1. Practical Considerations for CRRT
Helen Currier RN, BSN, CNN
Nancy McAfee RN, BSN, CNN

2. San Juan Islands

3. Advantages of CRRT
SLOW: Hemodynamically unstable patients may not tolerate the rapid ultrafiltration of intermittent hemodialysis
CONTINUOUS: Can help preserve metabolic stability in critically ill patients; can maintain fluid balance for oliguric patients who require high daily input (IV medications, parenteral nutrition)
Stuart has eloquently reviewed the advantages in his presentation.

4. CVVH SYSTEM Replacement fluid Drainage bag/UF Roller pump
Heparin
Drainage bag/UF
Roller pump
bm14 roller pump
IV pump
Venous
chamber
Roller pump
Hemofilter
From the patient
Air detector
To the patient 38

5. CVVHD SYSTEM Replacement fluid Drainage bag/UF bm14 roller pump
Heparin
Dialysate
Roller Pump
IV pump
bm14 roller pump
IV pump
Roller Pump
Venous
chamber
Hemofilter
From the patient
Air detector
To the patient 41

6. Success with CRRT Access Equipment Tubing/filter Prime Anticoagulation
Staffing
A variety of factors play into success. Sometimes it takes creativity to carry out the desired treatment.

7. Access-What Works? Hemodialysis /Pheresis Line
Shortest, fattest catheter possible
(highest flows with least resistance)
May need two single lumen lines
Leg position-be creative
Tape on the skin-may need to get creative
Stuart discussed different types of lines that are used. Once the line is in, however, it is up to nursing to make it work up to it’s potential. Taping may be all that is needed, but when it is a premie with fragile skin, that may not be the best option. Coban can be great, if not too tight. Beanie babies are exactly the right size to prop lines often.

8. Blood Pump Systems for CRRT
Each institution has their own machine loyalty, so I will attempt to keep biases out of this talk.

9. CRRT Machines: Current Generation

10. Tubing and Equipment Tubing volume ranges from 44-110 ml
Filter volume ranges from 28 – 83 ml
Hotline volume 18.5 ml
Blood volume of patient (~70 ml/kg)
PRISMA – 108 ml
BM-25 -Smallest filter + tubing + hotline = 90.5 ml
On the PRISMA the tubing and cassette are a single unit and hold 108 mL. I believe a smaller volume tubing is in the works. The BM-25 has interchangeable filters and the volumes vary as shown here.

11. Extracorporeal Volume
Blood volume in extracorporeal circuit is very large compared to a small infant or child
Patients require a blood prime if the circuit >10% of their blood volume
A major problem for infants is the volume of blood in the extracorporeal circuit. Since the circuit exceeds 10% of their blood volume they must receive a prime.

12. Blood Prime Whole blood PRBC + Albumin 5% PRBC + NS PRBC + FFP
Larger patients Albumin 5%
AN-69 filter requires special considerations
Key to remember with a blood prime, this is no longer their blood, it belongs to the circuit. When the circuit is DC’d it must not be returned to the patient or they risk hypervolemia.

13. Bradykinin Release Syndrome (Brophy et al Am J Kidney Dis
Bradykinin Release Syndrome (Brophy et al Am J Kidney Dis Jul;38(1):173-8 )
What is the link
Blood bank blood has
ICa of 0.04 mmol/l
K+ of mEq/l
pH of 6.4
Reaction can be mitigated by buffering the blood and giving IV calcium at initiation
Bradykinin syndrome was described by Brophy et al in This occurs when banked blood is used to prime a circuit with an AN-69 filter in place, such as used in the PRISMA circuit. This syndrome has been reported in centers using poysulfone mambranes.

14. Buffered System
ECMO circuits are commonly primed with a cocktail to correct the pH, Hct, and K of banked blood
Addition of THAM
calcium chloride
Heparin
Sterile Water
Sodium bicarb
Traditionally ECMO circuits use a cocktail to buffer the blood used to prime their circuits, but they use a mach larger volume of blood.

15. Bypass System Transfuse the PRBC post-filter directly into the patient
The patient is then connected to the circuit
Using the same rate for priming on and infusing the PRBC (mixed with NS or Alb)
Thus the patient’s blood can be used as a “bradykinin filter” (Brophy,et al 2001AJKD)
This modified version described by Brophy et al is much simpler. I understand it is very successful at avoiding the sensitivity seen in those early patients.

