Continuous renal replacement therapy in the adult intensive care unit
Continuous Renal Replacement Therapy in the Adult Intensive Care Unit: History and Current Trends1. Susan Dirkes, RN, MSA, CCRN and2. Kimberly Hodge, RN, CCRN-CMC +Author Affiliations 1. Susan Dirkes is a clinical educator at NxStage Medical, Lawrence, Mass. 2. Kimberly Hodge is the Advanced Cardiac Life Support and Pediatric Advanced Life Support senior educator for the Emergency Response Training Institute at Clarian Health, Indianapolis, Ind. 1. Corresponding author: Susan Dirkes, 6326 Sterling Dr, Newport, MI 48166 (e-mail: email@example.com). This article has been designated for CE credit. A closed-book, multiple- choice examination follows this article, which tests your knowledge of the following objectives: 1. Identify indications for intermittent dialysis and continuous renal replacement therapy (CRRT) 2. Review variations and advantages and disadvantages of CRRT 3. Examine potential complications of CRRT The authors review treatment of acute renal failure in critically ill patients, indications for intermittent hemodialysis and continuous renal replacement therapy, and the use of other variations of this therapy currently under investigation. Acute renal failure (ARF) is a common complication in critically ill adult patients in critical care units. ARF is defined as a sudden decline or cessation of renal function. Characteristics include inability of the kidneys to excrete wastes and maintain fluid, electrolyte, and acid-base balance.1,2 Despite advances in treatment, data from the past several decades continue to indicate that ARF still is associated with high mortality rates, ranging from 25% to 90%. 3,4 Factors that may influence the rates include the increasing age of patients and the existence of comorbid conditions (eg, diabetes, preexisting renal disease, vascular disease). 1 Historically, the treatment of ARF has been supportive. The primary focus of intermittent hemodialysis is to replace renal function by removing excess water and wastes. The standard of care for patients treated with intermittent hemodialysis may not be applicable to critical care patients because of the nature of the latter patients’ illness and catabolic state, the presence of systemic inflammatory syndrome with or without sepsis, and other organ failure. 5 In this article, we review treatment of ARF in critically ill patients, indications for intermittent hemodialysis and continuous renal replacement therapy (CRRT), and the use of other variations of CRRT currently under investigation. Next Section Management of ARF Medications ARF can be managed in some patients by nondialytic interventions such as loop diuretics (furosemide and bumetanide). Recently, the effect of diuretics in critically ill patients with ARF
has been questioned. Mehta et al6 and Shilliday et al7 found that the use of diuretics in critically illpatients with ARF was associated with an increased risk of death and nonrecovery of renalfunction. If medications are not effective, the choice of treatment and dialytic therapy shouldideally mimic the efficacy of the native kidney and, at the same time, not delay the recovery ofrenal function. Therapy should be individualized according to each patient’s urgency and need forthe therapy and hemodynamic tolerance.Intermittent HemodialysisIntermittent hemodialysis is still a commonly used treatment for ARF in the critical care unit forsome patients. The dialysis is typically done 3 times a week. This timing evolved to ensure thatpatients were treated sufficiently to provide an “adequate” state of health. 8 These treatmentprinciples applied to patients in chronic renal failure, not to critically ill patients.Intermittent hemodialysis is also used for many patients because it is relatively inexpensive(approximately $130 per treatment, not including staffing) and of short duration (typically 3–4hours).9 Treatment of a patient 3 times a week allows for a considerable increase in the serumlevels of urea nitrogen and creatinine and for variations in electrolyte, water, and acid-basebalance between treatments.Orders for intermittent hemodialysis typically require, at a minimum, removal of the previous 24hours’ fluid intake during the dialysis treatment. Critically ill patients are prone to hypotensionbecause of the severity of their illness. Therefore, removal of 2 to 3 L/h of fluid in a patient in anunstable condition may make it difficult to use conventional intermittent hemodialysis. 10,11As a result, critically ill patients with ARF will not achieve adequate water or waste removal withtraditional dialysis.12 Repeated episodes of hypotension during intermittent hemodialysis also canlead to ischemia of the nephrons each time the dialysis is performed. 2,13 Therefore, the ability ofthe remaining nephrons to survive, as well as the potentially adverse effects of aggressive fluidremoval, should direct the choice of therapy.Continuous Renal Replacement TherapyAs the search for better treatments for ARF continues, research findings are indicating that thetechnique and timing as well as the type of renal replacement therapy used may affect patients’survival and recovery of renal function.14–16The concerns about hemodynamic stability duringhemodialysis, nephron injury, and the inability to adequately remove excess water and soluteshave led to the development of a slower, less aggressive renal replacement therapy: continuousrenal replacement therapy (CRRT).CRRT is an extracorporeal process in which blood is removed from the arterial lumen of a catheterby a peristaltic blood pump and pushed through a semipermeable membrane before being pumpedback into patients via the venous lumen of the catheter. These catheters are typically placed in theinternal jugular or subclavian vein. When the blood passes through the membrane (hemofilter ordialyzer), electrolytes and small- and mediumsized wastes are removed from the blood byconvection and diffusion. Fluid removal is achieved by ultrafiltration at an established hourly rateand on a continuous basis.17Previous SectionNext SectionTypes of CRRTIn 1977, Kramer et al18 described a therapy called continuous arteriovenous hemofiltration inwhich a patient’s own blood pressure moved the blood from an artery to a vein through a highlyporous hemofilter. The blood flow through the hemofilter was driven by the patient’s mean arterialpressure, and ultrafiltration was achieved by raising and lowering the drain bag in relation to thepatient. The blood flow rate was slow because of frequent hypotension experienced by critically illpatients. It resulted in a low driving pressure of the blood through the circuit, much less than whata blood pump can achieve. This slow blood flow limited the volume of ultrafiltrate that could beobtained, which limited the adequacy of the dialysis. A major drawback to continuousarteriovenous hemofiltration was the use of a large catheter in a major artery, commonly thefemoral artery, a practice associated with risks for infection, distal thrombosis formation,disconnection, and exsanguination.
