Liverpool Health Service

Intensive Care Unit

Self Directed Learning Package:


Continuous Renal Replacement Therapy


















Written by: Nicholas Mifflin & Sharon-Ann Shunker








How to use this package

This package is designed to be used in the clinical area as a self directed
learning tool.

The package is divided into sections. At the end of each section is a self test
to determine how well you have understood the information contained in
that section. You will need to complete the self tests at the end of each
section and ensure that you have mastered the content before moving on to
the next section.

If you have any trouble with the self test, go back over the section and revise
the content. If you are still unsure then you will need to speak with one of
the educators in your area.

The answers to each of the self test questions are contained at the end of the
package. To gain the most benefit from this package attempt the questions
first before seeking this reference.

GOOD LUCK!!!































Learning package objectives

By the completion of this package, the registered nurse will be able to:

1. Define and classify acute renal failure according to its aetiology
2. Identify the signs and symptoms of acute renal failure
3. Discuss the various modalities of renal replacement therapy including
advantages and disadvantages
4. Identify the indications for continuous renal replacement therapy
5. Describe the basic principles of fluid and waste removal involved in
CRRT
6. Describe the various modes of CRRT
7. Recognise the importance of access in CRRT
8. Explain the process for troubleshooting a vascath
9. Differentiate solutions used for CRRT
10. Discuss the safety precautions required for commencing CRRT
11. Differentiate pre dilution from post dilution
12. State the complications of CRRT
13. Describe methods that optimise clearance of fluid and waste
14. Describe methods of prolonging filter life
15. Discuss the indications for ceasing therapy
16. Recognise common reasons for CRRT machine alarms
17. Discuss the nursing management of the patient on CRRT



A Brief Look at Renal Anatomy & Physiology




Structures of the Renal System:
The renal system is comprised of the
Kidneys and those structures including
the ureters, bladder and urethra that
form the urinary system.

The primary role of the kidneys is to
remove metabolic wastes and maintain
fluid and electrolyte balance. The
kidneys also have a role in:
Blood Pressure Control
Red Blood Cell Synthesis
Bone Metabolism
Acid- Base Balance

Renal dysfunction can negatively impact
on all of these roles.
11


Adrenal Gland
Ureter
Kidney
Bladder
Urethra





The kidneys are situated in the
retroperitoneum located between T12
and L3 on each side of the vertebral
column.
12

Two layers form them internally. The
outer layer is the Cortex that contains:
Glomeruli
Proximal Tubules
Cortical Portions of Loops of
Henle
Distal Tubules
Cortical Collecting Ducts
11,12


The inner layer or Medulla is comprised
of Renal Pyramids. The pyramids
contain:
Medullary portions of Loops of
Henle
Medullary Portions of Collecting
Ducts
12


Multiple pyramids taper and join
forming a minor calyx. Several
combined make a major calyx. The
major calyces join and enter a funnel
shaped renal pelvis that directs urine
into the ureter.
11

Cross Section of the Kidney:









Components of the Nephron:

Approximately one million nephrons
comprise each kidney. The nephron
consists of:
Glomerulus
Bowman Capsule
Proximal Convoluted Tubule
Loop of Henle
Distal Convoluted Tubule
Collecting Duct
11,12


There are two types of nephron:
Cortical Nephrons
Juxtamedullary Nephrons
11


Cortical Nephrons:
Approximately 85 %
Perform excretory and regulatory
functions
11


Juxtamedullary Nephrons:
Approximately 15 %
Responsible for concentration and
dilution of urine
11









Urine Formation:
Three processes required for urine formation include:
Glomerular Filtration
Tubular Reabsorption
Tubular Secretion
11,12




















Glomerulus
Filters fluid and solutes from blood
Proximal Convoluted Tubule
Reabsorbs Na
+
, K
+
, Cl
-
, HCO
3
-
, urea, glucose & amino
acids
Filtrate Continues
Loop of Henle
Reabsorbs Na
+
, K
+
& Cl
-

Blocks reabsorption of H
2
O
Dilutes/Concentrates Urine
Filtrate Continues
Distal Tubule
Na
+
, K
+
, Ca
++
, PO
4
selectively reabsorbed
H
2
O reabsorbed in presence of Antidiuretic Hormone
(ADH)
Filtrate Continues
Collecting Duct
Reabsorption similar to distal tubule
HCO
3
-
& H
-
reabsorbed/secreted to acidify urine
Filtrate leaves hyperosmotic/hypoosmotic depending on
the bodys requirements
11,12



Composition of Urine:
H
2
O
Electrolytes- Na
+
, K
+
, Cl
-
, HCO
3
-
End products of protein metabolism- urea, creatinine, PO
4
, SO
4
End products of nucleic acid metabolism- uric acid
Breakdown products of phosphoric and sulphuric acid
H
+
ions excreted bound to buffers such as PO
4
and NH
3
11


Renal Anatomy & Physiology in Summary:
Kidneys filter blood of waste products
Functional units of the kidneys are called nephrons
Nephrons consist of a glomerulus, tubule and collecting duct
Urine is formed through glomerular filtration, tubular reabsorption
and tubular secretion
Urine moves from the collecting duct via the renal pelvis and ureters
into the bladder, where it is excreted from the body through the
urethra
Some substances are reabsorbed into the blood and others excreted
into the filtrate
































Self Test 1

Q1. State the primary and secondary functions of the kidneys.







Q2. Name the functional units of the Kidneys and list their components.