16. Thermal Regulation Hotline® Blood warming tubing
Place at venous return to patient
Leave on at constant temperature of 39o C
Treat temp elevations if they occur
We had some difficulties managing the temps on the very small. We found it best to use the Hotline at the venous return and leave it set at a constant temp. We now treat fever if it occurs and use the hotline on all patients.

17. Anticoagulation Heparin Citrate infusion to CRRT circuit
Calcium infusion to patient at separate site
Monitor for metabolic alkalosis
Heparin
Heparin bolus then continuous infusion
Maintain activated clotting time (ACT) ~200
Risk of bleeding, thrombocytopenia
Sturat reviewed anticoagulation, and I believe there is another talk later on the subject.

18. CRRT Staffing in PICU/IICU
Nephrology/Dialysis RN sets-up & initiates therapy
PICU/IICU RN manages patient
Nephrology/Dialysis RN on call 24/7
Acuity assigned to pump as if a separate patient
Staffing determined by acuity
At CHRMC the nephrology team sets up the machine, institutes the therapy, and together with the ICU RN stabilizes the patient’s CRRT treatment. Once the patient is relatively stable on the circuit, the ICU RN assumes care of the circuit with the Nephrology/Dialysis RN available on call 24/7 for troubleshooting, and/or assistance with the therapy. In our PICU and IICU the pump is treated as a patient and assigned acuity for patient assignment. A single RN may care for both the patient and the pump together or there may be one RN for the patient and another for the pump. When the pump has a separate RN, this RN may have the pump paired with another patient depending on the acuity determined for the circuit. Since a patient on CVVH may be very ill it is not uncommon to have a separate RN assigned to the pump at least for the first shift or two.

19. CRRT is easier than standing on one foot in a tippy boat but it does take teamwork.

20. June, 2004 Coronado Springs Disney Orlando, Fl www.pcrrt.com
3rd International Conference on Pediatric Continuous Renal Replacement Therapy (PCRRT)
Hope to see you all on Orlando in June. Thank you for your time and kind attention.
June, 2004
Coronado Springs Disney Orlando, Fl

21. CRRT Modalities CAVH: Continuous Arteriovenous Hemofiltration
SCUF: Slow Continuous Ultrafiltration
CVVH: Continuous Venovenous Hemofiltration
CVVHD: Continuous Venovenous
Hemodialysis 32

22. bm25™: Blood Pump Module Blood monitor Blood flow rate:
 mL / min
-- Safety features:
 pressure monitors
 air detector
 clot trap
 venous clamp
 blood leak detector

23. bm25™: Fluid Control Module
Balancing monitor
Substitution pump / filtrate pump
Integrated scales
Fluid heater
TMP monitor
Operational ranges
Replacement fluid mL/hr
Filtrate pump ,000 mL/hr
Net UFR 0.1 – 2000 mL/hr

24. Baxter bm25™ 2 integrated modules Blood module (bm 11a™)
Balancing module / scales (bm14™)

25. CRRT Modalities CAVH: Continuous Arteriovenous Hemofiltration
SCUF: Slow Continuous Ultrafiltration
CVVH: Continuous Venovenous Hemofiltration
CVVHD: Continuous Venovenous
Hemodialysis 32

26. bm25™: Blood Pump Module Blood monitor Blood flow rate:
 mL / min
-- Safety features:
 pressure monitors
 air detector
 clot trap
 venous clamp
 blood leak detector

27. bm25™: Fluid Control Module
Balancing monitor
Substitution pump / filtrate pump
Integrated scales
Fluid heater
TMP monitor
Operational ranges
Replacement fluid mL/hr
Filtrate pump ,000 mL/hr
Net UFR 0.1 – 2000 mL/hr

28. Baxter bm25™ 2 integrated modules Blood module (bm 11a™)
Balancing module / scales (bm14™)

29. CVVH SYSTEM Replacement fluid Drainage bag/UF Roller pump
Heparin
Drainage bag/UF
Roller pump
bm14 roller pump
IV pump
Venous
chamber
Roller pump
Hemofilter
From the patient
Air detector
To the patient 38

30. CVVHD SYSTEM Replacement fluid Drainage bag/UF bm14 roller pump
Heparin
Dialysate
Roller Pump
IV pump
bm14 roller pump
IV pump
Roller Pump
Venous
chamber
Hemofilter
From the patient
Air detector
To the patient 41