renal failure, or other compromising conditions. A total maximum of -5% to -8% BVΔ is common for patients with the exceptions. 3. Recommended fluid removal guidelines for the hemodialysis patient who presents with fluid volume excess (FVE) and displays an A profile is to adjust the patient’s goal to increase UFR until a B Profile is created (See protocol for B Profile). B. The B Profile: Recommended fluid removal profile for the average patient on dialysis who is not at their dry weight related to extra fluid volume. B profiles can be obtained through Linear or Fly- the-Curve methodologies. I. B Profile: Linear: Profile resembles a 45 degree angle, obtaining a gradual BVΔ of -3% to -5% per hour to a maximum total BVΔ of approximately -10% to-15%. (Total maximum of -5% to -8% for patients with the exceptions described above). Dx: Fluid Overload - UFR On—Flat or Positive 1. Recommendations to guide the B: Linear Profile: Slope a. Observe Hct to avoid Hct Threshold (Crash Crit) b. Follow General Guidelines for CLM Hct-Based BVM (slower than -3%/hr) Observe Hct…………Avoid Hct Threshold EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised: 1. If trend is flat /positive….…………...Increase UFR 2. If trend is Flat or < 3% hr...………...Increase UFR
  • 4. 2. After the first 10 minutes of treatment, interventions (changes to increase UFR through Goal adjustments) if necessary, will be made by the clinician to guide the BVΔ to approximate a -3% to -5% reduction in BV per hour (B profile). Note: As a general guideline, the average anuric /oliguric chronic patient will decrease their BV by approximately -10% to -15%. Patients that are compromised, acute, or have high residual urine output patients (other exceptions as previously described) will only decrease to a total maximum of -5% to -8% BVΔ PAGE: 2 of 5 3. Immediate interventions will be made for profiles displaying a C profile (> -8% BVΔ per hour) 4. At the beginning of each treatment, set the Hct Limit (CLM alarm) based on patient assessment as follows: a. The initial Hct Limit will be set to reflect an approximate - 5% BVΔ and may be increased by 1 Hct point at a time after assessing the patient’s response to fluid removal: not to exceed a total of -15% BVΔ at treatment end; -8% for patients that are compromised, acute or that have high residual urine output. (See exceptions). b. If the Hct Threshold is known, the final Hct Limit will be set at 1-2 Hct points below the identified Hct Threshold (i.e.: Hct Threshold is 38; set the final Hct Limit at 36) 5. When the desired initial CLM Hct-Based blood volume reduction has been achieved, or any time in the treatment when assessing a patient’s fluid status conduct a dry weight check as described in #7 below and assess for plasma refill. • If the plasma refill continues during this assessment period, reset Hct Limit by adding 1 Hct point and resume ultrafiltration. • If no plasma refill is noted during the 10 min dry weight check (BV curve levels off and becomes flat, or increases < 1.5% whilst the Hct decreases by < 0.5 Hct points), leave the UFR in minimum as the patient is at dry weight 6. Repeat the dry weight check each time the new alarm is reached, or prn until a flat line is achieved signifying that the patient is reaching dry weight. 7. In the last 10 minutes of each treatment in which the patient’s BV has been reduced, a dry weight check will be done by reducing the UFR to minimum, and observing for plasma refill. If plasma refill is observed (BVΔ does not level off and continues to increase by ≥ 1.5%, and Hct decreases by ≥ 0.5, true, ideal dry weight has not yet been achieved and 200 ml will be added to the patient’s UF Goal the next TX. (Table I) 8. Monitor for patient symptoms/Intradialytic Morbidities (IDMs)/ Crashes) such as: a. Cramps b. Dizziness c. Nausea / Vomiting d. Headache e. Chest Pain f. SOB g. Diaphoresis h. Seizures i. Hypotension (systolic BP < 100 or decrease of 15 or greater) See age guidelines. j. Hypoxemia ( arterial sat <90%; venous sat <60%; Hgb <10gm/dl) k. Tachycardia ( HR > 100 or greater than 20-30% of starting HR) See age guidelines l. Bradycardia ( HR < 60) See age guidelines m. Cardiac arrhythmia 9. Treat patient symptoms per facility protocol. (See interventions under C profile) EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 5. 