Q3. Discuss the processes involved in urine formation






























Summary of Acute Renal Failure

Definition:


Acute renal failure (ARF) is a clinical syndrome, characterised by an
abrupt decline in glomerular filtration rate (GFR). There is a subsequent
retention of metabolic waste products and an inability to maintain
electrolyte and acid-base homeostasis. Regulation of fluid volume is
also affected.
1,7,8,16,18,23


ARF occurs rapidly resulting in fifty percent or more nephrons to lose
function, and as this occurs quickly the body is unable to compensate.
There are three classifications of ARF based on the location of the cause.
23


Prerenal

Renal dysfunction is largely related to systemic factors that limit blood flow
and reduce glomerular filtration rate. Examples include:
Hypotension
Hypovolaemic shock- dehydration, blood loss
Cardiogenic shock post MI
Septic Shock
Bilateral renal vascular obstruction- thrombosis
1,8,9,16,18,23



Intrarenal

Renal impairment occurs secondary to damage that is sustained at the site
of the nephrons. This may be the result of a number of conditions or
nephrotoxins:
Acute Tubular Necrosis (ATN)
Acute Glomerulonephritis
Acute Pyelonephritis
Acute Cortical Necrosis
Malignant Hypertension
Acute Vasculitis
Rhabdomyolysis - drugs, trauma
Nephrotoxins - IV contrast, aminoglycosides
1,8,9,16,18,23



Postrenal

Renal failure secondary to obstruction that prevents excretion of urine
Prostatic Hypertrophy
Renal Calculi
Tumour
Blocked Urinary Catheter
1,8,9,16,18,23



Signs & Symptoms

Fluid and electrolyte abnormalities
Metabolic acidosis
Anaemia
Pruritis secondary to uremic frost
Nausea & vomiting
Confusion
LOC
Congestive heart failure resulting in acute pulmonary oedema
1,8,16,18,23












































Self Test 2

Q1. Define Acute Renal Failure







Q2. Describe 3 forms of acute renal failure and the associated causes







Q3. List the signs and symptoms of acute renal failure




























Renal Replacement Therapy

Renal replacement therapy (RRT) is an extracorporeal technique of blood
purification. Blood passes over a semipermeable membrane (filter) allowing
solutes and water to cross over to a collection side. There are various
modalities included under the umbrella of RRT.
19

Continuous Modalities (CRRT)
Haemofiltration
Haemodialysis
Haemodiafiltration
Ultrafiltration

Advantages:

Better for haemodynamic instability
Readily accessible
Effective fluid removal and clearance of solutes
Can be performed by ICU staff rather than specialised renal nurses
2,4,5,9,17,20


Disadvantages:

Patient mobilisation is limited
Access complications
Anticoagulation
Reduced blood flow rates secondary to small filters when compared to
IHD
2,4,5,9,17,20



Intermittent Haemodialysis (IHD)


Advantages:

Quick and effective
Large amounts of fluid and solutes can be removed over a short
period
5,9


Disadvantages:

Access Complications- formal access such as A.V. Fistula is
eventually required
Requires specialised staff and is therefore not readily accessible
May not be well tolerated by haemodynamically unstable patients
Intermittent fluid removal with IHD can be associated with fluid
overload and increased electrolytes between treatments
5,9



Peritoneal Dialysis

This form of dialysis utilises the peritoneum as the semipermeable
membrane.

Advantages:
Comparatively Cheaper
No anticoagulation required

No haemodynamic instability
5,9,24


Disadvantages:
High incidence of peritonitis
Slow clearance
Access Formal access required (Tenkhoff catheter)
Limitations on patient as it is required frequently
5,9,24
















































Continuous Renal Replacement Therapy (CRRT)

Indications
Fluid Overload, pulmonary oedema
Worsening Metabolic Acidosis
Hyperkalaemia
Worsening Azotaemia
Drug overdoses
Removal of toxins
9



Basic Principles
The basic principles incorporated in the function of CRRT involve:
Convection
Diffusion
Ultrafiltration
Hydrostatic Pressure
2,4,9,17,20


Terminology

Diffusion
The movement of small and middle molecule solutes from an area of high
concentration to low concentration across a semipermeable-membrane.
5,9

22
Osmosis
The movement of water from an area of high water concentration to an area
of lower water concentration across a semi-permeable membrane.
5,9


22




Ultrafiltration
The movement of water and solutes across a semipermeable membrane by
solvent drag created by convection and hydrostatic pressure.
5,9


22

Convection
Water flow across a semi-permeable membrane by hydrostatic pressure that
drags solutes with it (the way a waterfall moves pebbles and sand)
9

Hydrostatic Pressure
The force that pushes fluid and solutes across the membrane. The
mechanical blood pump on the dialysis machine creates this.
5,9

Oncotic Pressure
Plasma proteins including albumin, globulin and fibrinogen create the
pulling pressure that favours fluid retention and opposes hydrostatic
pressure.
5,9

Counter Current
The flow of two fluids in opposing directions. The direction of dialysis flows
opposite to that of blood flow maximising the concentration difference
between blood and dialysate.
5


Dialysate
A synthetic solute free solution used to achieve diffusive solute clearance
5

Effluent
Erroneous term used to indicate the solute and solvent discarded form the
patient.
9

Replacement
Pre or post dilution fluid

Pre-dilution
Administration of the replacement fluid into the circuit prior to the filter
5,9

Post-dilution
Administration of replacement fluid into the circuit after the filter
5,9




Modalities
Slow Continuous Ultrafiltration (SCUF)
Continuous Arterio/Venovenous Haemofiltration (CAVH/CVVH)
Continuous Arterio/Venovenous Haemodialysis (CAVHD/CVVHD)
Continuous Arterio/Venovenous Haemodiafiltration
(CAVHDF/CVVHDF)

SCUF
Slow Continuous Ultrafiltration is the method used when fluid removal is
the only objective. Dialysate and replacement fluids are not utilised.
Maximum fluid removal is 2000ml/hr.
2,17,20


= pump

SCUF System Setup
13

CAVH/CVVH
Continuous Venovenous Haemofiltration uses convective clearance to
remove water and solutes. Replacement is used to replace ultrafiltrate.
Maximum fluid removal is 1000ml/hr.
2,17,20

= pump

CVVH System Setup
13



CAVHD/CVVHD
Continuous Venovenous Haemodialysis uses diffusion to remove fluid and
solutes. Dialysate is pumped in a counter current to blood flow. Maximum
fluid removal is 1000ml/hr.
2,17,20

= pump

CVVHD System Setup
13


CAVHDF/CVVHDF
Continuous Venovenous Haemodiafiltration utilises both convection and
diffusion to remove fluid and solutes. Dialysate and replacement is used.
Maximum fluid removal is 1000ml/hr.
2,17,20

= pump

CVVHDF System Setup
13









CRRT Modality Summary
2,17,20

Mode Filtering Process Removes Indication

Slow Continuous
Ultra Filtration
(SCUF)


Convection-
Ultrafiltration


Fluid, Minimal
solutes

Fluid Overload
Heart failure


Continuous
Arterio/Venovenous
Haemofiltration
(CAVH/CVVH)




Convection-
Ultrafiltration


Fluid removal.
Moderate solute
removal. Urea
clearance
approximately 15-
17ml/min


Moderate electrolyte
imbalances
Oliguria with
parenteral nutrition
or blood
requirements
Septic Shock





Continuous
Arterio/Venovenous
Haemodialysis
(CAVHD, CVVHD)




Diffusion



Fluid removal. More
aggressive solute
removal. Urea
clearance
approximately 17-
21ml/min.


