Nursing pt.1


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Nursing pt.1

  1. 1. Nursing Issues in Pediatric CRRT Helen Currier BSN, RN, CNN Assistant Director – Renal, Pheresis Scholar – Center for Clinical Research
  2. 2. CRRT Treatment Responsibilities: Points to Remember <ul><li>Nephrology Nurse </li></ul><ul><ul><li>Initiate treatment based on individual patient needs as assessed by the nephrologist </li></ul></ul><ul><li>Bedside Nurse </li></ul><ul><ul><li>Do not infuse other medications or blood products directly into the CRRT system </li></ul></ul><ul><ul><li>Cooling effects of CRRT may prevent temperature elevation </li></ul></ul><ul><ul><li>Adjust patient fluid removal rate hourly to maintain net UFR </li></ul></ul><ul><ul><li>Changes in net URF </li></ul></ul>
  3. 3. Before Treatment Equipment/Supplies <ul><li>Nephrology Nurse </li></ul><ul><ul><li>Prisma/Prisma tubing </li></ul></ul><ul><li>Bedside Nurse </li></ul><ul><ul><li>Order dialysis fluid; citrate and any replacement solutions </li></ul></ul><ul><ul><li>IV tubing for each infusion pump </li></ul></ul><ul><ul><li>3-way stopcocks </li></ul></ul><ul><ul><li>Extracorporeal circuit warmer </li></ul></ul><ul><ul><li>Extracorporeal circuit prime </li></ul></ul><ul><ul><li>Telephone at bedside </li></ul></ul>
  4. 4. Before Treatment Equipment/Supplies <ul><li>Nephrology Nurse </li></ul><ul><ul><li>Review and note CRRT orders </li></ul></ul><ul><ul><li>Verify consent </li></ul></ul><ul><ul><li>Notify bedside nurse of treatment orders and initiation time </li></ul></ul><ul><ul><li>Set-up and prime CRRT circuit with heparinized normal saline </li></ul></ul><ul><ul><li>Prime other lines in CRRT circuit </li></ul></ul><ul><ul><li>Verify catheter placement </li></ul></ul><ul><li>Bedside Nurse </li></ul><ul><ul><li>Review, clarify, and note CRRT </li></ul></ul><ul><ul><li>Draw baseline labs per CRRT orders </li></ul></ul><ul><ul><li>Explain procedure and answer questions as needed </li></ul></ul><ul><ul><li>Check cannulated limb for circulation </li></ul></ul>
  5. 5. Catheter Issues <ul><li>Design *largest diameter w/shortest length </li></ul><ul><ul><li>Diameter </li></ul></ul><ul><ul><ul><li>19% ↑ = flow 2x </li></ul></ul></ul><ul><ul><ul><li>50% ↑ = flow 5x </li></ul></ul></ul><ul><ul><ul><li>Increasing from 2.0mm to 2.1 mm increases flow 21% </li></ul></ul></ul><ul><ul><li>Length </li></ul></ul><ul><ul><ul><li>19% ↑ in diameter will compensate for doubling of length </li></ul></ul></ul><ul><li>Placement </li></ul><ul><ul><li>Site *RIJ (LIJ, IVC, Subclavian) </li></ul></ul><ul><ul><li>Tip *well within the atrium </li></ul></ul>
  6. 6. Catheter Issues <ul><li>Catheter flow </li></ul><ul><ul><li>Early – malposition </li></ul></ul><ul><ul><ul><li>Kink </li></ul></ul></ul><ul><ul><ul><li>Tip malposition – too high/low </li></ul></ul></ul><ul><ul><ul><li>Tip malposition – arterial against the wall </li></ul></ul></ul><ul><ul><ul><li>Tight suture </li></ul></ul></ul><ul><ul><ul><li>Tip in wrong vessel </li></ul></ul></ul><ul><ul><li>Late – thrombosis or fibrin sheath formation </li></ul></ul>
  7. 7. Catheter Issues <ul><li>Catheter related infection </li></ul><ul><ul><li>Local </li></ul></ul><ul><ul><ul><li>Exit site – s/s redness, drainage, crusting, swelling, odor, or pain </li></ul></ul></ul><ul><ul><ul><li>Tunnel – s/s swelling, pain, redness or ability to express draining down the tunnel track to the exit site </li></ul></ul></ul><ul><ul><li>Systemic </li></ul></ul><ul><ul><ul><li>Catheter related bacteremia </li></ul></ul></ul>