In the 1980s, a blood pump, such as those used in intermittent hemodialysis, and a double-lumencatheter in a large vein were used to provide a consistent blood-flow rate without the risksassociated with the arteriovenous approach. This method of CRRT was called venovenoushemofiltration and has been adopted as the standard for CRRT.CRRT mimics the functions of the kidneys in regulating water, electrolytes, and wastes bycontinuing 24 hours a day, for several days, slowly removing fluid and solutes. The indicationsthat led to the development of CRRT include patients who had fluid overload, diuretic resistance,hemodynamic instability, and azotemia.2Because fluid removal with CRRT is much slower thanwith intermittent hemodialysis, CRRT is an ideal therapy for critically ill patients in unstableconditions. For example, a net ultrafiltration rate of 12.5 mL/min is required to remove 3 L ofplasma water during 4 hours of intermittent hemodialysis. The same amount can be removed withCRRT in 24 hours with a net ultrafiltration rate of 2 mL/min.19 Removing fluid more slowly and insmaller volumes in hours or days may provide enhanced hemodynamic stability.Membranes in CRRTHigh-efficiency membranes are used in CRRT for maximum water and waste removal. High-efficiency membranes include high-flux dialyzers and hemofilters. The membranes used aresynthetic and biocompatible.20,21 The capability of dialysis membranes lies in the surface area,membrane thickness, pore size and density, and potential to adsorb proteins. 22 High-efficiencymembranes have both high membrane permeabilities and larger pore sizes and therefore aredesirable for CCRT. In all methods of CRRT, as blood flows through the hemofilter, plasma wateris filtered through the pores in the hemofilter membrane and produces the ultrafiltrate. Theultrafiltrate produced during CRRT is composed primarily of water, electrolytes, wastes, and somedialyzable drugs.23High membrane permeability and large pore size provide excellent clearance of small-molecular-weight solutes and larger substances, up to the maximum pore size. 24,25 Examples of small-molecular-weight substances (<0.5 kd) are urea, electrolytes, vitamins, and certain medications.Large-molecular-weight substances such as albumin, red and white blood cells, and drugs boundto proteins cannot pass through a hemofilter membrane (typically with a maximum pore size of 50kd) because of the large size of the substances.26Another potential benefit of the use of high-permeability dialyzers and hemofilters is the ability toremove cytokines, which are middle-molecular-weight substances, or decrease their concentrationby adsorption to the membrane.27 These inflammatory cytokines, such as interleukin-1 β ,interleukin-6, and interleukin-8, contribute to sepsis and may be altered or removed inCRRT.28 Although no conclusive data confirm the link between the beneficial clinical effectsobserved in patients with sepsis who have CRRT, the effect of cytokine removal by adsorptionand the preliminary observations of patients’ outcomes are encouraging.29,30Continuous Venovenous HemofiltrationContinuous venovenous hemofiltration (CVVH, Figure 1⇓) is defined as “a venovenous techniquewhere the ultrafiltrate produced during membrane transit is replaced in part or completely withappropriate replacement solutions to achieve blood purification and volume control.”31 In CVVH,convection and ultrafiltration are used to remove waste products. Convection is the movement ofsolutes under pressure through a membrane along with the movement of water. Convectivetherapies appear to have advantages over other continuous therapies because of the ability toremove a wider range of solutes with the ultra-filtrate, including some cytokines, a characteristicthat may affect patients’ outcomes.32,33
View larger version: In this page In a new window Figure 1 System for continuous venovenous hemofiltration.Physiological fluids termed replacement fluid are used to replace the majority of ultrafiltrateremoved hourly, in order to prevent instability and to replace electrolyte losses during CVVH.Replacement fluids generally consist of balanced electrolyte solutions that closely resemble thecomposition of the ultrafiltrate lost minus the wastes. 34 Replacement fluids are infused either intothe arterial side of the circuit before the hemofilter, a method called “predilution/prefilter,” or intothe venous side of the circuit after the hemofilter, a method called “postdilution/postfilter.” Bothmethods of fluid replacement achieve the goal of replacing ultrafiltrate volume and electrolyteswhile removing wastes by convection.23,35The predilution method of infusing replacement fluid also provides a continuous flush for thehemofilter that dilutes the blood flowing through the filter, a situation that may decreasehemofilter clotting and increase the clearance of solutes. 