Fluid overload with
haemodynamic
instability
Azotaemia
Electrolyte
disturbance and
acidosis
Parenteral nutrition
accompanying fluid
overload



Continuous
Arterio/Venovenous
Haemodiafiltration
(CAVHDF/CVVHDF





Convection &
Diffusion


Maximum fluid and
solute removal. Urea
clearance
approximately 25-
26ml/min.


Fluid Overload,
pulmonary oedema
Worsening Metabolic
Acidosis
Hyperkalaemia
Worsening Azotaemia
Drug overdoses
Removal of toxins


NB: There are other forms of CRRT however the above are most
applicable to LHS
















Self Test 3

Q1. What is renal replacement therapy?







Q2. List advantages and disadvantages of continuous modalities compared
to other forms of RRT







Q3. List Indications for CRRT







Q4. Describe the basic principles of fluid and solute removal involved in
CRRT.







Q5. Describe the different modes of CRRT.
















Vascular Access

Good access that allows high flow rates through the circuit is one of the key
aspects in CRRT that effects blood flow, clearance and filter life.

Catheters

Blood Flow is proportional to the diameter of the catheter- i.e. the wider the
tube the better the blood flow.
3,4
Therefore the largest diameter catheter
should be utilised. Vascaths available in Liverpool ICU include.
Gambro- 13fr ( 15cm &20cm)
Niagra- 13.5Fr (15cm & 24cm)
Gambro- 12Fr (15cm & 20cm)
Arrow Triple Lumen- 12 Fr (20cm)
Lumens are colour coded being red and blue. The red lumen is the arterial
port also known as the access port. This lumen supplies blood from the
patient to the filter. The blue lumen is the venous port also known as the
return port. Blood is returned via this lumen from the filter to the patient.
Differentiating these lumens is necessary when troubleshooting access or
return pressure alarms on the CRRT machines.
5


Catheter Location

Typically the vessels utilised for vascaths are the Internal Jugular, Femoral
and Subclavian veins. The choice of catheter site is dependant on many
factors including:

Skill of the accessing clinician
Size of the patient
Mobility of the patient
Anticipated Duration of therapy
Presence of other intravenous lines
Coagulopathy
3,4



Internal Jugular Vein

Advantages:
Allows for patient mobility
Easy to visualise insertion site

Disadvantages:
Requires Chest Xray prior to use
Kinking can occur when the patient moves their head
Sometimes attains insubstantial blood flows secondary to variations
in central filling and intrathoracic pressures. Positive pressure
ventilation can make this more apparent.
3,4,5







Femoral Vein

Advantages:
Easily accessible by most clinicians
May allow greater blood flows

Disadvantages:
Prone to kinking, more so in the obese patient
Does not allow for patient mobility
Difficult to visualise and dress insertion site
Higher incidence of infection secondary to the proximity to intestinal
flora.
3,4,5



Subclavian Vein

Advantages:
Allows for patient mobility
Easy to visualise and dress insertion site

Disadvantages:
Requires Chest Xray prior to use
Risk of pneumothorax on insertion
Risk of subclavian stenosis, which can impair suitability for an A-V
fistula on the affected side, if renal failure becomes chronic.
Sometimes attains insubstantial blood flows secondary to variations
in central filling and intrathoracic pressures. Positive pressure
ventilation can make this more noticeable.
3,4,5



Nursing Care for the Access Device

Regularly inspect insertion site for signs of infection, haematoma and
bleeding
Apply standard precautions and aseptic technique whenever
connecting or disconnecting lines to and from the catheter
Clean catheter and site with 0.5% chlorhexidine once weekly and prn
using an aseptic technique and cover with an occlusive dressing (IV
3000)
When catheter is not in use lumens should be Heparin-Locked to
prevent clotting within the catheter
5


NB: Form more information on care of a vas cath see policy-
management of central venous access devices in appendix

Heparin-Lock for a Vas-Cath

Apply standard precautions and utilise aseptic technique
Using 3 ampoules of 5000 units heparin in 1ml (15000 units/3ml)
inject the stated amount (located on each port) of this solution into
the Vas Cath port. Label lumens as Heparin Locked
9,10



Troubleshooting Access Device

Where the CRRT machine exhibits high-pressure alarms the problem may
stem from a malfunctioning catheter. Assess catheter patency as follows:

Apply standard precautions and utilise aseptic technique
Aspirate and flush 10ml of blood on the effected lumen to test
resistance to blood flow. Further, flush 10ml 0.9% sterile normal
saline.
22


Where resistance is present, a clot may be obstructing the catheter, but
more likely it is positioned against the vessel wall. Slightly withdrawing or
rotating the catheter may overcome this problem. Where this fails to resolve
the problem the catheter must be changed.
5,9,21

NB: Swapping the lumens- i.e. attaching the access line to the return port
and visa versa may also overcome this problem, however this can result in a
significant reduction in clearance and is therefore not recommended. It can
be used as a temporary measure to overcome access problems.
9



































Self Test 4

Q1. What is the importance of adequate access?







Q2. Sate the appropriate name and functions of the red and blue lumens on
a vascath







Q3. What are the three possible sites for vascath insertion? State the
advantages and disadvantages of each.







Q4. How would you troubleshoot a vascath?







Q5. How would you heparin lock a vascath?
















Preparation for Therapy

Orders & Equipment

Obtain a complete and correctly filled order for CRRT using the ICU
CRRT prescription form. NB: Pre dilution or Post dilution set
Obtain equipment according to ICU protocol Continuous Renal
Replacement Therapy (CRRT) using the PRISMA MACHINE. NB:
equipment for the PRISMA FLEX is identical except for the required
set, compatible warming line and one extra bag of GAMBRO or
HEMOSOL solution as ordered.

