Pediatric CRRT: The Dialysis-Centric Program Helen Currier BSN, RN, CNN, CENP Director, Renal & Pheresis Services Texas Children’s Hospital Houston, Texas

Did you know....

Do what you do best…. everyone has different strengths.

Getting Started

DME The Pediatric Ideal: CRRT Equipment – Separate and accurate pumps and scales for each component of CRRT – Range of blood flows with a minimum of 20ml/min – Thermoregulation – Maximum safety features

Supplies The Pediatric Ideal: CRRT Circuit – Minimum priming volume with low resistance – Exchangeable components – Biocompatible membrane

CRRT Product Line Management Financial Management – Group Purchasing Organization (GPO) – Expenses and Billing – Vendor Contract Compliance Materials – Supply Chain Management movement and storage of CRRT supplies, from point-of- origin to the bedside – Workflow – Inventory Control

Supply Chain Event Management (SCEM) Know non-clinical events and factors that might disrupt CRRT – Distribution Network Number and location of suppliers, production facilities, distribution centers, warehouses and customers – Distribution Strategy Centralized versus decentralized, direct shipment, third party logistics. – Information Share valuable information, including demand signals, forecasts, inventory and transportation – Inventory Management Quantity and location of inventory Explore potential scenarios and plan for solutions Don’t lose your edge....

Monitor for Achieving Therapy Goals Patient – Fluid volume balance – Electrolyte balance – Acid/Base balance – Body temperature – Vascular access for CRRT – Anticoagulation – Nutritional management Device – Blood flow rate – CRRT solutions – Prescribed CRRT Fluid flow rates to evaluate adequacy of clearance – Machine circuit pressure alarms – Integrity of pump tubing segments and/or integrity of transducer or pressure pods – System to minimize interruption of therapy

Partnership is not a four-letter word

CRRT Competency Management 1.Organize your CRRT competency assessment – Determine critical competencies to evaluate annually – Tie critical competencies to annual performance reviews 2.Understand JCAHO expectations – National Patient Safety Goals 3.Develop your CRRT competency assessment program – Design a compliant, consistent, and effective competency assessment program 4.Validate CRRT competency – Validate clinical proficiency 5.Maintain a consistent CRRT validation system – Ensure that clinical proficiency is assessed and validated in a consistent manner with our easy to implement skill sheets 6.Keep up with new CRRT competencies – Verify and document new—and existing—competencies, including those for new equipment

Simulation The world is in crisis and the need for superheroes couldn’t be greater....

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

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

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

Safety Culture: Becoming a Communication Superhero Teamwork across hospital units – Cooperation – Coordination Handoffs and transitions – Transferring patients from one unit to another – Shift changes

CRRT Treatment Responsibilities: Points to Remember 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

Before Treatment Equipment/Supplies Nephrology Nurse – CRRT Equipment/Circuit 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 Treatment Equipment/Supplies 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

Treatment Initiation 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

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

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

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

Staffing Nurses for CRRT Variations – Skill mix – Opened vs. Closed – Responsibilities Dialysis Critical Care Predictions – FTEs by shift – Budgeting FTEs Shortages Effects – Clinical Outcomes – Therapy Choice