36 Postdilution infusion of solutionsreplaces fluid and electrolytes but does not affect clotting in the hemofilter. Increasing the volumeof ultrafiltrate produced in CVVH by increasing the infusion of replacement fluid increasesclearance of both small- and middle-molecular-weight substances by solute drag.23,37,38Currently, no electrolyte solutions have been specifically approved by the Food and DrugAdministration for infusion as replacement fluid. Solutions that are used include lactate- orbicarbonate-based or custom pharmacy–mixed fluids. Because of the lack of these approvedreplacement solutions in volumes greater than 1 L, the cost of mixing custom solutions and theability to provide large volumes for patients’ treatment, some physicians use purchased custom-compounded pharmacy fluids in large volumes or may use commercial solutions as an off-labelprescription.Continuous Venovenous HemodialysisIn continuous venovenous hemodialysis (CVVHD, Figure 2⇓), diffusion and ultrafiltration areused to remove waste products. The fluids used are known as dialysate fluids. Dialysate is infusedcountercurrent to the blood flow, into the outside compartment of the hemofilter to provide adiffusion of wastes from the blood.39 The dialysate fluid is not infused into the blood as in CVVH,rather it is infused into the outside compartment of the hemofilter or dialyzer. In diffusive therapy,small molecular wastes and electrolytes diffuse from the high concentration in the blood into thesterile dialyzing fluid on the other side of the membrane and are removed in the ultrafiltrate.
View larger version: In this page In a new window Figure 2 System for continuous venovenous hemodialysis.Historically, CRRT fluids were run at lower flow rates, approximately 1 L/h, because no researchwas available that indicated better treatment efficiency with higher rates and because many oldermachines lacked the option to increase flow rates. When dialysate is run at lower flow rates, suchas 10 to 20 mL/min, the dialysate is almost completely saturated with the wastes. 19 However, if thedialysate is run at faster rates, 30 to 60 mL/min, the amount of small molecular waste clearedincreases. Diffusion in CVVHD does not affect clearance of larger molecular weight substances.Research40,41 indicates that increasing the dialysate rate improves the efficacy of dialysis. Mostcurrent CRRT equipment allows fluid rates to be prescribed at the higher rates, often up to 150 to200 mL/min to improve clearance.For CVVHD, dialysate solutions are available from a variety of sources. The solutions may bemixed by hospital pharmacies, peritoneal dialysate solutions may be used, or commercial solutionsapproved by the Food and Drug Administration may be purchased. Disadvantages of relying onhospital pharmacies to mix either dialysate or replacement solutions include the high cost of laborto produce multiple liters of solutions consistently and safely for ongoing CRRT treatments.Peritoneal dialysate solutions contain large amounts of glucose and are lactate based, making themless suitable for CVVHD. Lactate solutions may worsen metabolic acidosis in patients withmetabolic derangements and hepatic failure.42 Bicarbonate-based solutions are preferred forpatients with hepatic failure who cannot metabolize the lactate and are also more physiologicalthan are lactate solutions. Several commercial dialysate solutions in large volumes are currentlyavailable, such as PrismaSate (Gambro, Lakewood, Colo), Baxter Premixed Dialysate andACCUSOL (Baxter, Deerfield, Ill), PureFlow (NxStage Medical, Lawrence Mass), and Duosol (B.Braun, Bethlehem, Pa). These solutions provide a wide choice of electrolyte compositions and thechoice of bicarbonate- or lactate-based solutions to meet individual patients’ needs.Continuous Venovenous HemodiafiltrationIn continuous venovenous hemodiafiltration (CVVHDF, Figure 3⇓), diffusion, convection, andultrafiltration are used to remove wastes and water. In this method, dialysate and replacementfluids are used simultaneously in various combinations of rates. The goal is to offer both aconvective therapy, for clearance of middle-molecular-weight substances, and a diffusive therapy,for removal of smaller substances.43 This therapy was widely used to provide a more efficientdialysis when machines were limited in the ability to infuse large quantities of fluids. However,current technology for CRRT provides the ability to infuse fluid, either replacement or dialysate,at higher rates to provide efficient therapy. The ability to use only a single fluid effectively alsoimproves the simplicity of performing CRRT.