  8. 8. Treatment Initiation <ul><li>Nephrology Nurse </li></ul><ul><ul><li>Assess patient’s condition *fluid and electrolyte </li></ul></ul><ul><ul><li>Prep catheter ports </li></ul></ul><ul><ul><li>Aspirate appropriate blood volume from catheter and flush w/saline </li></ul></ul><ul><ul><li>Prime CRRT circuit w/priming solution and attach blood lines of equipment to catheter(s) </li></ul></ul><ul><ul><li>Start citrate drip </li></ul></ul><ul><ul><li>After 5’ w/stable VS, start replacement fluid and ultrafiltration </li></ul></ul><ul><ul><li>Change catheter site dressing if needed </li></ul></ul><ul><li>Bedside Nurse </li></ul><ul><ul><li>Assess patient’s condition *fluid and electrolyte </li></ul></ul><ul><ul><li>Baseline VS, Wt, PAWP (if applicable), CVP, BP, edema, lung/heart sounds, lab values </li></ul></ul><ul><ul><li>VS q 30’ x 2 then q 1 h </li></ul></ul><ul><ul><li>Monitor and document starting AP, VP, DFR, RFR, BFR, URF and infusion pump rates </li></ul></ul>
  9. 9. Nephrology Nurse <ul><li>How CRRT works </li></ul><ul><li>Reason for treatment </li></ul><ul><li>When and how to terminate treatment </li></ul><ul><li>Equipment operation </li></ul><ul><li>Most common alarms </li></ul><ul><li>When and how to reach the nephrology team </li></ul><ul><li>Fluid balance calculations </li></ul><ul><li>Assessment of clotting </li></ul><ul><li>How to adjust AP/VP limits, BFR, or UFR </li></ul><ul><li>How to verify dialysis fluid or replacement fluid and/or rate changes </li></ul>
  10. 10. Bedside Nurse: Competencies <ul><li>Verbalize </li></ul><ul><ul><li>How CRRT works (fluid and solute balance, changes in nutrition and medications) </li></ul></ul><ul><ul><li>Reason for treatment </li></ul></ul><ul><ul><li>When and how to terminate treatment </li></ul></ul><ul><ul><li>How to troubleshoot alarms (AP, VP, blood leak, error codes, air detector) </li></ul></ul><ul><ul><li>When and how to recirculate the system </li></ul></ul><ul><ul><li>How to care for catheter and catheter exit site </li></ul></ul><ul><ul><li>When and how to contact nephrologist or nephrology nurse </li></ul></ul><ul><ul><li>How to operate extracorporeal circuit warmer </li></ul></ul>
  11. 11. Bedside Nurse: Competencies <ul><li>Demonstrate </li></ul><ul><ul><li>How to calculate fluid balance </li></ul></ul><ul><ul><li>How to assess clotting in the system </li></ul></ul><ul><ul><li>How to adjust AP and VP limits, BFR, UFR </li></ul></ul><ul><ul><li>How to verify dialysis and replacement fluid solution and rates </li></ul></ul><ul><ul><li>Document continuing care in nursing notes and flow sheet </li></ul></ul>
  12. 12. CRRT Treatment Responsibilities: q 1 hour <ul><li>Bedside Nurse </li></ul><ul><ul><li>Monitor system for kinks, loose connections, patient bleeding </li></ul></ul><ul><ul><li>Evaluate changes in pressure reading VP or AP </li></ul></ul><ul><ul><li>Evaluate hemofilter and venous chamber for clotting or fibrin </li></ul></ul><ul><ul><li>Evaluate color of ultrafiltrate (no pink-tinged fluid) </li></ul></ul><ul><ul><li>Document arterial pressure (AP), venous pressure, BFR, and intake/output </li></ul></ul>
  13. 13. CRRT Treatment Responsibilities: q 2 hr into treatment/ q 6 hr thereafter <ul><li>Bedside Nurse </li></ul><ul><ul><li>Check circuit ionized Ca ++ (sample from venous port) and patient’s ionized Ca ++ (sample from site other than CRRT circuit) </li></ul></ul><ul><ul><li>Recheck CRRT circuit/patient ionized Ca ++ after any changes in anticoagulation – reference optimal ranges specified </li></ul></ul><ul><ul><li>Notify nephrology nurse if circuit clots </li></ul></ul>
  14. 14. CRRT Treatment Responsibilities: q 24 hr <ul><li>Bedside Nurse </li></ul><ul><ul><li>Assess patient’s fluid/electrolyte balance and overall condition, PAWP (if applicable), CVP, edema, lungs, heart </li></ul></ul><ul><ul><li>Evaluate serum chemistry for changes </li></ul></ul><ul><ul><li>Monitor serum calcium and pH for signs of citrate toxicity </li></ul></ul><ul><ul><li>Monitor for s/s of sepsis or local infection </li></ul></ul><ul><ul><li>Monitor for s/s of hypothermia </li></ul></ul><ul><ul><li>Assess and monitor patient’s nutritional status – daily weight, albumin, bowel patterns, skin turgor, muscle wasting </li></ul></ul><ul><ul><li>Monitor the integrity of the access dressing – change per protocol </li></ul></ul>