Please read and become familiar with this protocol in conjunction
with this package. (See appendix)


Preparation of Fluids

Losses in ultrafiltrate through CVVH and CVVHDF require replacing.
Replacement fluid should be a balanced electrolyte solution that will offset
the convective loss of electrolytes and plasma water during haemofiltration.
As stated earlier, replacement fluid is a pre or post dilution fluid. The fluids
available for such purpose in Liverpool ICU include HEMOSOL and
GAMBRO. These fluids are also used as dialysate in modalities where
diffusive clearance is also involved (CVVHDF, CVVHD).
3
To maintain acid-
base balance, it is necessary for these fluids to contain base that will provide
a buffer. Typically lactate serves this purpose as it is converted to
bicarbonate in the liver.
4,
GAMBRO is the fluid that contains lactate as
its buffer.

Lactate free solutions also exist where bicarbonate must be added
immediately prior to use.
4,
HEMOSOL is considered lactate free and thus
requires the addition of bicarbonate prior to use. This is accomplished by
breaking the seal within the bag to mix the solutions together.

HEMOSOL is the fluid of choice where the patient is severely acidotic or
suffering liver dysfunction that would prevent the metabolism of lactate to
bicarbonate. Utilising GAMBRO in this circumstance may contribute to a
worsening acidosis.

Specific to Dialysate

Both GAMBRO and HEMOSOL solutions require addition of KCL when used
as dialysate. KCL is added to these fluids to reduce loss K
+
of through
diffusion.
NB: KCL is only added to these fluids when patients K
+
level is
<5mmol/L.







Procedure

GAMBRO- Add 15mmol K
+
to 5L (already contains 5mmol K
+/
5L)
HEMOSOL- Add 20mmol K
+
to 5L (Contains no K
+
)

Addition of K
+
in these quantities will make a final concentration of 4mmol
K
+
/L.
9

Priming The Circuit

Both PRISMA and PRISMA FLEX machines contain on screen step by step
instructions for setting up and priming the circuit. For further information
on priming the PRISMA machine consult ICU protocol, Continuous Renal
Replacement Therapy (CRRT) using the PRISMA MACHINE. Further
information regarding the same processes for the PRISMA FLEX can be
found in the operators manual located on the back of the machine. Failing
this, please consult a senior staff member or educator that may assist you.

Access

Once the circuit is primed and ready to connect, 5ml of blood should be
aspirated and discarded to remove heparin from the line. The vascath
should then be checked for patency as described earlier in troubleshooting
access device. It is important that therapy with a good circuit not be
commenced on inadequate access. Circuits are expensive and poor access
will significantly reduce its functional duration. Always apply aseptic
technique when accessing catheter.
9



























Commencing Therapy


Providing access is adequate, access and return lines can be connected to
the corresponding lumens of the vascath using standard precautions and
aseptic technique. A full breakdown of this procedure is located in ICU
protocol Continuous Renal Replacement Therapy (CRRT) using the PRISMA
MACHINE.

Connecting Patient to CRRT (Running pt on)

Once patient is connected select desired flow rates for Dialysate,
Replacement, Blood Pump Speed, Ultrafiltrate/Fluid removal
according to order (Commence blood pump at 80-100ml/hr and
increase as tolerated by patient)
Assess patients haemodynamic status
Commence therapy
Administer 2500 units heparin bolus via the red port on the access
line. Omit heparin bolus if patient is coagulopathic or has been on
CRRT in the last 4 hours.
Monitor patient for haemodynamic instability for 15-30 minutes post
commencing therapy. Patient may experience a transient drop in
blood pressure, that will therefore require adjustment of pump speed
to compensate, depending on the sensitivity of the patient.
9,21



Safety

CRRT Machine should be plugged into an isolated power socket
When commencing therapy, colloid on a pump giving set should be
connected to patients intravenous access
10mg Metaraminol (Aramine) should be drawn up and readily
available. 10mg of Aramine is prepared in 20ml of 0.9% sodium
chloride. This in conjunction with colloid is precautionary, should the
patient become hypotensive. If the patient is on inotropes, Aramine
may not be necessary as blood pressure can be controlled with the
existing inotropic drugs.
9,21



Pre-dilution or Post-dilution

Pre-dilution involves administering replacement fluid prior to the filter. This
thereby reduces the viscosity of blood and hematocrit and in effect may aid
in preventing filter clotting. Unfortunately this method also dilutes the
concentration of solute in plasma, which can negatively impact on clearance.
In order to optimise clearance of solutes, replacement rate must be
increased in order to increase the rate of ultrafiltration.
3,9

Post-dilution therefore involves administering replacement fluid after the
filter. This does not dilute solutes in plasma, however the ability for optimal
clearance is lost when blood viscosity is not reduced and high flow rates are
then difficult to achieve. With reduced blood flow comes reduced
ultrafiltration. Utilising filters with larger surface areas in conjunction with
this method may improve clearance.
9

Complications
Hypotension that may result from aggressive fluid removal
Electrolyte imbalances
Cardiac Arrhythmias
Anaemia secondary to haemolysis of red blood cells
Thrombocytopaenia secondary to platelet aggregation in filter
Hypothermia secondary to extracorporeal blood circulation
Coagulopathy secondary to over heparinisation
Infection (line sepsis)
Heparin induced thrombocytopaenia
2,9,17,21













































Self Test 5

Q1. What is the purpose of dialysate and replacement fluids?







Q2. State the two fluids available at Liverpool ICU for CRRT, including the
major difference and the preparations required.







Q3. How do you prepare the vascath prior to commencing CRRT with a new
circuit?






Q4. List the safety aspects of connecting and commencing therapy.







Q5. Differentiate pre dilution from post dilution including benefits and
disadvantages.







Q6. List the complications of CRRT.







Optimising Clearance

Regardless of which CRRT machine is being used, optimising clearance is
dependant on two factors. These include improving diffusion and
convection/ultrafiltration.