View larger version: In this page In a new window Figure 3 System for continuous venovenous hemodiafiltration.Slow Continuous UltrafiltrationSlow continuous ultrafiltration (SCUF, Figure 4⇓) is a hemofiltration therapy used primarily forfluid removal.44 No dialysate or replacement fluids are used because wastes, electrolyte balance,and acid-base status may not be as critical an issue in patients who have SCUF and in patients whohave other CRRTs. As it is removed from the hemofilter, ultrafiltrate is regulated to provide aslow, continuous removal of plasma water for diuresis, for example, 50 to 500 mL/h to achievefluid balance. SCUF is a good therapy of choice when the only goal is fluid removal and thepatient does not have azotemia. View larger version: In this page In a new window Figure 4 System for slow continuous ultrafiltration.Patients who may benefit from SCUF include those who are refractory to diuretics or who needadjunctive fluid removal, such as patients with pulmonary edema, sepsis, heart failure, or acuterespiratory distress syndrome who need diuresis to improve pulmonary function.Research45,46 indicates that excess fluid that can be effectively and slowly removed in critically illpatients may improve oxygenation, cardiac output, and mean arterial pressure. In infants andchildren, research47,48suggests that earlier intervention with CRRT and fluid overload is associatedwith greater survival, indicating that fluid removal may have a beneficial effect on outcome.Previous SectionNext SectionAnticoagulation for CRRTDuring CRRT, a patient’s blood is outside the body and in contact with artificial tubing and filters.The result is stimulation of the coagulation cascade and, more important, the complement cascadeif a biocompatible membrane is not used. The goal for anticoagulation in CRRT is to reduceclotting in the hemofilter to maximize the CRRT circuit life. Avoiding interruptions in CRRT by
preventing clotting provides continuous therapy for the patient. Although CRRT is intended to runfor 24 hours a day, the average therapy time is actually closer to 16 hours a day because ofinterruptions.49 These interruptions can decrease the effect and efficacy of CRRT markedly. 50CRRT can be performed with or without anticoagulation. The choice of anticoagulant depends onthe physician’s preference, the patient’s condition, and the familiarity of the nursing staff withanticoagulation regimens.51 At times, the choice is to not give a patient an anticoagulant or use ananticoagulant in the CRRT system. Anticoagulation may not be indicated in patients who haverecently had surgery, have sepsis or immunosuppression, or have hepatic failure orthrombocytopenia. Another reason to use anticoagulants is to maximize the CRRT circuit life sothat the therapy is continuous for several days. This maximization can reduce the cost of thecircuit tubing and components, which often cost approximately $150 to $200 or more a set, andthereby reduce the cost of patients’ treatment.9,13Patients receiving anticoagulation for CRRT should be monitored on a routine basis. The mostcommon tests used to monitor coagulation are activated clotting time and activated partialthromboplastin time (aPTT).52 Activated clotting times can be measured at the bedside but requirethat the critical care staff maintain competency for point-of-care testing. Activated clotting timesmay be maintained at 180 to 220 seconds or according to institutional protocols. 53 The degree ofanticoagulation is most commonly determined by using aPTT. The aPTT is maintained at 1.5 to 2times normal to maintain patency of the circuitry.54 The bedside nurse is responsible formonitoring any adverse effects of anticoagulation, including hemorrhage, formation ofhematomas, thrombocytopenia, and allergic reactions.Heparin is the most widely used anticoagulant. Other options include citrate, direct thrombininhibitors, and flushes with isotonic sodium chloride solution. Ideally, anticoagulation is donewithout producing systemic anticoagulation in the patient. The type of therapy, the anticoagulantused, and the blood-flow rates are all key components of keeping the CRRT system free of clots(Table 1⇓.) View this table: In this window In a new window Table 1 Anticoagulation options in continuous renal replacement therapyHeparinHeparin is the least expensive anticoagulant and can be used either systemically or regionally.When heparin is used, the hemofilter may be flushed with a dilute heparin solution continuouslyor intermittently. Systemic heparinization includes infusing heparin into a separate intravenousaccess or into the arterial side of the CRRT circuit. Infusion of the heparin into the arterial side ofthe CRRT circuit allows mixing of the heparin with the blood from the patient before the bloodreaches the filter (prefilter). The heparin can be infused via an intravenous pump or a syringepump, depending on the CRRT system used. Systemic heparinization provides anticoagulation ofthe circuit as well as for the patient.Heparin-induced thrombocytopenia is a complication of heparin therapy. This complication is welldocumented and therefore has limited the popularity of heparin for anticoagulation in recentyears.55 Heparin-induced thrombocytopenia occurs when antibodies to heparin bind to coagulationfactor IV on platelets, causing platelet activation and aggregation. 56 These changes in turn causethe generation of venous and arterial thrombi and a decrease in the platelet count. Even afterheparin is discontinued, the platelet count may remain low. Consequently, in patients withheparin-induced thrombocytopenia, the concerns for thrombi and the associated costs of changingCRRT circuits frequently have led to the use of other anticoagulants in CRRT.
