1 / 27

Nursing Issues in Pediatric CRRT

Nursing Issues in Pediatric CRRT. Helen Currier BSN, RN, CNN Assistant Director – Renal, Pheresis Scholar – Center for Clinical Research. Nephrology Nurse Initiate treatment based on individual patient needs as assessed by the nephrologist. Bedside Nurse

tavia
Download Presentation

Nursing Issues in Pediatric CRRT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. 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 CRRT Treatment Responsibilities:Points to Remember

  3. 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 TreatmentEquipment/Supplies

  4. 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 Before TreatmentEquipment/Supplies

  5. Catheter Issues • Design *largest diameter w/shortest length • Diameter • 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

  6. 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

  7. Catheter Issues • Catheter related infection • Local • 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

  8. Nephrology 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 Treatment Initiation

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

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

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

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

  18. 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

  19. 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

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

  21. 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

  22. 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

  23. Fluid ManagementNursing • 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

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

  25. 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

  26. 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

More Related