THE CLINICAL APPLICATION OF CRRT—CURRENT STATUS: Clinical Nursing for the Application of Continuous Renal Replacement Therapy in the Intensive Care Unit

Abstract

Treatment of critically ill patients with continuous renal replacement therapy (CRRT) requires a set of new skills and knowledge base for the intensive care unit (ICU) nurse. After a decision to treat is made, nurses effectively manage the technique by following a series of steps in sequence. These sequential steps include patient and machine circuit preparation, connection of the extracorporeal circuit (EC) to the patient's vascular access, and nursing management of a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine "vital signs," and, when necessary, diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential for a successful CRRT nursing policy or protocol. This chapter provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Premature Circuit Clotting due to Likely Mechanical Failure during Continuous Renal Replacement Therapy

“…The finding that MCF was not associated with hemoconcentration, a higher platelet count, amount of transfused RBC, platelet, fresh-frozen plasma, amount of infused heparin, and modality of CRRT lends further indirect validity to the notion that this phenomenon is indeed due to factors that are independent of changes in hematological variables and that our case selection was justified. Finally, some authors have proposed that a lower level of competency of nursing staff preparing and monitoring circuit function is associated with mechanical failure in CRRT [23][24][25][26] . This suggests the need to investigate nursing expertise at the time of MCF.…”

Sepsis and acute kidney injury: Patophysiological mechanisms and basic principles of treatment

“…CVVHDFwith PMMA membrane, which has the ability to adsorb the inflammatory mediators (high capacity for cytokine adsorption), is administered at a dose of 35 ml/kg/h, in the course of 24-72h and provides significantly hemodynamic stability and homeostasis of the host's systemic and local immune system responses to infection (prevents the development of "cytokine storm"). When the concentration of IL-6 decreases below 1000 pg/ml, treatment is continued by standard CVVHDF with ultrafiltration of 35 ml/kg/h [60][61][62]. The standard AN69ST membrane is highly permeable, and binds heparin during the filling the extracorporeal circulation system with heparinized saline solution (during the preparation of the apparatus for the CVVHDF-AN69ST treatment), has a high adsorption capacity for the inflammatory mediators (high adsorption capacity of HMGB1 proteins) and exhibits anti-thrombogenic effects (also referred to as an antithrombotic membrane, SepXiris).…”

“…The modified AN69ST membrane is a surfacetreated polyacrylonitrile (AN69) hemofilter with a polyethyleneimine (PEI) layer, allowing for incorporation of a heparin layer by priming the membrane in a heparin-saline solution before CVVHDF, thereby significantlyreducing local thrombogenesis when compared with the original AN69 membrane. Also, heparin-primed AN69ST membranes are reportedly more biocompatible with advantages in terms of inflammatory cytokine adsorption.In patients with high risk of haemorrhage, venous anticoagulation is not required, and in patients with normal coagulation status for anticoagulation of extracorporeal circulation, unfractionated heparin is used in a dose of 50% less than the full dose [60][61][62]. Unfractionated heparin is used for anticoagulation of the extracorporeal circulation as a bolus of 2,000-5,000 IU (30 IU/kg) in the arterial segment of extracorporeal circulation after the blood-pump, and then continues with 5-10 IU/kg/h (target aPTT = 45-55s, 1.5-2 times in relation to the upper normal limit in the blood sample before the filter).In patients with increased risk of haemorrhage (platelet count less than 60 x 109/l, aPTT> 60s, INR> 2), the following options are applied: dialysis without heparin, predilution method of HDF, standard or modified AN69ST dialysis membrane, increased blood flow rate or regional citrate anticoagulation 60-62.…”

Nursing essential principles: continuous renal replacement therapy

“…The CVC should be well secured to the patient to prevent accidental removal. This can be achieved by using a suture and a dressing (Baldwin and Fealy, 2009).…”