Education Newsletter August 2022: CRRT

JoAnna Bentsen
September 20, 2022
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CRRT Refresh:
Therapies - Practice - Safety 
What are CRRT therapies, what is the difference? 
At VUMC, we use Two machines to deliver Four different therapy modes of CRRT. Based on what mode, fluids and solutions patients are receiving, you will be performing different functions within the patients body and kidney. 


Our fantastic CVICU providers to a wonderful job at managing our patients. In addition to their diligent work, the nephrology team is closely monitoring patients on CRRT. Ensure that you are notifying nephrology if CRRT is stopped, paused for multiple hours, your patient's status critically changes, or if you are having frequent circuits clotting.
SCUF: Also known as ultrafiltration, SCUF is used to remove fluid from patients that otherwise have normal kidney function. No fluid will be administered via dialysate or replacement solution.
This therapy may be used intra-operatively to manage fluid balance, in our ECMO patients with preserved kidney function, or on our heart failure patients.
***Every CRRT therapy mode utilizes ultrafiltration***
CVVH: Waste products are being removed via ultrafiltration and convection. Replacement fluid is infused pre-blood pump (PBP) along the access side of the blood circuit. This is when you use PrismaSOL (hung on the white scale) solution. 
This therapy mode is indicated for patients in acute renal failure and rhabdomyolysis. 
CVVHD: waste products are being removed via ultrafiltration and diffusion. PrismaSATE solution (hung on the green scale) is infused on the outside of the hemofilter, NEVER mixing with the blood. This countercurrent flow improves the pressure gradient, thus removing more wastes from the blood. 
CVVHD Think-> "HD- Diffusion- Dialysis- DialySATE solution" 
This therapy mode is indicated for patient in acute renal failure, managing electrolyte imbalances and lactic acidosis.
CVVHDF: The Tesla of Dialysis. 
Waste products are being removed via convection, diffusion and ultrafiltration. Removes all sized molecules. You will be infusing PrismaSOL and PrismaSATE solutions.
This therapy mode is indicated for patient in acute renal failure that also require large amounts of ultrafiltration (fluid removal).

Clinical Pearl(s):
- This is why CRRT bags are scanned PRIOR to hanging. Infusing a solution on the wrong side of filter will impair the function.
- All CRRT Machines are set up in "CVVHD" mode. You can always set a scale to run at '0' but you are not going to be able to add in therapy fluids if your machine isn't initially set up to do so.
 
Speaking about set up...
When setting up your Prismax OR Prismaflex machine, ensure that you are adding in a syringe EVEN IF you won't be utilizing this therapy. If you don't utilize heparin, a 20 cc syringe is primed with NS, put in the machine and labeled with "NS" 



When you are taking your CRRT machines down, ensure youre also WIPING them down, frequently machines are put away covered in blood, creating an infection risk to the future patient and an extra step for the future nurse taking out the machine.
 

ECMO Considerations with CRRT 
There are two options for set up when utilizing CRRT with a patient on ECMO.
1. Have a Vascath separate from the ECMO circuit 
2. Splice CRRT into the ECMO Circuit 
While perfusion does NOT need to be present when accessing a Vascath for a patient on ECMO, an FYI call to let them know its happening keeps everyone in the loop. 
IF you are spliced into the circuit, perfusion must be present and hook the CRRT circuit to the ECMO Circuit. 
Pearls for CRRT with ECMO
- Make sure you are clamping lines every time you change a bag to prevent air entrapment 
- Always Aspirate prior to flushing a vascath to ensure no air is entrapped into the patient then the circuit.  
- Access pressure will be positive
- Blood flow rate will be set at 400 by nephrology to combat higher pressures
 
Anticoagulation: Setting up and Maintaining Citrate 
 
 
Calcium and ACD-A Citrate is an effective anticoagulation method that is used specifically in CRRT patients. 
Citrate infused via the access line will bind up calcium within the circuit, creating an inability for activation of the clotting cascade, thus anticoagulating your CRRT circuit
Calcium infused via the purple pigtail of the vas cath will replace bound up calcium from the circuit, thus allowing for appropriate clotting within the patient. 