10. When symptoms resolve, continue protocol with new Hct Limit at 1-2 Hct points below the identified Hct Threshold 11. Follow up treatment of IDMs by completing the CQI Outcome Management Tool which assesses the possible root causes of the crash i.e.: posture, hypoxemia, medications that cause vasodilatation, medications that decrease plasma refill (i.e.: angiotension converting enzyme (ACE) inhibitors, calcium channel blockers), UFR too fast compared to patient refill rate, hypovolemia vs. hypervolemia, hypotonic vascular space, hypoalbuminemia, increased patient temperature, eating during TX, severe anemia (Hct ≤30/ Hgb ≤10, cardiac arrhythmia, high output cardiac failure related to high flow vascular access, septicemia, electrolyte/ acid base imbalances. PAGE: 3 of 5 12. Record data at 30-minute intervals: a. Profile observed b. %BVΔ c. Hct (Hct Threshold if identified) d. O² Saturation and changes if noted e. Any intradialytic morbidity (IDM) requiring nursing intervention f. Changes/interventions made due to information received from the CLM (i.e. increased UF Goal by 50 ml, O² administered, etc.) g. In the comment section of flow sheet, indicate reason for intervention as “per Crit-line”. h. Results of dry weight (plasma refill) check: % BVΔ and HctΔ 13. Record data post treatment: a. Maximum and Final BVΔ% b. Ending profile type ( A, B, or C) c. Post weight achieved after each treatment d. Extra fluid amount removed e. New dry weight (if reestablished) f. If plasma refill occurred (yes/no/ not checked / % BVΔ and HctΔ). g. Maximum and Ending Hct h. Hct Threshold if identified i. Hct Limit j. Record the minimum O² Sat and oxygen usage k. Intradialytic morbidities l. Post BP and Pulse 14. In subsequent treatments, the Goal and UFR will be adjusted so that the BVΔ results in maximum Hct being reached or exceeded until dry weight is established through the dry weight (plasma refill) check 15. If the Hct Threshold is identified, the final alarm line (Hct Limit) will be set during subsequent treatments at 1-2 Hct points below the Hct Threshold to avoid symptoms 16. The Hct Threshold will be reassessed each treatment by doing a dry weight (plasma refill) check 17. Prescribed dry weight will be adjusted for next treatment based on assessment of patient profiles, Maximum and ending Hct achieved, if Hct Threshold was identified, Pre/Post dialysis blood pressure measurements, patient intra / interdialytic symptoms, medication list, and results of plasma refill check as suggested in Table I below: Table I Reduction in Plasma Refill Intra/Interdialytic Dry Weight Change EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 6. BV Symptoms/ Post Dialysis Fatigue Yes No No No Yes No Yes Revise Up Yes Yes No Revise Down Yes Yes Yes Revise Down – assess other causes No Not checked No Revise Down 18. Following each treatment, CLM BV data will be downloaded or printed PAGE: 4 of 5 19. The following patient data will be assessed monthly: • Beginning /Maximum and Ending Hct/ Hct Threshold • Pre/post BP / pulses • Pt profile: BVΔ • Results of dry weight (plasma refill) check • Number/ type of antihypertensives and need for adjustments • Medications that could be causing patient symptoms • Dry weight / changes • Intra/ Interdialytic Morbidities (IDMs) • Hypoxemia / application of oxygen • Hospitalizations for Fluid Overload • Patient comments • Residual Renal Function II. B profile: Flying-the-Curve: Profile resembles an initial steep change, obtaining a BVΔ of no more than -8% for the first hour, then a more gradual change of approximately -3% to -4% per hour for the remainder of the treatment to a total BVΔ of approximately -10% to- 15%. (-8% total maximum for exceptions as described above). This Profile creates the highest mobilization of tissue fluid by increasing albumin/oncotic pressure. Improved URR occurs related to the creation of a diffusion gradient for urea and preventing ischemia and shunting (80% urea is in the skin, muscle, bone). Note: the Fly-the-Curve profile may eliminate the need for Isolated UF (Sequential) as it maximizes fluid removal using the same principles without the risk of rebound hyperkalemia or sacrificing clearance of solutes. During the first hour, plasma osmolality increases related to increases in plasma proteins, urea, atrial natriuretic peptide (ANP), and middle molecules as fluid is rapidly removed. Blood sugar is generally higher and core body temperature lower in the first hour. All of these conditions promote plasma refill. 1. Recommendations to guide the B: Fly-the-Curve Profile: a. Observe Hct to avoid Hct Threshold (Crash Crit) b. Follow General Guidelines for CLM Hct-Based BVM 2. At the beginning of each treatment, the Hct Limit will initially be set at -5% BV change. The patient’s Goal and UFR will be set to remove up to ½ of their Gain during the first hour. (Maximum allowed to be determined by the pediatric nephrologist). 