Nursing Issues in Pediatric CRRT Helen Currier BSN, RN, CNN Assistant Director – Renal, Pheresis Scholar – Center for Clinical Research

CRRT Treatment Responsibilities: Points to Remember Nephrology Nurse Initiate treatment based on individual patient needs as assessed by the nephrologist Bedside Nurse Do not infuse other medications or blood products directly into the CRRT system Cooling effects of CRRT may prevent temperature elevation Adjust patient fluid removal rate hourly to maintain net UFR Changes in net URF

Before Treatment Equipment/Supplies Nephrology Nurse Prisma/Prisma tubing Bedside Nurse Order dialysis fluid; citrate and any replacement solutions IV tubing for each infusion pump 3-way stopcocks Extracorporeal circuit warmer Extracorporeal circuit prime Telephone at bedside

Before Treatment Equipment/Supplies Nephrology Nurse Review and note CRRT orders Verify consent Notify bedside nurse of treatment orders and initiation time Set-up and prime CRRT circuit with heparinized normal saline Prime other lines in CRRT circuit Verify catheter placement Bedside Nurse Review, clarify, and note CRRT Draw baseline labs per CRRT orders Explain procedure and answer questions as needed Check cannulated limb for circulation

Catheter Issues Design *largest diameter w/shortest length Placement 19% ↑ = flow 2x 50% ↑ = flow 5x Increasing from 2.0mm to 2.1 mm increases flow 21% Length 19% ↑ in diameter will compensate for doubling of length Placement Site *RIJ (LIJ, IVC, Subclavian) Tip *well within the atrium

Catheter Issues Catheter flow Early – malposition Kink Tip malposition – too high/low Tip malposition – arterial against the wall Tight suture Tip in wrong vessel Late – thrombosis or fibrin sheath formation

Catheter Issues Catheter related infection Local Systemic Exit site – s/s redness, drainage, crusting, swelling, odor, or pain Tunnel – s/s swelling, pain, redness or ability to express draining down the tunnel track to the exit site Systemic Catheter related bacteremia

Treatment Initiation Nephrology Nurse Bedside Nurse Assess patient’s condition *fluid and electrolyte Prep catheter ports Aspirate appropriate blood volume from catheter and flush w/saline Prime CRRT circuit w/priming solution and attach blood lines of equipment to catheter(s) Start citrate drip After 5’ w/stable VS, start replacement fluid and ultrafiltration Change catheter site dressing if needed Bedside Nurse Assess patient’s condition *fluid and electrolyte Baseline VS, Wt, PAWP (if applicable), CVP, BP, edema, lung/heart sounds, lab values VS q 30’ x 2 then q 1 h Monitor and document starting AP, VP, DFR, RFR, BFR, URF and infusion pump rates

Nephrology Nurse How CRRT works Reason for treatment When and how to terminate treatment Equipment operation Most common alarms When and how to reach the nephrology team Fluid balance calculations Assessment of clotting How to adjust AP/VP limits, BFR, or UFR How to verify dialysis fluid or replacement fluid and/or rate changes

Bedside Nurse: Competencies Verbalize How CRRT works (fluid and solute balance, changes in nutrition and medications) Reason for treatment When and how to terminate treatment How to troubleshoot alarms (AP, VP, blood leak, error codes, air detector) When and how to recirculate the system How to care for catheter and catheter exit site When and how to contact nephrologist or nephrology nurse How to operate extracorporeal circuit warmer

Bedside Nurse: Competencies Demonstrate How to calculate fluid balance How to assess clotting in the system How to adjust AP and VP limits, BFR, UFR How to verify dialysis and replacement fluid solution and rates Document continuing care in nursing notes and flow sheet

CRRT Treatment Responsibilities: q 1 hour Bedside Nurse Monitor system for kinks, loose connections, patient bleeding Evaluate changes in pressure reading VP or AP Evaluate hemofilter and venous chamber for clotting or fibrin Evaluate color of ultrafiltrate (no pink-tinged fluid) Document arterial pressure (AP), venous pressure, BFR, and intake/output

CRRT Treatment Responsibilities: q 2 hr into treatment/ q 6 hr thereafter Bedside Nurse Check circuit ionized Ca++ (sample from venous port) and patient’s ionized Ca++ (sample from site other than CRRT circuit) Recheck CRRT circuit/patient ionized Ca++ after any changes in anticoagulation – reference optimal ranges specified Notify nephrology nurse if circuit clots

CRRT Treatment Responsibilities: q 24 hr Bedside Nurse Assess patient’s fluid/electrolyte balance and overall condition, PAWP (if applicable), CVP, edema, lungs, heart Evaluate serum chemistry for changes Monitor serum calcium and pH for signs of citrate toxicity Monitor for s/s of sepsis or local infection Monitor for s/s of hypothermia Assess and monitor patient’s nutritional status – daily weight, albumin, bowel patterns, skin turgor, muscle wasting Monitor the integrity of the access dressing – change per protocol

Potential Complications with Pediatric Hemofiltration Circuit Volumes Hypothermia Anticoagulation Fluid Management Blood Flow Rates Nutrition Solutions

Circuit Volumes Significant when dealing with pediatrics General Guidelines Circuit volumes should be < 10% of the patients intravascular blood volume

Blood Priming Indications Circuit volume > 10% of the patients blood volume Hemodynamic instability Infants

Complications of Blood Priming Blood Bank pRBC tend to be high in K+ Close K+ monitoring needed at initiation pRBC HCT are approximately 80% 1:1 dilution with normal saline Blood prime need to be done at time of initiation. Citrate binds calcium hypotension

Hypothermia Significant in pediatrics The smaller the more difficult Heat loss related to rate of blood flow and volume of blood in circuit Blood flow rate Higher blood flow rate decrease heat loss due to less time outside of the body

Hypothermia Nursing intervention External warming devices Radiant warmers Baer hugger Heating mattress Blood warmers Solutions heaters Monitoring Skin breakdown and patient temperature

Anticoagulation Nursing assessment Monitor ACT q 1-2 hours via Hemochron® Maintain ACT range 150-200” Monitor for active bleeding Monitor circuit for cracks and clotting

Fluid Management Ultrafiltration controller necessary Pumps up to 30% inaccurate Ultrafiltration rate 0.5-1ml/kg/hr Difficulty in accurate assessment of measurement of u/f with less room for error in small children

Fluid Management Nursing Accurate Intake and Output assessments Hourly ultrafiltration calculations Monitoring vital signs Heart Rate, CVP, Blood pressures Patient Weights q 12 hours or daily IMPORTANT - Look at your patient

Access Difficulties What is the correct access? ? Best placement In flow vs out flow difficulties

In Flow Difficulties Obstruction or clot “upstream” of inflow high intrathoracic pressure with HIFI up against the vessel wall Clamp on inflow Access kinked at skin site Consider reversing or changing access

Out Flow Difficulties Clamp on access/”arterial” line Inflow port up against vessel wall Patient “dry” e.g. with femoral site High of blood flow requirements based upon flow ability of access Consider reverse flow, change access, decrease blood flow rates