Improving Diffusion

Using filters with larger surface areas is one means of improving diffusion.
6
Currently Liverpool ICU stock consists of M100 and ST 100 filter sets. The
M100 circuits incorporate an AN69 hollow fiber filter. These filters are
comprised of Acrylonitrile and sodium methallyl sulfonate copolymer and
have a surface area of 0.9m
2
. The ST 100 sets are similar but have a surface
area of 1.0 m
2
. The filter is comprised of identical materials, however also
includes the surface treatment agent polyethylene imine.
14
This surface
treatment aims to encourage heparin binding during priming that can
ultimately reduce heparin requirements for anticoagulation of the circuit.
This may also benefit patients who require heparin free dialysis.
15

A second means of improving diffusion involves utilising an appropriate
dialysate fluid. Eg. Withholding addition of KCL to dialysate fluid when the
patient is hyperkalaemic so that serum potassium concentration remains
higher than that in the dialysate. K
+
will therefore be filtered off the patient
from an area of high to low concentration.

Improving Convection/Ultrafiltration

Improving convection/ultrafiltration is largely accomplished through high
flow rates (Dialysate, Replacement, Ultrafiltration & Blood Pump). As
mentioned earlier pre dilution assists in achieving higher flow rates by
reducing the viscosity of blood and hematocrit. Location and care of the
vascath is also shown to influence flow considerably.
6,9




















Prolonging Filter Life

Prolonging filter life simply refers to preventing the filter clotting and
maintaining its functional ability to remove fluid and waste. Factors that
prolong filter life include:

High blood flow rates
Pre dilution and warming of fluid
Adequate Access
Anticoagulation
3,4,9


Anticoagulation

On priming the circuit 5000 units of heparin should be added to each
1L bag of warmed normal saline
Unless the patient is coagulopathic or has been on CRRT in the past 4
hours, 2500 units of heparin should be administered as a bolus, via
the red pre filter port of the access line, as therapy is commenced.
A heparin infusion of 15000 units in 50ml 0.9% sodium chloride can
be administered according to ICU HEPARIN SODIUM protocol for
anticoagulation of the dialysis circuit via the designated anticoagulant
line of the circuit.
Aim for a pre filter APTT (from pre filter port or arterial line/patient)
between 30-40 seconds.
10


NB: If patient is coagulopathic run heparin free CRRT- refer to
protocol for further precautions.

NB: Full information for anticoagulation of the dialysis circuit is available in
ICU HEPARIN SODIUM protocol. Please read and become familiar with this
protocol in conjunction with this package. (See appendix)


Discontinuing CRRT (Running Patient Off)

Refers to ending therapy either temporarily or permanently

Indications
When indications for CRRT are no longer present
When return pressures are elevated associated with filter clotting
When alarms are indicating poor clearance
For procedures in theatre or CT
21













Procedure

1. Observe standard precautions and aseptic technique. Use sterile gloves
when disconnecting lines from the Vascath.
2. Press 'stop' and choose to end treatment. The PRISMA will then prompt
you to return blood to the patient after providing the following:
Attach a secondary giving set to 500mL bag of normal saline, add
three-way tap to the end of this line and prime.
Connect the red access line of the PRISMA circuit to the three-way
tap, using aseptic technique.
Return blood by following on screen prompts
Remove circuit as per onscreen prompts.
3. Flush each lumen of the Vascath with 10mL normal saline.
4. Heparin Lock as per protocol

NB: If only a temporary disconnection and filter is still viable then connect
both lines to a three-way tap. Circuit can then be reconnected to patient as
normal when recommencing therapy.
21




































Self Test 6

Q1. What factors need to be manipulated in order to optimise clearance?







Q2. Describe methods of optimising clearance.







Q3. List four factors that can prolong filter life.








Q4. When would anticoagulation NOT be used?







Q5. What are the indications for terminating therapy?














Common Alarms & Troubleshooting

There are various alarms that occur on both CRRT machines available in
Liverpool ICU. The most common are discussed. Troubleshooting options are
available in operators manual and instruction cards attached to each
machine. On screen prompts are also issued when alarms are triggered.

Access Pressure High

Possible Triggers include:
Red clamps closed
Blocked or kinked vascath secondary to clot or position
Blocked or kinked access line
High blood flow rate
High airway pressures
Patient coughing
9,13


Return Pressure High

Possible Triggers include:
Blue clamps closed
Blocked or kinked vascath secondary to clot or position
Blocked or kinked return line
High airway pressures
Filter Clotting/Clotted
9,13


Treatment obviously involves correcting the above problems. Where
filter clotting is a possibility blood should be returned ASAP


Access or Return Disconnect

Triggered by low pressure in either of the lines. May indicate disconnection
somewhere in the circuit. Check that all lines are connected securely.


Air in Blood

Possible Triggers include:
Fluid level in bubble trap below sensor
Air in circuit
Incomplete priming
Return line not installed in Air detector
Dirty sensor
Leaking connection
9,13


NB: This alarm must not be bypassed. It is a protective mechanism
against the possibility of air embolism. Do not override until
troubleshooting procedures in operators manuals have been fully
followed.
9,13




There are many alarms that may be triggered during CRRT. If in doubt follow
the on screen prompts or refer to the operators manual for guidance. Most
alarms that occur will be related to the following:

Vascath obstruction due to position of patient
Access or return lines kinking or clotting
Bag placement on scales is incorrect
Clotting of the filter/circuit
Poorly placed blood leak detector
Air in the circuit
Periodic self test failure
9,13



Diaphragm Reposition Procedure

13


13
Performed if pod is accidentally
removed or machine alarms
indicating problem

-ve Pods (Access & Effluent)
Stop Pump
Clamp line above & below
pod
Remove pod & clean port
Inject maximum of 1cc
normal saline into pod using
20 g needle
Reinstall pod
Resume therapy

