Practical Considerations for CRRT Helen Currier RN, BSN, CNN Nancy McAfee RN, BSN, CNN

San Juan Islands

Advantages of CRRT SLOW: Hemodynamically unstable patients may not tolerate the rapid ultrafiltration of intermittent hemodialysis CONTINUOUS: Can help preserve metabolic stability in critically ill patients; can maintain fluid balance for oliguric patients who require high daily input (IV medications, parenteral nutrition) Stuart has eloquently reviewed the advantages in his presentation.

CVVH SYSTEM Replacement fluid Drainage bag/UF Roller pump Heparin Drainage bag/UF Roller pump bm14 roller pump IV pump Venous chamber Roller pump Hemofilter From the patient Air detector To the patient 38

CVVHD SYSTEM Replacement fluid Drainage bag/UF bm14 roller pump Heparin Dialysate Roller Pump IV pump bm14 roller pump IV pump Roller Pump Venous chamber Hemofilter From the patient Air detector To the patient 41

Success with CRRT Access Equipment Tubing/filter Prime Anticoagulation Staffing A variety of factors play into success. Sometimes it takes creativity to carry out the desired treatment.

Access-What Works? Hemodialysis /Pheresis Line Shortest, fattest catheter possible (highest flows with least resistance) May need two single lumen lines Leg position-be creative Tape on the skin-may need to get creative Stuart discussed different types of lines that are used. Once the line is in, however, it is up to nursing to make it work up to it’s potential. Taping may be all that is needed, but when it is a premie with fragile skin, that may not be the best option. Coban can be great, if not too tight. Beanie babies are exactly the right size to prop lines often.

Blood Pump Systems for CRRT Each institution has their own machine loyalty, so I will attempt to keep biases out of this talk.

CRRT Machines: Current Generation

Tubing and Equipment Tubing volume ranges from 44-110 ml Filter volume ranges from 28 – 83 ml Hotline volume 18.5 ml Blood volume of patient (~70 ml/kg) PRISMA – 108 ml BM-25 -Smallest filter + tubing + hotline = 90.5 ml On the PRISMA the tubing and cassette are a single unit and hold 108 mL. I believe a smaller volume tubing is in the works. The BM-25 has interchangeable filters and the volumes vary as shown here.

Extracorporeal Volume Blood volume in extracorporeal circuit is very large compared to a small infant or child Patients require a blood prime if the circuit >10% of their blood volume A major problem for infants is the volume of blood in the extracorporeal circuit. Since the circuit exceeds 10% of their blood volume they must receive a prime.

Blood Prime Whole blood PRBC + Albumin 5% PRBC + NS PRBC + FFP Larger patients Albumin 5% AN-69 filter requires special considerations Key to remember with a blood prime, this is no longer their blood, it belongs to the circuit. When the circuit is DC’d it must not be returned to the patient or they risk hypervolemia.

Bradykinin Release Syndrome (Brophy et al Am J Kidney Dis Bradykinin Release Syndrome (Brophy et al Am J Kidney Dis. 2001 Jul;38(1):173-8 ) What is the link Blood bank blood has ICa of 0.04 mmol/l K+ of 40-60 mEq/l pH of 6.4 Reaction can be mitigated by buffering the blood and giving IV calcium at initiation Bradykinin syndrome was described by Brophy et al in 2001. This occurs when banked blood is used to prime a circuit with an AN-69 filter in place, such as used in the PRISMA circuit. This syndrome has been reported in centers using poysulfone mambranes.

Buffered System ECMO circuits are commonly primed with a cocktail to correct the pH, Hct, and K of banked blood Addition of THAM calcium chloride Heparin Sterile Water Sodium bicarb Traditionally ECMO circuits use a cocktail to buffer the blood used to prime their circuits, but they use a mach larger volume of blood.

Bypass System Transfuse the PRBC post-filter directly into the patient The patient is then connected to the circuit Using the same rate for priming on and infusing the PRBC (mixed with NS or Alb) Thus the patient’s blood can be used as a “bradykinin filter” (Brophy,et al 2001AJKD) This modified version described by Brophy et al is much simpler. I understand it is very successful at avoiding the sensitivity seen in those early patients.