Regional heparinization involves use of an anticoagulant in the circuit only, not systemicheparinization in the patient. Heparin is infused directly via a syringe or an intravenous pump intothe circuit blood prefilter. Protamine, a heparin antagonist, is delivered via an intravenous pumpinto the circuit near the catheter on the return blood line to deactivate the heparin. 57Anticoagulation monitoring for regional heparinization requires determining the aPTT of bloodfrom the patient (eg, blood obtained via a peripheral site or an arterial catheter) and the aPTT ofblood in the CRRT circuit (usually from the postfilter preprotamine infusion side of the CRRTcircuit) regularly. The goal in regional heparinization is a normal aPTT for the patient and anaPTT of approximately 100 seconds for the postfilter level. Advantages of monitoring of aPTT inboth the circuit and the patient include “tight” heparinization, that is, the heparin is not sent to thepatient, and therefore anticoagulation occurs only in the circuit. Disadvantages include therequirement for meticulous monitoring of laboratory results and frequent adjustment of dosage ofboth the heparin and the protamine.Direct Thrombin InhibitorsArgatroban (GlaxoSmithKline, Research Triangle Park, NC) and lepirudin (Refludan, BerlexPharmaceuticals, Richmond, Calif ) are both direct thrombin inhibitors. Direct thrombin inhibitorsare used for their anticoagulant properties in patients with heparin-induced thrombocytopenia whoare undergoing CRRT and require anticoagulation. Lepirudin is cleared by the kidneys andtherefore may not be the drug of choice for patients in ARF. Argatroban is eliminated by the liverand is therefore more suitable for use in patients with renal failure. 56 Both Argatroban andlepirudin are infused via an intravenous pump into the arterial or access side of the CRRT system.Both drugs are considerably more expensive than heparin.CitrateCitrate is also used in CRRT because of the compound’s excellent anticoagulant ability andpotential to prolong circuit life. Calcium is an essential component of the clottingcascade.58 Citrate binds to the calcium in the patient’s blood within the CRRT system and preventsclotting. Citrate is infused prefilter into the CRRT system, and calcium is typically infused viaanother intravenous line outside the circuit. Ionized calcium levels are routinely monitoredbecause the ionized form of calcium is a the biologically active form of calcium and accounts forabout 50% of the calcium in the blood in normal conditions.59Citrate is available as a trisodium citrate or as anticoagulant citrate dextrose formula A. Trisodiumcitrate has a higher sodium content than does anticoagulant citrate dextrose formula A (420mmol/L vs 112.9 mmol/L).51 Citrate is used in CVVH, CVVHD, CVVHDF, and SCUF. Citratecan be used as a replacement fluid that contains less sodium than normal. 60 In CVVHD, a dialysatethat also has less sodium than normal may be used to manage the sodium in the citrate solution.Typically, calcium-free solutions are preferred in CRRT to prevent interaction with the infusedcitrate. Some clinicians use replacement or dialysate solutions containing calcium because theamount of calcium in these solutions is small and unlikely to affect the efficacy of the citrate. 61Alkalosis is a potential complication of CRRT and, in particular, citrate anticoagulation becausethe body metabolizes citrate into bicarbonate.62,63 The resulting alkalosis can be treated byadministering sodium chloride to provide hydrogen ions to produce hydrochloric acid, infusinghydrochloric acid, or reducing the citrate infusion rate. 23,64 Citrate anticoagulation in patients withhepatic failure or with lactic acidosis may be contraindicated because these patients may not beable to metabolize citrate.54 An essential requirement of citrate anticoagulation is diligentmonitoring of all laboratory values, including levels of ionized calcium and sodium and acid-basestatus.Flushes With Isotonic Sodium Chloride SolutionWhen a patient’s condition warrants that no anticoagulant be used, the circuit may be flushed atintervals with small boluses of isotonic sodium chloride solution to reduce stagnation of blood inthe hemofilter or dialyzer and keep the circuit free of clots. Some protocols dictate that when no
anticoagulant is used, the circuit should be flushed with 50 to 100 mL of isotonic sodium chloridesolution each hour to reduce stagnation of the blood in the membrane itself. Isotonic sodiumchloride solution is not an anticoagulant, so this maneuver may deter clotting in the hemofilter, butit also increases the volume of fluid intake for the patient.Maintaining the patency of the CRRT circuit for a patient who is not given an anticoagulant maypose a challenge. Other options to reduce clotting in the circuit include the use of blood tubing thatminimizes the air-blood interface, such as eliminating the arterial or venous air traps. Tubingdesigns that provide methods for air removal without using a large air-blood interface and use ofcircuit design in which the blood flow moves in straight lines instead of around a blood pump mayreduce stagnation and pooling of the blood as the blood flows through the circuit. Becausereplacement fluid is infused directly into the blood prefilter in CVVH, preventing clotting in thehemofilter by diluting the blood may be helpful. Use of a well-placed, large-bore catheter also canhelp streamline blood flow from the patient and back to the patient.Fluid Management in CRRTMost patients undergoing CRRT are oliguric, anuric, and possibly volume overloaded. Thevolume of hourly ultrafiltrate removed depends on an hourly fluid-balance calculation and anassessment of the patient’s volume status. Fluid management in CRRT typically involves hourlycalculation of the patient’s non-CRRT system intake (eg, infusions , medications, feedings) plusfluid