+ve Pods (Filter & Return)
Same as above
Aspirate maximum of 1cc















Summary of Nursing Care for the Patient on CRRT

Continuous monitoring of haemodynamic parameters
Pressure area care and hygiene needs
Optimise blood pressure prior to commencing therapy
Colloid and Metaraminol precautions when running patient on
When anticoagulation is running an initial APTT should be checked 4
hours after commencing therapy. 6 hourly APTT is attended thereafter
and heparin infusion titrated according to protocol
Electrolytes, urea and creatine (EUC) and calcium, magnesium and
phosphate (CMP) should be checked 2 hours after commencing
therapy. 6 hourly EUC/CMP thereafter. Where electrolytes need
replacing, do so in accordance with ICU electrolyte protocols.
Strict monitoring of fluid balance to prevent excessive fluid losses
when removing fluid- this should monitored hourly and documented
on CRRT observation chart to prevent incorrect fluid removal
secondary to scale malfunction.
Attend CRRT observation chart monitoring pressures in particular
that may warn of filter clotting or access problems
Monitor Vascath site for signs of infection. Clean and dress as
required as earlier described.
Monitor patients temperature and actively warm using a bear hugger
blanket if necessary
Maintain standard precautions and aseptic technique when priming,
connecting, disconnecting the circuit. This also applies when
changing fluids or disposing of ultrafiltrate
As with all intensive care patients the MFASTHUG pneumonic should
be followed- i.e. Mouth care, Feeding, Analgaesia, Sedation,
Thromboembolism prophylaxis, Elevated bed head, Stress ulcer
prophylaxis and Glucose control + Gut- aperients etc
2,5,8,17,20























Self Test 7


Q1. List the common triggers for alarms on the CRRT machines.







Q2. How would you reposition the diaphragms on both positive and
negative pressure pods when required?







Q3. What nursing care is necessary for the patient undergoing CRRT?



















Answers

Self Test1

Q1. State the primary and secondary functions of the kidneys.

The primary role of the kidneys is to remove metabolic wastes and maintain
fluid and electrolyte balance. The kidneys also have a role in Blood Pressure
Control, Red Blood Cell Synthesis, Bone Metabolism and Acid- Base
Balance.

Q2. Name the functional units of the Kidneys and list their
components.

The functional units of the kidneys are known as nephrons. The nephron
consists of a Glomerulus, Bowman Capsule, Proximal Convoluted Tubule,
Loop of Henle, Distal Convoluted Tubule and Collecting Duct.
Or
Glomerulus, tubule and collecting duct.

Q3. Discuss the processes involved in urine formation

Three process involved in urine formation include Glomerular Filtration,
Tubular Reabsorption and Tubular Secretion. Glomerular filtration occurs
as blood passes through the glomerulus being filtered of fluid and solutes.
Tubular reabsorption and secretion occurs progressively through the areas
of the tubule. Fluid, electrolytes and waste products are excreted as filtrate
depending on the bodys requirements.

Self Test2

Q1. Define Acute Renal Failure

Acute renal failure (ARF) is a clinical syndrome, characterised by an abrupt
decline in glomerular filtration rate (GFR). There is a subsequent retention of
metabolic waste products and an inability to maintain electrolyte and acid-
base homeostasis. Regulation of fluid volume is also affected.

Q2. Describe 3 forms of acute renal failure and the associated causes

Prerenal ARF is largely related to systemic factors that limit blood flow and
reduce glomerular filtration rate. Related causes may include hypotension,
hypovolaemic shock, cardiogenic shock, septic shock and thrombosis that
results in bilateral renal vascular obstruction.

Intrarenal ARF is the result of damage sustained at the site of the nephrons.
This could be secondary to a number of conditions or nephrotoxins
including: Acute tubular necrosis, acute glomerulonephritis, acute cortical
necrosis, malignant hypertension, acute vasculitis, rhabdomyolysis, IV
contrast and aminoglycosides.


Post renal ARF occurs secondary to obstruction that prevents excretion of
urine. This may relate to prostatic hypertrophy, renal calculi, tumour or
blocked urinary catheter.

Q3. List the signs and symptoms of acute renal failure

Fluid and electrolyte abnormalities
Metabolic acidosis
Anaemia
Pruritis secondary to uremic frost
Nausea & vomiting
Confusion
LOC
Congestive heart failure resulting in acute pulmonary oedema

Self Test 3

Q1. What is renal replacement therapy?

Renal replacement therapy (RRT) is an extracorporeal technique of blood
purification. Blood passes over a semipermeable membrane (filter) allowing
solutes and water to cross over to a collection side. There are various
modalities included under the umbrella of RRT.

Q2. List advantages and disadvantages of continuous modalities
compared to other forms of RRT

Advantages:
Better for haemodynamic instability
Readily accessible
Effective fluid removal and clearance of solutes
Can be performed by ICU staff rather than specialised renal nurses

Disadvantages:
Patient mobilisation is limited
Access complications
Anticoagulation
Reduced blood flow rates secondary to small filters when compared to
IHD

Q3. List Indications for CRRT

Fluid Overload, pulmonary oedema
Worsening Metabolic Acidosis
Hyperkalaemia
Worsening Azotaemia
Drug overdoses
Removal of toxins





Q4. Describe the basic principles of fluid and solute removal involved in
CRRT.

Diffusion involves the movement of small and middle molecule solutes from
an area of high concentration to low concentration across a semipermeable-
membrane. Convection occurs with water flow across a semi-permeable
membrane by hydrostatic pressure that drags solutes with it (the way a
waterfall moves pebbles and sand). Ultrafiltration is the movement of fluid
and solutes across a semipermeable membrane secondary to convection or
hydrostatic pressure. Positive pressure pushes the fluid across where
negative pressure pulls the fluid across. The force that pushes fluid and
solutes across the membrane is known as hydrostatic pressure. The
mechanical blood pump on the dialysis machine creates this.



Q5. Describe the different modes of CRRT.

Slow Continuous Ultrafiltration utilises convection and ultrafiltration to
remove fluid. It is indicated for fluid overload. SCUF does not require
dialysate or replacement fluids.

Continuous Venovenous Haemofiltration incorporates convection and
ultrafiltration to remove fluid and moderate solutes. Replacement fluid is
used. This modality is indicated for moderate electrolyte imbalances, oliguria
whilst receiving TPN or blood and for patients in septic shock.

Continuous Venovenous Haemodialysis filters via diffusion. Fluid is removed
together with more aggressive solute removal. Replacement fluid is not used.
CVVHD is warranted for fluid overload with haemodynamic instability,
Azotaemia, electrolyte disturbances and acidosis.

Continuous Venovenous Haemodiafiltration uses both diffusive and
convective processes. Both replacement and dialysate solutions are used for
maximum fluid and solute removal. This mode of CRRT is indicated for fluid
overload, pulmonary oedema, worsening metabolic acidosis, hyperkalaemia
worsening Azotaemia, drug overdoses and removal of toxins


Self Test 4

Q1. What is the importance of adequate access?