3. If the patient’s BVΔ is decreasing greater than -5% in the first half hour- decrease the Goal to slow down the rate of change. 4. After the first half hour, if the patient has tolerated the fluid removed, and has EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 7. decreased to no more than -5% BVΔ, the Hct Limit can be moved by 1 Hct point to approximately -8%. The percent change per hour is dependent upon the child’s weight as follows: Weigh patient < 35 kg > 35 kg 1. Blood volume change up to -8% per hour 1. Blood volume change -8% per hour during first 60 minutes during first 90 minutes (approx -12%) 2. Blood volume change up to -4% per hour 2. Blood volume change up to - 4% during remainder of dialysis per hour during remainder of dialysis (up to approx -15% Total) (up to approx -15% Total) PAGE: 5 of 5 5. Adjust the ultrafiltration rate by increasing or decreasing the goal by increments of 50 to 200 ml every 20- 30 minutes until the above desired blood volume change is achieved, or as ordered by the nephrologist. 6. Upon completion of the first hour when the initial goal has been met, or sooner if the Hct Limit has been reached: • Assess for Plasma Refill (Dry Weight Check) by reducing the UFR to minimum for 10 minutes. • If Plasma Refill is noted: a. The Dialysis Machine will be reprogrammed to remove the remaining ½ of the patient’s gain divided over the remainder of the hemodialysis treatment time to achieve a BVΔ as stated above (to a maximum total of approximately -15%; -8% for patient’s with exceptions), or until reaching the Hct Limit, avoiding the Hct Threshold. b. The Hct Limit will be reset by adding 1 Hct point at a time and as previously described under B Linear Profile guidelines • If no Plasma Refill is noted, the BV curve remains flat / begins to level off, during any Dry Weight check, the UFR will be left in minimum. These patients are already near their Hct Threshold (Crash Crit) and dry weight. 7. Continue with steps 5- 19 under B Linear Profile. C. C Profile: Represents an impending crash. Appears as a steep BVΔ of >-8% per hour, a sudden discontinuity, or sudden dip, and can occur at any time during the treatment. The plasma refill rate is not able to keep up with the UFR. Hypovolemia and intradialytic morbidity will ensue if there is no intervention. Note: -8% BVΔ is only permissible in the first hour of a calculated Fly the Curve Profile. 1. Recommended guidelines for the hemodialysis patient who displays a C Profile: a. Observe Hct to avoid Hct Threshold (Crash Crit) b. Follow General Guidelines for CLM Hct-Based BVM c. All interventions / dry weight checks will be marked with assessment arrows by pressing the up or down arrow on the CLM key pad. Arrows can be inserted every 5 minutes. 2. Adjust Goal to decrease UFR to create a B Profile (See protocol for B Profile) 3. Asymptomatic patient: Assess for and treat possible root causes. Interventions include but are not limited to: • changing position to a modified Trendelenburg • assessing for and treating hypoxemia • reducing the UF Goal to return to a B profile, or set UFR to minimum to assess plasma refill for a dry weight check EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:
  • 8. • applying thermal control to maintain isothermia (dialysate temperatures between 35-36 Celsius) • assessing for a hypo-osmolality ( low serum sodium, serum albumin, serum protein) • assessing for medications that could cause a reduction in peripheral vascular resistance (PVR) • postponing eating until after dialysis and recommending small meals prior to and for one hour after the treatment • assess for cardiac issues: i.e.: poor ejection fraction, tachycardia, bradycardia, irregular heart rate, high output cardiac failure from high vascular access flow. 4. Symptomatic patient: Assess for and treat possible root causes. • follow facility resuscitation protocol • reassess dry weight: set UFR to minimum, assess for plasma refill • assess for and treat possible root causes as above • consider future need for – or need to eliminate variable sodium • infuse replacement fluids per facility policy • record Hct Threshold: modify Hct Limit 1-2 Hct points below the Hct Threshold • reassess for and record new dry weight if established • continue with protocol to maintain a B profile when symptoms are resolved 5. Continue with steps 5- 19 above under B Linear Profile. EFFECTIVE DATE: 1-26-09 REFERENCES: Crit-Line™ III TQA Reference Manual, Hema Metrics™ Revised:

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