loss ordered by the physician minus non-CRRT system output (eg, urine, drainage fluid,blood loss).23 Excess fluid volume to be removed in a patient with fluid overload is usually termed“net loss” and is ordered by a physician. An example of net loss volume ordered may be 25 to 200mL/h more than the hourly intake to ensure a slow and gentle removal of the excess fluid volume(Table 2⇓). View this table: In this window In a new window Table 2 Typical calculation of fluid balance for continuous renal replacement therapyThe CRRT system infuses and removes fluid after the fluid balance is calculated and the desiredvolumes are input to the system. The system monitors the volume of the dialysate and/orreplacement fluids infused and the volume of fluid removed on an ongoing basis. Scales orbalancing chambers are used to manage the administration and removal of fluid. Any volume offluid infused outside the CRRT system, such as infusions, tube feedings, boluses, and medications,is not accounted for unless the volume is programmed into the machine to be removed.If a scale system is used, the scales balance the weight of the volume of fluid programmed to belost on the infusion scale and the weight gained on the output scale. In a balancing chambersystem, the balance chambers empty and fill precisely, to balance the fluid volume programmed inand out, ensuring that the fluid volume desired is accurate.In either type of system, to verify accuracy, a nurse can monitor the therapy history, if available,for the volume of actual fluid removed at the end of each hour and compare that volume with thevolume that was programmed. The volumes programmed to be infused and removed by the systemshould be within the manufacturer’s error specifications of the system in use. If the volumes areincorrect, or if the nursing assessment indicates an error, additional troubleshooting is required toachieve the patient’s goals and to ensure the patient’s safety. Every time an alarm occurs, or thepumps stop on the system, the fluid removal is also stopped. Therefore, under certain conditions,the programmed volume of fluid to be removed may not be the volume that was removed that
hour. Regardless of the type of system used, the fluid balance should be calculated hourly oraccording to the institutional standard to monitor the patient’s status and fluid balance.Before CRRT is started, patients should have a complete nursing assessment (Table 3⇓). Theassessment includes evaluation of the fluid status and the volume of fluid the patient is receivingeach hour, the patient’s baseline blood pressure, dosages of any vasopressors being administered,weight (“dry” weight before admission and current weight), presence of edema, central venouspressure, pulmonary artery occlusion pressures, cardiac index, and cardiac output if the patient hasa pulmonary artery catheter in place. Other helpful measurements include arterial blood gases,arterial oxygen saturation, and mixed venous oxygen saturation. Once CRRT is started, ongoingmeasurements of these parameters indicate the patient’s tolerance of the procedure as well as anyimprovement in fluid status. View this table: In this window In a new window Table 3 Nursing management during continuous renal replacement therapy (CRRT)Decreases in blood pressure, central venous pressure, pulmonary pressures, and weight mayindicate that fluid is being lost and the patient is experiencing the benefits of CRRT. A markeddecrease in blood pressure, mixed venous oxygen saturation, or arterial oxygen saturation; anincrease in edema; or weight gain may indicate that the therapy objectives are not being achievedor that the circuit is not functioning properly. In this instance, a physician should be notified andfluid removal should be decreased or stopped until the patient’s condition becomes more stable.Because one goal of CRRT is to reduce fluid overload, the bedside nurse should discuss thepossibility of reducing intake to minimal volumes of fluids if at all possible and concentratingmedications and infusions to minimize fluid intake.Mechanical failures can occur if alarms are ignored or bypassed without determining the cause ofthe alarms. If scales are not properly calibrated, the volumes of fluid administered and removedmay not be the programmed volumes. Bypassing alarms without correcting the cause of the alarmis a safety hazard.Previous SectionNext SectionHypothermia in CRRTHypothermia is a complication of CRRT.73,74 The typical blood circuit can contain anywhere from110 mL to 200 mL or more of blood outside the body at any time, a situation that contributes tocooling of the patient. Solutions such as replacement fluid and dialysate are used at roomtemperature. Infusion rates of 2 to 5 L/h or more provide a more efficient treatment than do slowerrates; however, such large volumes of fluid can quickly lower a patient’s temperature if the fluidsare not warmed.75,76 Effects of hypothermia include dysfunction of clotting factors and platelets,activation of fibrinolysis, and cardiac dysrhythmias.77 Some CRRT manufacturers offer a bloodwarmer for the blood in the circuit, but most systems have some type of plate or convectivewarmer for warming the therapy fluids.Before CRRT is started and once it has begun, the patient’s temperature should be routinelymonitored and the warmer temperature increased as necessary to keep the patient’s temperaturenear normal. If increasing the warmer temperature does not correct the hypothermia adequately, orfluid warming options are not available, warming blankets and increases in the room temperaturemay be used. Nursing tasks include monitoring the patient’s temperature, implementing warminginterventions if needed, and monitoring for signs and symptoms of infection (eg, increased whiteblood cell counts), because the patient’s temperature is masked by the cooling effect of the circuit.
