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

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)

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

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

Success with CRRT Access Equipment Tubing/filter Prime Anticoagulation Staffing

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

Blood Pump Systems for CRRT

CRRT Machines: Current Generation

Tubing and Equipment Tubing volume ranges from 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

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

Blood Prime Whole blood PRBC + Albumin 5% PRBC + NS PRBC + FFP Larger patients Albumin 5% AN-69 filter requires special considerations

What is the link –Blood bank blood has ICa of 0.04 mmol/l K+ of mEq/l pH of 6.4 Reaction can be mitigated by buffering the blood and giving IV calcium at initiation Bradykinin Release Syndrome (Brophy et al Am J Kidney Dis Jul;38(1):173-8 )

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

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)

Thermal Regulation Hotline® Blood warming tubing Place at venous return to patient Leave on at constant temperature of 39 o C Treat temp elevations if they occur

Anticoagulation Heparin Heparin bolus then continuous infusion Maintain activated clotting time (ACT) ~200 Risk of bleeding, thrombocytopenia Citrate Citrate infusion to CRRT circuit Calcium infusion to patient at separate site Monitor for metabolic alkalosis

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

3rd International Conference on Pediatric Continuous Renal Replacement Therapy (PCRRT) June, 2004 Coronado Springs Disney Orlando, Fl

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

bm25™: Blood Pump Module Blood monitor –Blood flow rate:  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 mL/hr Filtrate pump ,000 mL/hr Net UFR 0.1 – 2000 mL/hr

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

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

bm25™: Blood Pump Module Blood monitor –Blood flow rate:  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 mL/hr Filtrate pump ,000 mL/hr Net UFR 0.1 – 2000 mL/hr

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

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

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