Continuous Renal Replacement Therapy GAMBRO Emily Castro BSN

Continuous Renal Replacement Therapy GAMBRO Emily Castro, BSN, MSN, CCRN Critical Care Nurse Educator 1

Objectives • To review the different modalities of CRRT therapy • To understand the concept of changing the modality of CRRT therapy (for example: switching from CVVHDF to SCUF mode) • To understand the different alarms in CRRT therapy and corresponding troubleshooting techniques 2

SCUF Modality Slow Continuous Ultra. Filtration Return Blood Pump Effluent Access PBP Pump Infusion or Anticoagulant

SCUF Modality Slow Continuous Ultra. Filtration • Primary therapeutic goal: –Safe and effective management of fluid removal from the patient 4

CVVHD Modality Continuous VV Hemo. Dialysis • Primary therapeutic goal: – Small solute removal by diffusion – Safe fluid volume management • Dialysate volume automatically removed through the Effluent pump Solute removal determined by Dialysate Flow Rate. 5

CVVHD Modality Continuous VV Hemo. Dialysis Return Hemofilter Dialysate Pump Dialysate Fluid Effluent Blood Pump Effluent Pump Access PBP Pump Infusion or Anticoagulant

Dialysate Solutions • Flows counter-current to blood flow • Remains separated by a semi-permeable membrane • Drives diffusive transport – dependent on concentration gradient and flow rate • Facilitates removal of small solutes • Physician prescribed • Contains physiologic electrolyte levels • Components adjusted to meet patient needs 7

CVVH Modality (Continuous VV Hemofiltration) • Primary Therapeutic Goal: • • Removal of small, middle and large sized solutes Safe fluid volume management • Replacement solution is infused into blood compartment pre or post filter • Drives convective transport • Replacement fluid volume automatically removed by effluent pump Solute removal determined by Replacement Flow Rate. 8

CVVH Modality Continuous VV Hemofiltration Return Blood Pump Replacement Pump 2 Replacement 2 Effluent Pump Effluent Replacement Pump 1 Replacement 1 Access PBP Pump Infusion or Anticoagulant 9

Pre-Dilution Replacement Solution Return Hemofilter • Decreases risk of clotting Blood Pump Effluent Pump Replacement Pump Access PBP Pump • Higher UF capabilities • Decreases Hct. In filter Effluent Replacement Fluid Infusion or Anticoagulant

Post-Dilution (Post- Filter) Replacement Solution Return • Consider lowering replacement rates (filtration %) Access Hemofilter Blood Pump • Higher BFR (filtration %) • Higher anticoagulation Replacement Pump Effluent Pump Replacement Pump PBP Pump • More efficient clearance (>15%) Replacement Fluid Effluent Replacement Fluid Infusion or Anticoagulant

Replacement Solutions • Infused directly into the blood at points along the blood pathway • Drives convective transport • Facilitates the removal of small middle and large solutes • Physician Prescribed • Contains electrolytes at physiological levels • Components adjusted to meet patient needs 12

CVVHDF Modality Continuous VV Hemodiafiltration Primary therapeutic goal: – Solute removal by diffusion and convection – Safe fluid volume management – Efficient removal of small, middle and large molecules • Replacement and dialysate fluid volume automatically removed by effluent pump Solute removal determined by Replacement + Dialysate Flow Rates. 13

CVVHDF Modality Continuous VV Hemo. Dia. Filtration Return Blood Pump Dialysate Fluid Effluent Pump Replacement Fluid Access PBP Pump Infusion or Anticoagulant 14

Switching CRRT Modality • We always prime the machine in CVVDHF mode. • In CVVHDF mode all pumps can be activated. The dialysate pump functions the same as in CVVHD mode. The PBP pump functions the same as in the other modes. The replacement pump functions the same as in CVVH mode. 15

Switching CRRT Modality • CVVHDF mode allows the user to switch from one therapy mode to another by simply deactivating one or more solution pumps. For example: deactivating the dialysate pump would deliver CVVH; deactivating the replacement pump delivers CVVHD; deactivating both dialysate and replacement solution pumps deliver the SCUF mode. However, there will be an increased chance of clotting in the deaeration chamber and filter when post filter replacement and PBP solution pumps are deactivated. 16

Switching CRRT Modality • In practice, SCUF can also be delivered safely by maintaining PBP rate and Post filter replacement rate at less than 8 m/kg/hr dosage; consult the attending nephrologist. In other words, we can still run treatment in the SCUF mode using low PBP and Post Filter replacement solution rates; discuss with the attending nephrologist. • When post-filter replacement rate is set at 200 ml/hr, the CVVH mode shows on the screen of Prismaflexx machine. • Remember: a minimum of 200 ml per hour of post-filter replacement pump rate is highly recommend to create a buffer between blood and air to prevent clotting in the dearation chamber and blood return line, as well as prevent air bubble formation. 17