Previous SectionNext SectionAir EmbolusAir embolus can occur if a patient receives air in the blood returned. CRRT systems have airdetectors built in to detect even microbubbles of air. If the system’s safety mechanisms arebypassed, a patient can receive an air embolus. Alarms can occur if the air is not properly removedfrom the blood circuit during priming or if a port in the circuit is loose or open. Air also can occurin the circuit if the access cannot provide the blood flow programmed on the machine. In thissituation, the blood pump will run, but a vacuum is created, causing air to move through thecircuit. In each of these situations, the nurse caring for the patient is responsible fortroubleshooting the system to determine the source of the air or for checking the help screens onthe system to determine if therapy can be resumed.After the system is primed and brought to the bedside and before the connection with the patient isestablished, the circuit should be checked to ensure that all air has been removed. It is imperativeto verify that the arterial or access side of the access tubing is securely connected to the catheterand, even more important, that the venous or return side of the tubing is securely attached to thecatheter. If the venous side of the blood tubing is not connected securely to the catheter, an airembolism can occur because the blood will have traveled past the machine’s air detector. Nursesmust continually assess the circuit tubing for the presence of air.Previous SectionNext SectionMinimizing Blood Loss in CRRTMinimizing blood loss in patients receiving CRRT is always a priority. Prompt attention to alarmsand knowledge of troubleshooting can prevent loss of blood in the circuit. Nurses caring for apatient receiving CRRT should know how to perform an automatic or manual return of thepatient’s blood when CRRT is discontinued or the circuit is clotted. As mentioned earlier, somecircuits can hold 200 mL or more of blood. Ongoing blood loss due to failure to rinse the bloodback to the patient or to an inability to detect signs of clotting in the hemofilter is detrimental tothe patient and may affect the patient’s safety. Nurses’ yearly competency testing should include areview of rinsing patients’ blood back in addition to a review of machine alarms.Previous SectionNext SectionTransport ProceduresAt times, a patient receiving CRRT may need to go out of the critical care unit for a diagnosticprocedure or test (eg, computed tomography or angiography). Before the patient leaves the criticalcare unit, the connection with the CRRT system is discontinued, and the patient’s blood isreturned to the patient by flushing the blood back with isotonic sodium chloride solution. Themachine is placed in a recirculation mode while the patient is away. When the patient returns tothe critical care unit, the system is taken out of recirculation mode, the connection between thepatient and the machine is reestablished, and therapy is resumed. Flushing the patient’s blood backin this situation not only minimizes blood loss but also allows maximum use of the CRRT circuitif the circuit is not clotted.Institutions should have protocols in place to guide the length of time CRRT can be discontinuedwhile the isotonic sodium chloride solution recirculates. Protocols can be developed by using themanufacturer’s guidelines and recommendations from the infection control service and the bloodbank.Previous SectionNext SectionInnovative Developments With CRRT
Timing of therapy, early initiation of renal replacement therapy, and the adequacy of dialysis (eg,“dialysis dose”) may affect patients’ outcomes.78–81 The impact of adequate amount or dose ofdialysis in ARF has been long debated. In CRRT, an adequate dose is considered the amount ofdialysis, with fluids, based on the patient’s weight required to provide a therapeutic treatment, asopposed to conventional dialysis in which not only the patient’s weight but also the time ondialysis is taken into account.35,79 Some think that the actual dose of dialysis delivered in ARF islow and is strongly affected by the patient’s underlying disease process, hypercatabolic state,hemodynamic instability, and volume overload.1,14,82The importance of dose of dialysis is being examined in a randomized trial 83 by researchers at theDepartment of Veterans Affairs and the National Institutes of Health. The purpose of the trial is todetermine the effect of conventional dialysis dose versus intensive dialysis on patients’ outcomes.The aim is to compare traditional methods of dosing in CRRT and intermittent hemodialysis, aswell as in slow extended dialysis.Other dose-related research suggests that higher blood-flow rates (200–300 mL/min) can enhanceclearance in CRRT. These higher blood-flow rates combined with fluid infusion rates determinedon the basis of body weight may improve morbidity and mortality and also preserve renalfunction. Ronco et al84 studied administration of replacement fluid at rates of 20, 35, and 45 mL/kgper hour with use of moderate blood-flow rates in CRRT. In patients given fluids at rates of 20mL/kg per hour, survival was 41%, whereas in patients given fluids at 35 and 45 mL/kg per hour,survival was 57%. In addition, 90% or more of the survivors in the 35 and 45 mL/kg per hourgroup had full return of renal function. The weight-based fluid doses used in the study84 werehigher than the smaller volumes of fluids thought to be beneficial in the past.Slow Extended Daily DialysisA therapy that some think provides the same or similar benefits of 24-hour CRRT is termed slowextended daily dialysis (SLEDD) or “SHIFT” therapy, because the therapy is completed during asingle nursing shift. SLEDD is done exactly as CRRT is but is completed in a shorter time, such as8 to 12 hours instead of 24 hours of continuous treatment. Compared with other methods ofCRRT, SLEDD requires higher fluid-flow rates, higher blood-flow rates, and higher hourlyvolumes of fluid removed to condense the treatment. 85 The shorter duration allows patients to betreated with renal replacement, for example, during the night shift but also be free for tests,rehabilitation, or discontinuation of ventilator support during the day.Diligent assessment of patients’ hemodynamic stability and fluid-volume status is imperativewhen SLEDD is used because compared with other CRRT methods, approximately double theamount of fluid may need to be removed in a shorter time. During SLEDD, anticoagulant may notbe required because of the shorter treatment time. Some researchers 86,87 have indicated thatSLEDD or SHIFT therapy combines excellent waste removal and supports cardiovascular stabilityand is still as efficient as a 24-hour CRRT.Nonrenal Indications for CRRTNovel approaches of using CRRT to treat sepsis have been proposed. A method of high-volumeultrafiltration of 4 to 6 L/h for 6 to 8 hours termed pulse hemofiltration may provide benefits suchas elimination of cytokines and middle-molecular-weight substances known to cause sepsis.88–90 Researchers91,92continue to examine using continuous hemofiltration to remove inflammatorymediators in patients with sepsis.Ronco et al93 suggest that the management of patients with multi-organ dysfunction syndromeshould focus not only on renal replacement but also on a multiorgan support therapy. Multiorgansupport therapy is based on the principle that all organs share one thing in common: contact withblood. Therefore, blood purification and modulation of the blood composition may have apotential effect on all body organs. On the basis of this principle, CRRT may support severalorgans at one time by early detection and correction of the abnormalities that occur in multiorgandysfunction syndrome.The results of other studies94–96 suggest that sepsis can be treated by using hemoperfusion. Inhemoperfusion, a plasma filtrate sorbent filter is used in place of a hemofilter on a CRRT-typecircuit. In hemoperfusion, adsorption of the solutes is a primary mechanism of cytokine clearance.