  15. 16. Potential Complications with Pediatric Hemofiltration <ul><li>Circuit Volumes </li></ul><ul><li>Hypothermia </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Fluid Management </li></ul><ul><li>Blood Flow Rates </li></ul><ul><li>Nutrition </li></ul><ul><li>Solutions </li></ul>
  16. 17. Circuit Volumes <ul><li>Significant when dealing with pediatrics </li></ul><ul><li>General Guidelines </li></ul><ul><ul><li>Circuit volumes should be < 10% of the patients intravascular blood volume </li></ul></ul>
  17. 18. Blood Priming <ul><li>Indications </li></ul><ul><ul><li>Circuit volume > 10% of the patients blood volume </li></ul></ul><ul><ul><li>Hemodynamic instability </li></ul></ul><ul><ul><li>Infants </li></ul></ul>
  18. 19. Complications of Blood Priming <ul><li>Blood Bank pRBC tend to be high in K+ </li></ul><ul><ul><li>Close K+ monitoring needed at initiation </li></ul></ul><ul><li>pRBC HCT are approximately 80% </li></ul><ul><ul><li>1:1 dilution with normal saline </li></ul></ul><ul><ul><li>Blood prime need to be done at time of initiation. </li></ul></ul><ul><ul><li>Citrate binds calcium </li></ul></ul><ul><ul><ul><li>hypotension </li></ul></ul></ul>
  19. 20. Hypothermia <ul><li>Significant in pediatrics </li></ul><ul><ul><li>The smaller the more difficult </li></ul></ul><ul><li>Heat loss related to rate of blood flow and volume of blood in circuit </li></ul><ul><li>Blood flow rate </li></ul><ul><ul><li>Higher blood flow rate decrease heat loss due to less time outside of the body </li></ul></ul>
  20. 21. Hypothermia Nursing intervention <ul><li>External warming devices </li></ul><ul><ul><li>Radiant warmers </li></ul></ul><ul><ul><li>Baer hugger </li></ul></ul><ul><ul><li>Heating mattress </li></ul></ul><ul><ul><li>Blood warmers </li></ul></ul><ul><ul><li>Solutions heaters </li></ul></ul><ul><li>Monitoring </li></ul><ul><ul><li>Skin breakdown and patient temperature </li></ul></ul>
  21. 22. Anticoagulation <ul><li>Nursing assessment </li></ul><ul><ul><li>Monitor ACT q 1-2 hours </li></ul></ul><ul><ul><ul><li>via Hemochron® </li></ul></ul></ul><ul><ul><li>Maintain ACT range 150-200” </li></ul></ul><ul><ul><li>Monitor for active bleeding </li></ul></ul><ul><ul><li>Monitor circuit for cracks and clotting </li></ul></ul>
  22. 23. Fluid Management <ul><li>Ultrafiltration controller necessary </li></ul><ul><ul><li>Pumps up to 30% inaccurate </li></ul></ul><ul><li>Ultrafiltration rate 0.5-1ml/kg/hr </li></ul><ul><li>Difficulty in accurate assessment of measurement of u/f with less room for error in small children </li></ul>
  23. 24. Fluid Management Nursing <ul><li>Accurate Intake and Output assessments </li></ul><ul><li>Hourly ultrafiltration calculations </li></ul><ul><li>Monitoring vital signs </li></ul><ul><ul><li>Heart Rate, CVP, Blood pressures </li></ul></ul><ul><li>Patient Weights </li></ul><ul><ul><li>q 12 hours or daily </li></ul></ul><ul><li>IMPORTANT - Look at your patient </li></ul>
  24. 25. Access Difficulties <ul><li>What is the correct access? </li></ul><ul><li>? Best placement </li></ul><ul><li>In flow vs out flow difficulties </li></ul>
  25. 26. In Flow Difficulties <ul><li>Obstruction or clot “upstream” of inflow </li></ul><ul><ul><li>high intrathoracic pressure with HIFI </li></ul></ul><ul><ul><li>up against the vessel wall </li></ul></ul><ul><li>Clamp on inflow </li></ul><ul><li>Access kinked at skin site </li></ul><ul><li>Consider reversing or changing access </li></ul>
  26. 27. Out Flow Difficulties <ul><li>Clamp on access/”arterial” line </li></ul><ul><li>Inflow port up against vessel wall </li></ul><ul><li>Patient “dry” e.g. with femoral site </li></ul><ul><li>High of blood flow requirements based upon flow ability of access </li></ul><ul><li>Consider </li></ul><ul><ul><li>reverse flow, change access, decrease blood flow rates </li></ul></ul>