Good access that allows high flow rates through the circuit is one of the key
aspects in CRRT that effects blood flow, clearance and filter life.


Q2. State the appropriate name and functions of the red and blue
lumens on a vascath

The red lumen is the arterial port also known as the access port. This lumen
supplies blood from the patient to the filter. The blue lumen is the venous

port also known as the return port. Blood is returned via this lumen from
the filter to the patient.


Q3. What are the three possible sites for vascath insertion? State the
advantages and disadvantages of each.

Internal Jugular Vein

Advantages:
Allows for patient mobility
Easy to visualise insertion site

Disadvantages:
Requires Chest Xray prior to use
Kinking can occur when the patient moves their head
Sometimes attains insubstantial blood flows secondary to variations
in central filling and intrathoracic pressures. Positive pressure
ventilation can make this more apparent.

Femoral Vein

Advantages:
Easily accessible by most clinicians
May allow greater blood flows

Disadvantages:
Prone to kinking, more so in the obese patient
Does not allow for patient mobility
Difficult to visualise and dress insertion site
Higher incidence of infection secondary to the proximity to intestinal
flora.

Subclavian Vein

Advantages:
Allows for patient mobility
Easy to visualise and dress insertion site

Disadvantages:
Requires Chest Xray prior to use
Risk of pneumothorax on insertion
Risk of subclavian stenosis, which can impair suitability for an A-V
fistula on the affected side, if renal failure becomes chronic.
Sometimes attains insubstantial blood flows secondary to variations
in central filling and intrathoracic pressures. Positive pressure
ventilation can make this more apparent.

Q4. How would you troubleshoot a vascath?

Using aseptic technique, assess catheter patency by aspirating and flushing
10ml of blood on the effected lumen to test resistance to blood flow. Further,
flush 10ml 0.9% sterile normal saline. Where resistance is present, a clot

may be obstructing the catheter, but more likely it is positioned against the
vessel wall. Slightly withdrawing or rotating the catheter may overcome this
problem. Where this fails to resolve the problem the catheter must be
changed. The lumens may be swapped, however this is only a temporary
measure as there is a loss in clearance.

Q5. How would you heparin lock a vascath?

Apply standard precautions and utilise aseptic technique
Using 3 ampoules of 5000 units heparin in 1ml (15000 units/3ml)
inject the stated amount (located on each port) of this solution into
the Vas Cath port. Label lumens as Heparin Locked

Self Test 5

Q1. What is the purpose of dialysate and replacement fluids?

Dialysate fluid is used as a means to encourage diffusive clearance.
Replacement fluid is a pre or post dilution fluid used to replace losses in
ultrafiltrate.

Q2. State the two fluids available at Liverpool ICU for CRRT, including
the major difference and the preparations required.

GAMBRO is the fluid that contains lactate as its buffer. HEMOSOL is
considered lactate free and thus requires the addition of bicarbonate prior to
use. This is accomplished by breaking the seal within the bag to mix the
solutions together. Both GAMBRO and HEMOSOL solutions require addition
of KCL when used as dialysate. 15mmol K
+
is added to 5L of GAMBRO.
20mmol K
+
is added to 5L of HEMOSOL. Both make a final concentration of
4mmol K
+
/L. KCL is added to these fluids to reduce loss K
+
of through
diffusion.


Q3. How do you prepare the vascath prior to commencing CRRT with a
new circuit?

Once the circuit is primed and ready to connect, 5ml of blood should be
aspirated and discarded to remove heparin from the line. Assess catheter
patency by aspirating and flushing 10ml of blood on the effected lumen to
test resistance to blood flow. Further, flush 10ml 0.9% sterile normal saline.

Q4. List the safety aspects of connecting and commencing therapy.

CRRT Machine should be plugged into an isolated power socket
When commencing therapy, colloid on a pump giving set should be
connected to patients intravenous access
10mg Metaraminol (Aramine) should be drawn up and readily
available. This in conjunction with colloid is precautionary, should
the patient become hypotensive. Inotropes can be titrated for control
of hypotension, if the patient is on them rather than utilising
Aramine.





Q5. Differentiate pre dilution from post dilution including benefits and
disadvantages.

Pre-dilution involves administering replacement fluid prior to the filter. This
thereby reduces the viscosity of blood and hematocrit and in effect may aid
in preventing filter clotting. Unfortunately this method also dilutes the
concentration of solute in plasma, which can negatively impact on clearance
by reducing the diffusion gradient. In order to optimise clearance of solutes,
replacement rate must be increased in order to increase the rate of
ultrafiltration.

Post-dilution therefore involves administering replacement fluid after the
filter. This does not dilute solutes in plasma, however the ability for optimal
clearance is lost when blood viscosity is not reduced and high flow rates are
then difficult to achieve. With reduced blood flow comes reduced
ultrafiltration. Utilising filters with larger surface areas in conjunction with
this method may improve clearance.

Q6. List the complications of CRRT.

Hypotension that may result from aggressive fluid removal
Electrolyte imbalances
Cardiac Arrhythmias
Anaemia secondary to haemolysis of red blood cells
Thrombocytopaenia secondary to platelet aggregation in filter
Hypothermia secondary to extracorporeal blood circulation
Coagulopathy secondary to over heparinisation
Infection
Heparin induced thrombocytopaenia

Self Test 6

Q1. What factors need to be manipulated in order to optimise
clearance?

Regardless of which CRRT machine is being used, optimising clearance is
dependant on two factors. These include improving diffusion and
convection/ultrafiltration.

Q2. Describe methods of optimising clearance.

Using filters with larger surface areas and appropriate dialysate fluid can
optimise diffusive clearance. Improving clearance via
convection/ultrafiltration is largely accomplished through high flow rates
(Dialysate, Replacement, Ultrafiltration & Blood Pump). Pre dilution assists
in achieving higher flow rates by reducing the viscosity of blood and
hematocrit. Location and care of the vascath is also shown to influence flow
considerably.






Q3. List four factors that can prolong filter life.

High blood flow rates
Pre dilution and warming of fluid
Adequate Access
Anticoagulation

Q4. When would anticoagulation NOT be used?

