Document

Report
Troubleshooting Issues in CVVH
Timothy L. Kudelka RN, BSN
Pediatric Dialysis Program
C.S. Mott Children’s Hospital
University of Michigan
Where to Begin?
• As Nephrologist, Intensivist and Nurses we all
need to address the issues of troubleshooting
CRRT.
• Many systems are still adapted (pieced) and
others now self-contained with simplified
operating interface and build-in software.
• Troubleshooting issues still remain.
Access
• If you don’t have it you might as well go
home.
• This is the most important aspect of
CVVH therapy.
•
•
•
•
Adequacy.
Filter life.
Increased blood loss.
Staff satisfaction.
Troubleshooting Access
• How can you tell if
you have a problem
before starting?
• What if you have
problems during
treatment?
• Check placement
first, then use
syringe to test
resistance and
blood return.
• Check line for kink,
then assess patients
position or need for
sedation.
Access
• Clotting or sluggish catheter.
• tPA (tissue plasminogen activator).
(Spry et al., Dialysis&Transplantation. Jan. 2001).
• Normal saline flush.
• Reason to replace catheter.
• Clotted catheter with no response to tPA.
• Exit site blood leakage with no response to pressure
dressing.
• Severe kinked catheter.
• Bad re-circulation issues.
Pressures
• Arterial or outflow pressures
• High negative pressure = access problem.
• High positive pressure = filter problem.
• Moderate to high positive pressure + high return (venous)
pressure = access problem.
• Venous or return pressures
• Moderate to high positive pressure + high arterial pressure =
filter problem.
• High return pressure + moderate arterial pressure = access
Anticoagulation
• None.
• Heparin.
• Bolus 10-20 units/kg then infuse at 10-20 units/kg/hr
adjust per ACT.(Heparin induced thrombocytopenia).
• Citrate.
• Initiate infusion rate at 1.5x the BFR(in mls/hr).
• Calcium chloride infusion at 0.16x the citrate rate.
(Hypocalcemia,metabolic alkalosis.
Suggestion
•
•
•
•
•
•
Normal saline flush.
Flashlight lines and filter.
Correct priming technique.
Maintain good BFR.
Monitor ACT levels (200-250).
Quick response to troubleshooting
issues.
Ultrafiltration
• How much to ultrafiltrate?
• Net ultrafiltration should be in the range
of 1-2 mls/kg/hr.
• Neonates u/f rate 0.5-1ml/kg/hr.
U/F Issues
• Attention to intravascular volume.
• Oncotic pressures.
• U/F controllers.
– Infusion pumps up to 30% inaccurate.
(Smoyer et al, CRRT1998)
• Filter size and life.
U/F Issues
• Accurate assessment is difficult with
less room for error in smaller children.
– Bed scales.
– Frequent weights or weights of U/F in IV
controller U/F method.
– Measured volume status.
– Monitor sHct.
– Vasopressor clearance.
Membrane Reactions
• Bradykinin release syndrome
• Causes of syndrome
• ACE inhibitors
• Low blood ph
• AN-69 membranes have been
associated with “Bradykinin release
syndrome” (Brophy et al. AJKD 2001)
Membrane Reactions
• What is the common link?
– AN-69 membrane.
– Blood prime.
– Low ph. (Blood bank blood ph).
• Technique to reduce membrane
reaction.
Membrane Reactions
• Correct blood from the blood bank.
• Bypassing the membrane.
• Bypass maneuver.
Bypass Maneuver
To view this
dialysis clip, go to
the Resources
References and
Procedures folder,
then the UNHS
Procedures folder
on the CD-Rom.
Thermal Issues
• Patient.
– Radiant heat methods.
• Warming blankets.
• Overhead warmer.
• Warm water bottles.
– Prevention of heat loss.
• Environmental conditions.
• Exposure. (Hats on infants, plastic wrap).
Thermal Issues
• Circuit
– Blood
• Blood warmers
•  Extracorporeal volume
•  Risk of clotting
– Dialysate or replacement fluid
• Prismatherm®
• High volume fluid warmer.
Transport Issues
• Patient that require transport while on
CVVH.
– Battery pack.
– Re-circulation.
• Blood prime/blood loss.
• Machine issues.
• Length of re-circulation. (1-2 hrs).
Prescription
• Need for daily orders.
• Recommendations on order sheet.
• Types of solutions.
– PD are problematic r/t lactate and high glucose.
– Pharmacy made solutions risk of error and expensive.
– Bicarbonate based solution-less risk,  expense.
• Nursing orders/labs.
Nursing Report
• Standard forms for documentation.
• Review of orders.
• The key to good team work is accurate
nursing reporting of problems and
troubleshooting techniques.
Nursing Training
•
•
•
•
•
•
•
•
Basic concepts of CRRT.
Knowledge of circuit function.
Documentation and review of protocols.
Troubleshooting issues and techniques.
Simulator – for non-stressful practice.
One-on-one hands on with experienced staff.
Continuous education.
Development and implementation of QA tool.
Forms
• Forms available on your CD-ROM
Thanks To:
Dr. Timothy E. Bunchman MD
Dr. Patrick D. Brophy MD
University of Michigan Pediatric
Dialysis Team.
Pediatric Critical Care Nursing.
My Wife.

similar documents