Continuous Renal Replacement Therapy (CRRT)

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Continuous Renal Replacement Therapy (CRRT)
Continuous Renal
Replacement Therapy
(CRRT)
Annette Fernandez, Zack Hedrick, Kristin Toliver, Jasmine Wells
NURS 451: Clinical Management of Adult Health Nursing III
Sentara Princess Anne Hospital
Learner Goals and Objectives
• Identify what diseases can lead to the implementation of
CRRT
• Discuss dialysis and CRRT, and identify the difference
between dialysis and CRRT
• Identify medications used for patients on CRRT and lab
values to monitor
• Identify complications of CRRT and precautions to take
while monitoring patients on CRRT
Case Study
• B.V. is a 29 year old male who is a native of Guatemala,
only Spanish speaking, and no family in the area except for a
cousin, and has a history of Alcohol abuse
• Presented to the ED with abdominal pain and distension,
vomiting, diarrhea, HR 101, increased work of breathing,
crackles, and diminished breath sounds
• EKG shows peaked T waves; Chest x-ray reveals pleural
effusion; Amylase and Lipase are elevated.
• BV went into respiratory failure, was intubated and
mechanically ventilated, then admitted to the ICU for
further monitoring.
B.V. has Acute Pancreatitis
• His symptoms are clinical manifestations of pancreatitis.
• BV was also found to be in acute renal failure.
• Diagnostic tests for pancreatitis, amylase and lipase, were
elevated.
• CT of the abdomen showed an acutely inflamed pancreas
• Pancreatic enzymes induce inflammation of his diaphragm.
• Movement of the diaphragm decreases and fluid shifts.
Acute Renal Failure (ARF)
• Associated with mortality of 15-60%
• Co-existing non-kidney conditions
• Prerenal
• Any condition that decreases blood flow, blood pressure or kidney
perfusion i.e., abdominal compartment syndrome
• Intrarenal
• Any condition that produces an ischemic or toxic insult directly at
parenchymal nephron tissue i.e., pancreatitis & use of contrast dye
• Postrenal
• Any obstruction that hinders the flow of urine from beyond the
kidney through the remainder of the urinary tract i.e., kidney stones
Pancreatitis Related to ARF
• Two most common causes: gallstone migration and alcoholism
• Normally inactive enzymes prematurely activated  autodigestion of
pancreatic tissue
• Obstruction of or damage to pancreatic duct system, alterations in
secretory process, infection, ischemia
• Release of enzymes  increased capillary membrane permeability 
leakage of fluid into interstitium  edema & relative hypovolemia
• Elastase  dissolves elastic fibers of blood vessels and ducts 
hemorrhage
• Other enzymes  destruction of phospholipids of cell membranes 
pancreatic and adipose tissue necrosis
Patients with ARF r/t
Pancreatitis
• Mortality rate of patients with ARF 58% - 74.7%
• Examine risk factors of ARF, prognosis, and seek
preventative measures
• Hypoxemia is a significant risk factor
• Amylase released from pancreas may impair renal
microcirculation – ischemia
• Abdominal compartment syndrome – significant risk factor
of ARF: ascites & bowel ileus
• Increased abdominal pressure reduces blood supply to other
organs – poor kidney perfusion
Indications for CRRT
• Need for large fluid removal in hemodynamically unstable
patient
• Hypervolemic or edematous patients unresponsive to
diuretic therapy
• Patients with MODS
• Ease of fluid management
• Patients that cannot tolerate hemodialysis or peritoneal
dialysis
• Inability to be anticoagulated
CRRT
•
CRRT is a newer mode of dialysis
•
Continuous Renal Replacement Therapies (CRRT) are dialysis treatments
that are provided as a continuous 24 hour per day therapy. (Sarkar, 2009)
•
Monitored by a CC nurse and may last many days
•
Venous blood is circulated through a highly porous hemofilter
•
CRRT allows for continuous removal of fluid from the plasma
•
Critically ill patients are hypotensive and cannot provide adequate flow
through the hemofilter, an electric roller pump milks the tubing to augment
flow
•
So CRRT is a mode of renal replacement therapy for hemodynamically
unstable, fluid overloaded, catabolic septic patients and finds its application
in management of acute renal failure especially in the critical care /intensive
care unit setting.
Dialysis vs CRRT
•
Hemodialysis is 3-4 times per week whereas CRRT is continuous
•
Both hemo and CRRT – access and return of blood are achieved through a
large venous catheter, and use a semipermeable membrane
•
CRRT uses an electric pump to milk the tubing and augment flow as MAP
may not be sufficient to pump blood through filter
•
CRRT may be better tolerated than HD by critically ill patients because this
method avoids rapid shifts of fluids and electrolytes
•
Procedures for CRRT are similar to HD but are temporary
•
The major difference between intermittent and continuous therapies is the
speed at which water and wastes are removed.
•
Intermittent hemodialysis removes large amounts of water and wastes in a
short period of time, whereas, continuous renal replacement therapies
remove water and wastes at a slow and steady rate.
Pro’s and Con’s of CRRT
• Advantages
• CRRT by its lower rate of fluid removal can lead to steady state fluid
equilibrium in hemodynamically unstable, critically ill patients with
associated comorbid conditions
• It provides excellent control of azotemia, electrolytes and acid base
balance. These patients are catabolic thus, removal of urea is
mandatory to effectively control azotemia.