Goal of Treatment • To remove 35 ml/kg/hr of effluent to optimize therapy benefits; consult with the attending nephrologist. • Always enter patient weight when initiating therapy. • If 35 ml/kg/hr is not being achieved (this number is found on status screen), reassess the goal of treatment; consult the attending nephrologist. • If the goal of treatment is to remove small molecules (thru diffusion) then increase the dialysate solution flow rate. • If the goal of the treatment is to remove more middle molecules (convective clearance/solute drag) then increase the replacement solution flow rate (such as to remove the proteins seen in sepsis). 18

Access Alarms ACCESS ALARMS- ACCESS TOO POSITIVE • (access pressures should be negative) • Cause: Machine cannot detect your access because the blood flow rate is probably too low (100 -150 ml/min). • Action to take: Increase your blood flow rate to at least 180 ml/min. 19

Access Alarms ACCESS ALARMS- ACCESS TOO NEGATIVE • Cause: Machine is having to pull too hard to get blood out of access catheter. THEREFORE, it is not a machine problem…it is a vascular access problem. Nurse needs to troubleshoot vascular access. • Actions to take: • Draw up 10 mls of blood using a 20 -30 ml syringe from the access catheter. If this cannot be easily done over 6 seconds, THE MACHINE WILL NOT BE ABLE TO PULL OFF blood from access catheter. • Flip ports (connect blue return line to red port and red access line to blue port), or call surgeon to reposition line (could be up against a valve). If nothing works, line will need to be replaced. 20

Access Alarms ****beware of “flipping of ports” on vascular access because it will cause some degree of recirculation of the same blood, decrease filter clearance of the blood and increased clotting of filter…. . it is only a temporary solution…line will probably need to be changed**** 21

Set Up Alarms BLOOD DETECTED • Cause: This alarm occurs during the priming mode when the tubing has been improperly inserted into the blood leak detector or the blood leak detector is dirty. • Action to take: Re-seat the tubing or clean the blood leak detector with alcohol and then push “NO BLOOD” on the screen. 22

Set Up Alarms ALARM: “WRONG SET HAS BEEN LOADED” • Action to take: Clean bar code reader with alcohol. ALARM: “BLOOD IN SET” • Action to take: Must make sure that there this a secure fitting on the return line of the dearation chamber. 23

Run Alarms NET FLUID LOSS ALARMS (-33 OML) • Action to take: Make sure the “pin” is completely cracked when hanging a new bag and no lines are left clamped, otherwise, fluid flow will be impeded and cause net fluid loss alarms. NET FLUID GAIN ALARMS (+33 OML) • Action to take: Always remember to hook effluent line into tubing guide on machine, otherwise, over time the effluent tubing will naturally kink and impede drainage into the effluent bag and cause excess fluid gain alarms. 24

Run Alarms FILTER • Actions to take: • To avoid multiple blood transfusions, always try to return blood to patient before disconnecting patient or patient will lose 160 mls of blood. If it says “filter is clotting”…be proactive: stop treatment and return blood. • Septic patients have a tendency to clot off filters frequently due to increased circulating proteins (TNF/cytokines) which will clog up the intimal lining of the filter. There is no treatment other than to treat the sepsis. As the sepsis improves…. so will the lifespan of your filter! 25

Run Alarms HIGH TMP ALARMS (transmembrane pressure) • This is tracked on the green graph on the status screen and represents the pressure across the filter from the pushing and pulling action across the membrane. • Actions to take: • Decrease the blood flow rate (only a temporary solution). • Be proactive: stop the treatment and return the blood and initiate a new filter. 26

Run Alarms PRESSURE ALARMS • Actions to take: Go into SYSTEM TOOLS and force a self-test. This will reposition the pressure pods and hopefully resolve the pressure alarm. If the pressure alarm persists, the nurse will need to do a manual DRP-diaphragm reposition procedure, by following the directions on the screen, referring to your owner’s manual or calling GAMBRO 24 hr support at 800 -525 -2623. 27

Reminder ***Reminder: after priming the machine, must reprime machine with a one liter bag of 0. 9% NS if machine sits idle for more than 15 minutes without initiating therapy*** 28

Equipment Malfunction Report • Call BIOMED at ext# 4241 and provide the following information: – – – Your unit Your name Machine serial number Problem (describe) Alarm (error message) Biomed number • For technical support or any clinical questions call GAMBRO at 800 -525 -2623 (which is located at the back of the CRRT machine) 29