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Troubleshooting Issues in CVVH
Timothy L. Kudelka RN, BSN
Pediatric Dialysis Program
C.S. Mott Children’s Hospital
University of Michigan
Where to Begin?
• As Nephrologist, Intensivist and Nurses we all need to address the issues of troubleshooting CRRT.
• Many systems are still adapted (pieced) and others now self-contained with simplified operating interface and build-in software.
• Troubleshooting issues still remain.
Access
• If you don’t have it you might as well go home.
• This is the most important aspect of CVVH therapy.
• Adequacy.• Filter life.• Increased blood loss.• Staff satisfaction.
Troubleshooting Access
• How can you tell if you have a problem before starting?
• Check placement first, then use syringe to test resistance and blood return.
• What if you have problems during treatment?
• Check line for kink, then assess patients position or need for sedation.
Access• Clotting or sluggish catheter.
• tPA (tissue plasminogen activator). (Spry et al., Dialysis&Transplantation. Jan. 2001).
• Normal saline flush.
• Reason to replace catheter.• Clotted catheter with no response to tPA.• Exit site blood leakage with no response to pressure
dressing.• Severe kinked catheter.• Bad re-circulation issues.
Pressures• Arterial or outflow pressures
• High negative pressure = access problem.• High positive pressure = filter problem.• Moderate to high positive pressure + high return (venous)
pressure = access problem.
• Venous or return pressures• Moderate to high positive pressure + high arterial pressure =
filter problem.• High return pressure + moderate arterial pressure = access
Anticoagulation
• None.
• Heparin.• Bolus 10-20 units/kg then infuse at 10-20 units/kg/hr
adjust per ACT.(Heparin induced thrombocytopenia).
• Citrate.• Initiate infusion rate at 1.5x the BFR(in mls/hr).• Calcium chloride infusion at 0.16x the citrate rate. (Hypocalcemia,metabolic alkalosis.
Suggestion
• Normal saline flush.
• Flashlight lines and filter.
• Correct priming technique.
• Maintain good BFR.
• Monitor ACT levels (200-250).
• Quick response to troubleshooting issues.
Ultrafiltration
• How much to ultrafiltrate?
• Net ultrafiltration should be in the range of 1-2 mls/kg/hr.
• Neonates u/f rate 0.5-1ml/kg/hr.
U/F Issues• Attention to intravascular volume.
• Oncotic pressures.
• U/F controllers.– Infusion pumps up to 30% inaccurate. (Smoyer et al, CRRT1998)
• Filter size and life.
U/F Issues
• Accurate assessment is difficult with less room for error in smaller children.– Bed scales.– Frequent weights or weights of U/F in IV
controller U/F method.– Measured volume status.– Monitor sHct.– Vasopressor clearance.
Membrane Reactions
• Bradykinin release syndrome
• Causes of syndrome• ACE inhibitors • Low blood ph
• AN-69 membranes have been associated with “Bradykinin release syndrome” (Brophy et al. AJKD 2001)
Membrane Reactions
• What is the common link?– AN-69 membrane.– Blood prime.– Low ph. (Blood bank blood ph).
• Technique to reduce membrane reaction.
Membrane Reactions
• Correct blood from the blood bank.
• Bypassing the membrane.
• Bypass maneuver.
Bypass Maneuver
To view this dialysis clip, go to the Resources References and Procedures folder, then the UNHS Procedures folder on the CD-Rom.
Thermal Issues
• Patient.– Radiant heat methods.
• Warming blankets.• Overhead warmer.• Warm water bottles.
– Prevention of heat loss.• Environmental conditions.• Exposure. (Hats on infants, plastic wrap).
Thermal Issues
• Circuit– Blood
• Blood warmers Extracorporeal volume Risk of clotting
– Dialysate or replacement fluid• Prismatherm®
• High volume fluid warmer.
Transport Issues
• Patient that require transport while on CVVH.– Battery pack.– Re-circulation.
• Blood prime/blood loss.• Machine issues.• Length of re-circulation. (1-2 hrs).
Prescription
• Need for daily orders.
• Recommendations on order sheet.
• Types of solutions.– PD are problematic r/t lactate and high glucose.– Pharmacy made solutions risk of error and expensive.
– Bicarbonate based solution-less risk, expense.
• Nursing orders/labs.
Nursing Report
• Standard forms for documentation.
• Review of orders.
• The key to good team work is accurate nursing reporting of problems and troubleshooting techniques.
Nursing Training
• Basic concepts of CRRT.• Knowledge of circuit function.• Documentation and review of protocols.• Troubleshooting issues and techniques.• Simulator – for non-stressful practice.• One-on-one hands on with experienced staff.• Continuous education.• Development and implementation of QA tool.
Forms
• Forms available on your CD-ROM
Thanks To:
Dr. Timothy E. Bunchman MD
Dr. Patrick D. Brophy MD
University of Michigan Pediatric Dialysis Team.
Pediatric Critical Care Nursing.
My Wife.