Thermal Regulation Hotline® Blood warming tubing Place at venous return to patient Leave on at constant temperature of 39o C Treat temp elevations if they occur We had some difficulties managing the temps on the very small. We found it best to use the Hotline at the venous return and leave it set at a constant temp. We now treat fever if it occurs and use the hotline on all patients.

Anticoagulation Heparin Citrate infusion to CRRT circuit Calcium infusion to patient at separate site Monitor for metabolic alkalosis Heparin Heparin bolus then continuous infusion Maintain activated clotting time (ACT) ~200 Risk of bleeding, thrombocytopenia Sturat reviewed anticoagulation, and I believe there is another talk later on the subject.

CRRT Staffing in PICU/IICU Nephrology/Dialysis RN sets-up & initiates therapy PICU/IICU RN manages patient Nephrology/Dialysis RN on call 24/7 Acuity assigned to pump as if a separate patient Staffing determined by acuity At CHRMC the nephrology team sets up the machine, institutes the therapy, and together with the ICU RN stabilizes the patient’s CRRT treatment. Once the patient is relatively stable on the circuit, the ICU RN assumes care of the circuit with the Nephrology/Dialysis RN available on call 24/7 for troubleshooting, and/or assistance with the therapy. In our PICU and IICU the pump is treated as a patient and assigned acuity for patient assignment. A single RN may care for both the patient and the pump together or there may be one RN for the patient and another for the pump. When the pump has a separate RN, this RN may have the pump paired with another patient depending on the acuity determined for the circuit. Since a patient on CVVH may be very ill it is not uncommon to have a separate RN assigned to the pump at least for the first shift or two.

CRRT is easier than standing on one foot in a tippy boat but it does take teamwork.

June, 2004 Coronado Springs Disney Orlando, Fl www.pcrrt.com 3rd International Conference on Pediatric Continuous Renal Replacement Therapy (PCRRT) Hope to see you all on Orlando in June. Thank you for your time and kind attention. June, 2004 Coronado Springs Disney Orlando, Fl www.pcrrt.com

CRRT Modalities CAVH: Continuous Arteriovenous Hemofiltration SCUF: Slow Continuous Ultrafiltration CVVH: Continuous Venovenous Hemofiltration CVVHD: Continuous Venovenous Hemodialysis 32

bm25™: Blood Pump Module Blood monitor Blood flow rate:  30-350 mL / min -- Safety features:  pressure monitors  air detector  clot trap  venous clamp  blood leak detector

bm25™: Fluid Control Module Balancing monitor Substitution pump / filtrate pump Integrated scales Fluid heater TMP monitor Operational ranges Replacement fluid 300- 9000 mL/hr Filtrate pump 100 - 11,000 mL/hr Net UFR 0.1 – 2000 mL/hr

Baxter bm25™ 2 integrated modules Blood module (bm 11a™) Balancing module / scales (bm14™)

CRRT Modalities CAVH: Continuous Arteriovenous Hemofiltration SCUF: Slow Continuous Ultrafiltration CVVH: Continuous Venovenous Hemofiltration CVVHD: Continuous Venovenous Hemodialysis 32

bm25™: Blood Pump Module Blood monitor Blood flow rate:  30-350 mL / min -- Safety features:  pressure monitors  air detector  clot trap  venous clamp  blood leak detector

bm25™: Fluid Control Module Balancing monitor Substitution pump / filtrate pump Integrated scales Fluid heater TMP monitor Operational ranges Replacement fluid 300- 9000 mL/hr Filtrate pump 100 - 11,000 mL/hr Net UFR 0.1 – 2000 mL/hr

Baxter bm25™ 2 integrated modules Blood module (bm 11a™) Balancing module / scales (bm14™)

CVVH SYSTEM Replacement fluid Drainage bag/UF Roller pump Heparin Drainage bag/UF Roller pump bm14 roller pump IV pump Venous chamber Roller pump Hemofilter From the patient Air detector To the patient 38

CVVHD SYSTEM Replacement fluid Drainage bag/UF bm14 roller pump Heparin Dialysate Roller Pump IV pump bm14 roller pump IV pump Roller Pump Venous chamber Hemofilter From the patient Air detector To the patient 41