• CRRT can help in administration of parenteral nutrition and
obligatory I.V medications like pressors & inotropes by creating an
unlimited space by virtue of Continuous ultrafiltration.
• Disadvantages
• This mode of therapy requires regular monitoring of hemodynamic
status and fluid balance (ultrafiltration rate, replacement fluid); regular
infusion of dialysate; continuous anticoagulation; ongoing alarms and
an expensive mode of therapy above all.
How CRRT Works
Medications While on CRRT
• Maintain Hemodynamic Stability
•
•
•
•
Usually Hypotensive- give Vasopressors
Levophed, Neosynepherine, Vasopressin
Helps adequate flow/pressure through hemofilter.
Maintain a MAP > 70
• Electrolyte Replacement
• Correct any electrolyte imbalance.
• Calcium Chloride, magnesium sulfate, potassium chloride
• Fluid Replacement
• Large volumes of fluid being removed, called ultrafiltrate.
• Needs to be replaced to avoid intravascular dehydration.
Medications Cont.
• Anticoagulation
• Needed to maintain patency of pump, keep hemofilter from becoming
obstructed.
• Dose should be low, Systemic anticoagulation is not the goal.
• Heparin and Citrate
• Dialysate Formula
• Used to help filter wastes
• Prismasate: bicarbonate-based solution, helps control acid-base balance
• Contains electrolytes
• Insulin
• Dialysates have high levels of glucose
• Ketoacidosis
Lab Values to Monitor
•
Electrolyte Levels
• Potassium, magnesium, sodium, calcium, phosphorus
•
BUN and Creatinine levels
•
•
•
•
•
Decides if CRRT is needed
CRRT is prescribed when BUN is approximately 60 mg/dL.
CRRT is usually done before BUN reaches 90 and creatinine exceeds 9 mg/dL.
Fluid overload and severe electrolyte imbalance may require earlier intervention.
PTT and Platelet levels
• Abnormalities with these may indicate risk for bleeding.
•
Pancreatic enzyme levels
• Lipase, Amylase, higher production due to the pancreatitis
Complications of CRRT
• Decreased Ultrafiltration Rate
• Filter clotting
• Hypotension
• Fluid/Electrolyte imbalance
– Edema
• Bleeding
• Access dislodgement
– Infection
• Hypothermia
Nursing Interventions
• Decreased Ultrafiltration Rate
– Lower height of collection container, position pt on back, control
coagulation time
• Filter clotting
– Control/maintain anticoagulation (heparin/citrate), Call physician,
remove system, prime catheters with anticoagulation solution,
Prime new system, Start predilution with 1 L NS per hour
• Hypotension
– Control amount of ultrafiltration, control access site, clamp lines
Nursing Interventions Cont.
• F&E imbalance
– Observe for changes in CVP, vitals, and ECG, monitor output values q
hour, control ultrafiltration
• Bleeding
– Monitor calcium if using citrate, monitor PTT (heparin) values q hr
and adjust dose within parameters to maintain anticoagulation,
Observe dressing and filtrate for evidence of blood loss
• Dislodgement/Infection
– Strict sterile technique when dressing vascular access, observe access
site q 2 hr, and have clamps available and within reach at all times
Prevention of Complications
• The nurse should:
– Monitor fluid intake and output every hour (daily weights are
important)
– Detects potential complications (bleeding, hypotension,
hypothermia, and infection)
– Identify trends in electrolyte laboratory values (calcium,
potassium, sodium; also BUN and Creatinine)
– Make sure the operation of the CRRT equipment is safe
– Provide patient and family education about the use of CRRT
and condition
Conclusion
• Pancreatitis among other disease processes can lead to ARF
which may result in CRRT implementation
• CRRT is continuous but temporary for critically ill patients
that are hemodynamically unstable
• Hemodynamic stability and electrolyte replacement is the
main focus of medication administration and the
monitoring of lab values
• It is the nurses responsibility to monitor a CRRT patient for
potential complications, implement the appropriate actions,
and promote the patients safety during treatment
Objectives Reviewed
• Identified what diseases can lead to the implementation of
CRRT
• Discussed dialysis and CRRT, and identified the difference
between dialysis and CRRT
• Identified medications used for patients on CRRT and lab
values to monitor
• Identified complications of CRRT and precautions to take
while monitoring patients on CRRT
References
Baxter. (2013). Continuous renal replacement therapy (crrt).
Retrieved from http://www.baxter.com/healthcare _
professionals/therapies/renal/acute_kidney_treatment/
continuous_renal_replacement_therapy.html
Chaturvedi, M. (2004). Continuous renal replacement therapy
(crrt). Retrieved from http://lane.stanford.edu/portals/cvicu/
HCP_GU_Tab_3/Intro_to_CRRT.pdf
Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of nursing. (6th
ed.). Philadelphia, PA: Lippincott Williams, & Wilkins.
Urden, L. D., Stacey, K. M., & Lough, M. E. (2010). Critical care
nursing diagnosis and management. (6th ed.). St Louis MO:
Mosby Elsevier.
References Cont.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical
nursing: Patient centered collaborative care. (7th ed.). St
Louis MO: Elsevier Inc.
Sarkar, S. (2009). Continuous renal replacement therapy (CRRT).
Internet Journal Of Anesthesiology, 21(1)
Tillman, J. (2009). Heparin versus citrate for anticoagulation in
critically ill patients treated with continuous renal
replacement therapy. Nursing In Critical Care, 14(4), 191199. doi:10.1111/j.1478-5153.2009.00339.x

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