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.