Anticoagulation is not used if the patient is coagulopathic. A heparin bolus
is not given if the patient has had CRRT within the last 4 hours.

Q5. What are the indications for terminating therapy?

When indications for CRRT are no longer present
When return pressures are elevated associated with filter clotting
When alarms are indicating poor clearance
For procedures in theatre or CT

Self Test 7


Q1. List the common triggers for alarms on the CRRT machines.

Vascath obstruction due to position of patient
Access or return lines kinking or clotting
Bag placement on scales is incorrect
Clotting of the filter/circuit
Poorly placed blood leak detector
Air in the circuit
Periodic self test failure


Q2. How would you reposition the diaphragms on both positive and
negative pressure pods when required?

If the pump has not stopped with an alarm, it should first be stopped. Apply
clamps above and below the affected pod. Remove the pod and clean the
port. If the pod is negative (Access & Effluent), inject a maximum of 1cc
normal saline using a 20g needle into the pod. Conversely, if the pod is
positive then a maximum of 1cc should be aspirated from the pod. Following
this step the pod can be reinstalled into the appropriate port and therapy
resumed.


Q3. What nursing care is necessary for the patient undergoing CRRT?

Continuous monitoring of haemodynamic parameters
Pressure area care and hygiene needs
Optimise blood pressure prior to commencing therapy

Colloid and Metaraminol precautions when running patient on
When anticoagulation is running an initial APTT should be checked 4
hours after commencing therapy. 6 hourly APTT is attended thereafter
and heparin infusion titrated according to protocol
Electrolytes, urea and creatine (EUC) and calcium, magnesium and
phosphate (CMP) should be checked 2 hours after commencing
therapy. 6 hourly EUC/CMP thereafter. Where electrolytes need
replacing, do so in accordance with ICU electrolyte protocols.
Strict monitoring of fluid balance to prevent excessive fluid losses
when removing fluid- this should monitored hourly and documented
on CRRT observation chart to prevent incorrect fluid removal
secondary to scale malfunction.
Attend CRRT observation chart monitoring pressures in particular
that may warn of filter clotting or access problems
Monitor Vascath site for signs of infection. Clean and dress as
required as earlier described.
Monitor patients temperature and actively warm using a bear hugger
blanket if necessary
Maintain standard precautions and aseptic technique when priming,
connecting, disconnecting the circuit. This also applies when
changing fluids or disposing of ultrafiltrate
As with all intensive care patients the MFASTHUG pneumonic should
be followed- i.e. Mouth care, Feeding, Analgaesia, Sedation,
Thromboembolism prophylaxis, Elevated bed head, Stress ulcer
prophylaxis and Glucose control + Gut- aperients etc


References

1. Agraharkar, M., Gupta, R., Agraharkar, A., & Workeneh, B.T. (2006).
Acute renal failure, [Online]. Available:
http://www.emedicine.com/med/topic1595.htm [2006,
September 13].


2. Astle, S. (2001). A new direction for dialysis. RN. 64(7), 56-60, 62


3. Baldwin, I., Bridge, N., Elderkin, T. (1998). Nursing issues, practices
and perspectives for the management of continuous renal
replacement therapy in the intensive care unit. In Bonett, J.,
Hattley, S., & Bastick, M. Continuous renal replacement
information package. A quick guide to CRRT. (pp1-41) Gosford:
NSCCH.


4. Bellomo, R., Baldwin, I., Ronco, C. (2001). Atlas of haemofiltration. In
Bonett, J., Hattley, S., & Bastick, M. Continuous renal replacement
information package. A quick guide to CRRT. (pp1-41) Gosford:
NSCCH.


5. Bonett, J., Hattley, S., & Bastick, M. (2005). Continuous renal
replacement information package. A quick guide to CRRT. (pp1-
41) Gosford: NSCCH.


6. Brunet, S., Leblanc, M., Geadah, M., Parent, D., Courteau, S., &
Cardinal, J. (1999). Diffusive and convective solute clearances
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7. Cannon, J.D. (2004). Recognizing chronic renal failurethe sooner
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8. Campbell, D. (2003). How acute renal failure puts the brakes on
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9. Castro, P., & Shunker, S. (No date). Continuous renal replacement
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10. Crawley, T. Shunker, S. & Edgtton-Winn, M. (2004). Heparin sodium.
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11. Glann, J.K. (2002). Renal disorders and therapeutic management. In
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care nursing- diagnosis and management. (pp745-777). St
louis: Mosby.


12. Henke, K. (2003). Renal physiology. Dimensions of Critical Care
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13. Hospal. (2000). Prisma system operators manual, Gambro Dasco


14. Hospal. (No date) Renal intensive care- PRISMA. Filter instruction
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15. Hospal (No date). AN69ST membrane- the bioactive membrane
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16. Kaplan, A.A. (2003). Renal failure. In F.S. Bongard, & D.Y. Sue.
Current critical care diagnosis & treatment (2
nd
Ed.). [Online].
Available:
http://online.statref.com/TOC/TOC.aspx?FxId=5&SessionId=7
A4937EMGZBYBIEJ


17. Kaplow, R., & Barry, R. (2002). Continuous renal replacement
therapies: a more gentle blood filtering technique allows for
fewer complications. American Journal of Nursing. 102(11), 26-
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18. Lameire, N., Van Biesen, W., & Vanholder, R. (2005). Acute renal
failure. The Lancet. 365(9457), 417.


19. Medtel. (No date). Kimal- Continuous renal replacement therapy
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renal replacement information package. A quick guide to CRRT.
(pp1-41) Gosford: NSCCH.


20. Paton, M. (2003). Continuous renal replacement therapy: slow but
steady. Nursing 2003. 33(6), 48-50


21. Sommer, N., Edgtton-Winn, M., & Shunker, S. (2004). Continuous
renal replacement therapy (CRRT) using the prisma machine.
ICU protocol. Liverpool: LHS



22. Toltec International. (2006). How haemodialysis works. [online]
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23. Ward, K. (2005). Kidneys dont fail me now. Nursing Made Incredibly
Easy. 3(2), 18-26


24. Zabat, E. (2003), When your patient needs peritoneal dialysis. Nursing 2003,
33(8), 52-54.









































Appendix