Continuous Renal Replacement Therapy Developed by: Critical Care and Hemodialysis Educators, February 2009 King Faisal Specialist Hospital and Research Center, Nursing Development and Saudisation.

Principles Modes TroubleshootingMiscellaneous

Row 1, Col 1 Convection is the movement of solutes from an area of high concentration to low Concentration. True or False. False

1,2 Which port should you use to take an ACT/ PTT sample from ? Where is this port located? Red Port Located before the filter and before the blood pump

1,3 Why is it important during bag change to always use the ‘Bag Change’ screen? To put the scale on hold

1,4 Name 3 safety equipments needed to run a CRRT machine? Blue clamps, Temporary disconnector adaptor, Quick reference guide manual, Manufacturer manual, Crank

2,1 Describe Ultrafiltration. The slow movement of fluids (solution) from high pressure to low pressure.

2,2 Which mode(s) will remove solutes mainly? CVVHD, CVVHDF

2,3 What does ‘Temporarily Disconnect’ mean? When should this be performed? It’s to disconnect the patient from the circuit temporary, no longer than one hour. Performed for a procedure usually i.e. CT scan, or change patient’s room

2,4 How do you troubleshoot “low arterial pressure alarm” Reduce the blood flow rate, check the vascular access, check the lines for kinks, flush the normal saline and assess lines.

3,1 In order to remove more solutes (middle and larger molecules) what principle is best Used? Convection

3,2 Your dehydrated and & oliguric patient has the following lab results: Urea:15 K+=7.0 Creatinine=210 What is the best mode to use? CVVHD

3,3 What would you do if the TMP pressure is high? --Flush filter with saline bolus (if ordered) check for clots. -Consider pre-substituate dilution -Consider heparin.

3,4 What is a “Blood leak alarm”? How would you troubleshoot it? Filter is cracked Visible blood tinge fluid seen in filtrate bag Return blood to patient ASAP and terminate treatment

4,1 Your patient is fluid overloaded. His potassium is 3.5. What CRRT Principle/s would apply to this patient? Ultrafiltration and or Convection

4,2 What CRRT modality do you see in this picture? Explain indications for use for this mode CVVHDF

4,3 Can we switch CRRT bloodlines connected to the patient’s vascular access in case of high pressure alarm? Explain!!! Should NEVER be the first troubleshooting option Only done if it’s the only way to save the circuit (especially with peds) Because Recirculation decreases clearance up to 40%

4,4 What would you do in a code situation while patient is connected to a CRRT machine? Stop machine and try to return patient’s blood (especially for peds) if enough nurses and room space are available. Never try to disconnect patient from CRRT machine while CPR is running

5,1 On the CRRT machine describe where diffusion occurs and explain. In the membrane, dialysate and blood flow in opposite direction.

5,2 Your patient has the following lab values: K+: 6.8 Urea: 12 Creatinine: 200 Which solution is best used for this patient. Multibic 0K, Multibic 2K, Multibic 3K? Give reason why? Multibic 2 or 3 To prevent disequilibrium syndrome.

5,3 State 2 indications for “Deaeration”. 1.Getting rid of air in substituate line and/or chamber 2.Getting rid of air in dialysate line and or chamber

5,4 Your patient has the following order: CVVH mode BFR:100 UFR:200 Substituate: 2000 Are you okay with this order? Explain No, the BFR/UFR is too high >20%. Should discuss the order with nephrologist to consider: Decrease of substituate rate as a first option or Increase the BFR if patient’s hemodynamically stable Decrease of UFR (last option)