The sorbent filter used can be either charcoal or a synthetic material. The filters adsorb cytokinesand appear to improve survival in animal models of sepsis. 97A similar treatment for sepsis is coupled plasma filtration. 98 In this treatment, plasma is filtered toimprove blood purification; blood is passed through a hemofilter-type membrane with larger poresso that the blood is separated from the plasma water and proteins, which are removed. The plasmais then pumped through another filter to remove water and smaller molecular weight substances.Because the substances removed are larger than those removed in CRRT alone, the benefit ofcoupled plasma filtration may be an increase in the removal of cytokines from the plasma ofpatients who have sepsis. This model is based on the benefits of plasmapheresis in critically illpatients.99Treatment of decompensated heart failure with ultrafiltration has been studied in the past andcurrently is being examined more closely.100,101 Patients who have myocardial dysfunction orcongestive heart failure are often refractory to conventional therapy (eg, diuretics and inotropicagents). CRRT for the removal of excess fluid can improve myocardial elasticity andcardiovascular stability and optimize fluid balance for patients who may also have some degree ofrenal impairment.102 Some applications of this therapy include the use of traditional CRRTmachines to perform SCUF for short periods and the use of more specialized equipment andperipheral intravenous blood access for simple removal of plasma water.The use of a bioengineered artificial kidney is yet another exciting area of research. 103 Humes etal103 have performed research in the treatment of patients in ARF in which CRRT is used intandem with a bioartificial kidney, known as a renal tubule assist device. CRRT can replace somefunctions of the kidneys, such as water and waste removal, but it does not provide the metabolic,immunological, or endocrine functions of the kidneys. This bioartificial kidney contains humanrenal proximal tubule cells that are grown and seeded inside the fibers of a conventional hollowfiber dialyzer. Humes et al postulate that when the tubule cells are bathed in ultrafiltrate from theCRRT circuit, the cells act similar to a human kidney. The use of human renal tubule cells mayprovide a dynamic, interactive, and individualized therapy that responds to the pathophysiologicalconditions of critically ill patients, reducing morbidity and mortality by providing a morecomplete renal replacement therapy.104,105 Phase 2 clinical trials with the bioartificial kidney haverecently been completed, and some results are promising.Studies106,107 to date have indicated that mortality does not differ between patients who have hadCRRT and patients who have had intermittent hemodialysis, but critically ill patients mayexperience other benefits from CRRT that are not possible with intermittent hemodialysis.Although CRRT has many benefits, like any other therapy, it does not guarantee survival. Patientsrequiring CRRT are often in a tenuous situation, and once CRRT is started, the therapy may ormay not be discontinued without resulting in death. The decision to initiate CRRT requires clearand explicit understanding by patients and their families about the indications for the therapy andthe potential that the therapy may or may not affect recovery. Critical care nurses have aresponsibility to advocate for patients and patients’ families, encourage questions, and participatein education of patients and patients’ families about CRRT.Recent research indicating treatment with larger volumes of fluids each hour to provide a moreadequate therapy may affect how CRRT continues to be used in critical care units. 84,88–90 Somecenters have set standards for care of patients receiving CRRT that require a ratio of 1 nurse to 1patient, not only because of the severity of illness of patients receiving CRRT but also because ofthe additional burden of managing multiple liters of fluid volumes each hour and monitoring anextracorporeal blood circuit.65,71 This paradigm shift may contribute to an increased nursingworkload if containers of therapy fluid and ultrafiltrate require replacement and disposal severaltimes a shift or per hour. (Note: most commercial fluid and disposal bags are 2.5- to 7-L bags.) Ifthe practice of using higher volumes of fluids increases, the issue of nursing time required toreplace multiple liters of fluids for therapy and dispose of larger volumes of ultrafiltrate morefrequently will have to be addressed.Previous SectionNext SectionSummary