pCRRT Conference 2017 Challenges of Implementing a CVVH Program in a Neonatal Intensive Care Unit Teresa Jones, RN, CCRN The Challenges of implementing a CVVH program in a Neonatal Intensive care unit

Children’s Healthcare of Atlanta 2 hospital campuses that offer CRRT Egleston campus: CVVH is part of the service line provided by the ECMO and Advanced Technologies Team for over 20 years. During the past 3 years, Children’s performed over 600 procedures on more than 200 patients B.Braun Diapact® with Citrate/ Calcium protocol from this organization The Children’s Healthcare of Atlanta system has 3 hospital campuses and 7 urgent care centers and neighborhood facilities. 2 hospitals campuses offer CRRT CVVH is our preferred modality of CRRT AND at the Egleston campus, CVVH is part of the service line of the ECMO and Advanced Technologies team. CRRT has been provided at this campus for over 20 years. In the last 3 years, we have preformed over 600 procedures on more that 200 patients. We use the b Braun Diapact with the citrate / calcium protocol that can be found on the pCRRT website.

Continuous Venovenous Hemofiltration Routinely performed in the Pediatric Intensive Care and Cardiac Intensive Care Units. Neonates in need of CVVH were transferred to the PICU. Nephrology is consulted for CVVH and initiates orders, but once started, fluid and electrolyte management is typically done by the critical care team Neonatology had expressed interest in treating Inborn Errors of Metabolism in the NICU CVVH is routinely performed in the Pediatric and Cardiac Intensive care units. Any neonates in need of CVVH were transferred to the PICU for therapy and management Nephrology is consulted for all CVVH needs and they write the orders. Once CVVH is initiated, fluid and electrolyte management is typically done by the critical care team with nephrology following closely. During this past year, Neonatology has expressed interest in keeping Inborn Errors of Metabolism patients and other neonates requiring CVVH in the NICU for treatment.

Immunosuppression and chemotherapy treatment began Patient 3 day old infant transferred to Children’s NICU with pancytopenia, coagulopathy and heptosplenomegaly. Evaluation confirmed the diagnosis as Hemophagocytic Lymphohistiocytosis (HLH) Immunosuppression and chemotherapy treatment began Nephrology was consulted for increasing creatinine and anasarca. CVVH was ordered and initiated on day 11 of admission Neonatologist and family wanted infant to remain in the NICU Early this year, a 3 day old infant was referred to Children’s NICU with pancytopenia, coagulopathy, and hepatosplenomegaly. Further evaluation confirmed the diagnosis as Hemophagocytic Lymphohistiocytosis (HLH) He immediately began treatment for HLH which included immunosuppression and chemotherapy. A few days later, nephrology was consulted for increasing creatinine and anasarca. CVVH was ordered and initiated on day 11 of admission after surgeons placed a vascath. Both the Neonatologist and family expressed strong feelings about staying in the NICU for CVVH treatment.

Challenges NICU nurses were not educated on management of CVVH patients or care of a vascath. The few NICU nurses familiar with the CVVH pump (ECMO specialist) had no knowledge of citrate anticoagulation protocol Neonatology physicians not familiar with citrate/calcium protocols, citrate gap, or fluid management of a CVVH patient. NICU very rarely cares for long term HLH patients. No positive pressure rooms. Staff unaware of special precautions needed for patients receiving chemotherapy: reverse isolation, proper disposal of diapers and soiled items There were several challenges for providing care to this first “CVVH patient in the NICU”. CVVH is an advanced nursing competency and the NICU nurses had not been educated on the management of CVVH patients or guidelines for care of a patient with a vascath. The few NICU nurses that were familiar with the CVVH pump were ECMO specialist that worked with the pump in other units but had no knowledge of citrate anticoagulation since our “ECMO patients on CVVH” are on heparin protocol. A further challenge came from the renal management of this patient. Remember that nephrology only consults on these patients and the critical care teams usually manage fluid and electrolytes. Not all Neonatology physicians were familiar with citrate / calcium protocols, citrate gap, or fluid management of a CVVH patient. A final challenge came from the NICU very rarely caring for long term HLH patients. The unit has no positive pressure rooms for immunosuppressed patients. Staff were unaware of the special precautions needed for patients receiving chemotherapy including reverse isolation, and proper waste disposal of diapers and soiled items.

Caring for the patient Compromised reached by having PICU nurses trained in CVVH float to the NICU to care for this infant. NICU nurse floated to PICU. PICU nurses not familiar with NICU layout, supplies, or protocols necessitating help from a NICU resource nurse. Lack of nursing resources to assist with the CVVH pump. ECMO/ Advanced Technology primers provided breaks to nurses. Neonatologist given in-service and tip sheets on CVVH and anticoagulation management So how did we overcome these challenges: The nursing managers from the units reached a compromise that had a PICU nurse trained in CVVH floating to the NICU to care for the patient. And had a NICU nurse floating to the PICU in an exchange. That looks good on paper but remember this is a high acuity patient and the PICU nurse is in an unfamiliar environment. It may sound like a simple thing but: The PICU nurses are not use to the layout of NICU bedside supply cart. This prevented them from finding supplies quickly. Each shift, the PICU nurse have to be given a special passcode to get into the NICU medication Pyxis. Even the NICU ventilators are foreign to the PICU nurses. The NICU has different procedures and protocols for hanging central line nutrition and drips. A NICU resource nurse was made available to hang certain fluids for the PICU nurse. If there was a problem or alarm with the CVVH pump, there were no unit resources to help troubleshoot the machine. The ECMO / Advance Tech primer had to be called to help. These in-house primers were also the ones who provided lunch relief and breaks for the CVVH nurse. The neonatologist were great and very eager to learn about CVVH. In-Services were provided and the doctors were given tip sheets on CVVH and anticoagulation management.

The infant was successfully managed on CVVH in the NICU for 10 days. How did things go The infant was successfully managed on CVVH in the NICU for 10 days. Only one circuit change was required for clot formation. Unfortunately, infant developed a life threatening intraparenchymal hemorrhage and the family withdrew care on day 21. So how did we do: The infant was successfully managed on CVVH in the NICU for 10 days with only one circuit change needed for problematic clot formation. Unfortunately, the infant developed a life threatening brain hemorrhage and the family chose to withdraw care on day 21.

Neonatology physicians will undertake CVVH training Going Forward This case was a test for future neonatal cases to be managed in the NICU while on CVVH A core group of NICU nurses will undergo CVVH training; will be mentored in the NICU, shift to shift, by PICU nurses until competence is assured Neonatology physicians will undertake CVVH training Nephrology will increase their daily involvement in the management of future patients Admittedly, this was a difficult first” CVVH in the NICU” case but we learned a lot. So going forward how do we care for these occasional neonatal CVVH patients. We will train a core group of NICU nurses and have PICU personnel pair with these nurses on a shift to shift bases until competence is assured. Neonatology physicians will undertake more formal CVVH management training. Nephrology will increase their daily involvement in the management of future patients by rounding daily with the neonatology group.

Thank You We are interested in the experiences of other programs, questions, and comments. Teresa Jones, RN, CCRN Advanced Technologies Specialist teresa.jones@choa.org Melissa Vreeland, RN melissa.vreeland@choa.org I want to thank the pCRRT course directors for this opportunity to present our abstract. We are very interested in other programs experiences, questions and comments. So please share your thoughts with me and my colleague Melissa Vreeland. Thank You