Prior to setting up your calcium and citrate you need multiple pieces of a BUNDLE including:
1. Prismasate bath with ZERO calcium (requires a cosign every time you hang)
2. Calcium Chloride infusion (mg/hr) / ACD-A Citrate (mL/hr) infusions: these must be set up on an independent IV pole dedicated to these medications.
3. PRN Calcium Bolus ordered 
Without all components of the bundle you CANNOT start your calcium and citrate.

Clinical Pearls for Ionized Calcium Protocol:
- Drawn every 8 hours, ionized calcium (i-CAL) levels will guide your anticoagulation profile.
- I- CALs  are processed via VUMC CENTRAL lab, not our respiratory lab.
- You need to label your specimens when they are sent down to notify which one is the circuit, and which one is the patient calcium levels. 
- Similar to a heparin drip, changes to these labs are made within your eStar orders tab by clicking the 'modify' tab. 
Stopcocks On the Return Line- Lets talk about it:
Under the guidance of our nephrology medical director and our reps at Baxter, it is NOT approved or warranted to place a stop cock on the blue return line and the vascath. Why? Well, a couple of reasons... 
1. Any stop cock on the return line creates a high risk of air entrapment to your patient. The CRRT machine has two clamps between the de-airation chamber to prevent air within the return line, by placing a stopcock it bypasses already placed safety mechanisms. 
2. If the Stopcock were to become disconnected, there would be no alarm on the machine to alert the nurse of this. Your patient can lose large amounts of blood before the RN can visualize the lost connection between the stopcock and the return, creating the potential for serious patient harm.
 
Please elevate any questions or concerns that you have with this practice requirement.
 
Clearing up Charting 
CRRT Charting happens in real time!
When calculating your fluid to be removed, your number populates in row "F" of your NetCalc Tool. After this is calculated, you scroll back up to the hourly monitoring and document this number in the 'patient fluid removal rate' line. Row F and the patient fluid removal rate should match every hour, not vary an hour behind like shown in the picture. This ensure correct fluid is being removed for the patient. 
 
What the Effluent?!
Auto-Effluent is only approved for the Prismax platform. When using the Prismaflex (green) machine, you MUST change your bags as opposed to setting up a pseudo-auto-effluent set up with suction tubing. 

Problems that arise when utilizing auto-effluent on a non-compatible platform is:
  1. A direct line from the machine to a toilet with non-sterile flow both ways, with no valves within the 'effluent tubing' created out of the suction drainage tubing.
  2. Prismaflex machines calculate fluid removal by a combination of weight distribution between the four scales. If fluid is continuously removed, it creates incorrect fluid removal and dosing for CRRT. The updated Prismax machine re-distributes weight at liter weights between 2 bags for its auto-effluent, so that machine platform does not have this problem. 
  3. Fall risk for patient and family members to have a clear tube running across the ground. 
Breaking away from CRRT I have one VERY important Pharmacy update for you all! 

The CVICU has started to stock sugammadex within our omnicell (woo!) Sugammadex is a paralytic reversal, previously only given by anesthesia when the patient landed from the OR.
By being able to stock this drug in CVICU it allows more control over the patients paralysis, allowing for later reversal. 
Reminders for reversal agents within the CVICU
- If utilizing Sugammadex for reversal, only physicians will administer this drug.
- If reversing with other drugs like robinul, midlevels or MD are administering this drug.
**RN's are never administering paralytic reversal** 
 
 
  • There are four CRRT modes, each use different bags and therapies. Know what type of clearance you're achieving based on your therapy.
  • Always set up CRRT in mode "CVVHDF" so you can utilize any scale you need to.
  • When you set up a machine, ensure you put a syringe on, even if you don't use heparin.
  • Perfusion does not need to be present when accessing a vas cath, use precautions to prevent air entrapment.
  • When setting up citrate, you must have every piece of the bundle prior to starting.
  • NOTHING can go between the return line on the circuit and the patients vas cath. 
  • Perform real time charting on CRRT. This includes when charting your patient fluid removal rate within the CRRT specific flow sheet.
  • Only Prismax machines can use auto effluent. Do not make a pseudo-effluent with the green machine.
  • Sugammadex is now in the Omnicell, it must be administered by an MD. 
Upcoming Unit Involvement Opportunities for CVICU
CVICU Website Link
 
CVICU INQUIRER | August 2022
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