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Nursing ConsiderationsCJ 2019

ConsiderationsSAFETY CHECKSAnticoagulationPRESCRIPTIONFluid managementAccessObservationsInfection controlNutritionMonitoringAir EmbolusTemperature Control

Safety ChecksCheck settings & prescriptionCorrect PPE including face visorEquipment to recirculate available (1L fluid bag & spike & 3way tap OR spike with y-connector)

PrescriptionEach filter circuit should beprescribed on fresh CRRTPrescription & Monitoring formGreen DocsBlue Nurse

AccessVenousVenousBlood is withdrawn fromthe proximal lumen (arterialside) and returned throughthe distal lumen (venousside)

Pre-treatment checklist - Vascath 3 sizes of Vascath: 15cm – Right I.J./subclavian 20cm – Left I.J./subclavian 24cm - FemoralCheck that you are using the right line for the rightsite!!‘Trialsysis Lines’ available if you need an extra lumenfor access

Assess Flow AdequacyYou must be able to easily withdraw AND inject 20mls of blood in lessthe 3 secsIf unable to do so – refer to docs & NIC.Don’t start the filter before taking adviceDocument on audit form

Unused VasCath?Should be heplocked with 5000iu of heparin with volumestated on the side of the VasCathLabel, Label, Label – no-one wants to give heparin ratherthan adrenaline in an emergency!!DocumentCoag concerns? Discuss with senior medical team

SWAPPING LUMENS CAN LEAD TO RECIRCULATION& REDUCED CLEARANCE

InfectionPatients with AKI have an increased susceptibilityto infectionInfection is cited as the principle cause of death inCKD patients requiring haemodialysisCVC’s have been identified as the principle cause ofinfection.

Hooking up or off CRRT ?Surgical-ANTTMain Critical Aseptic FieldSterile Gloves

PPE

Line CareChloraPrep for skin cleansingAsceptic Non Touch TechniqueTransparent film dressings able to visualise and monitor site for inflammation /bleeding.7 days if dry & intact or as needed

MonitoringCardiac Monitoring, BP, SpO2, RR continuoustemperature monitoringFluid Balance Add up hourly Find out fluid balance aim on ward roundBloods Clotting (Anti-coag) Biochemistry – electrolytes Filter Observation Chart

TemperatureLower body temperature by as much as 4C due to heat lossvia extracorporeal circuit – 110 -200ml blood outside thebody at any time.Hypothermia: disruption of enzyme function - clotting,dysrhythmiasNeed continuous temperature monitoringReplacement fluids warmed via filter – never ever switch offthe heater!Use warming blanket if insufficient response

Fluid ManagementMost patients undergoing CRRT are oliguric, anuric or volumeoverloaded.Fluid management typically involves calculation of patients intake (infusions, feed etc) fluid loss via filter. (Also – insensible losses – e.g.loss of circuit, sweating, GI losses.)Fluid loss and Fluid balance aims should be stated explicitly onprescription form and monitored hourly on ICU chart & Obs form.

Replacement Fluid Use potassium free bags if K 5.5 Need to check & sign

ObservationsWorkshop later !

AnticoagulationAIM: To prevent clotting of extracorporeal circuit withoutharming the patientWHY? Clotting processes begin as soon as the blood hits thecircuit.HOW? Prime filter circuit with saline containing heparin if patient has normalclotting profile. Heparin infusion administered via filter. Follow the protocols on prescription chart Clotting deranged? – Check with Docs

DecisionTree

PEDVTHeparinCIRCUIT

Argatroban

Nutrition

Air EmbolusCan occur if a patient receives air in the blood returnedIn built air detectors – even microbubblesIf the systems safety mechanisms are bypassed a patientcan recieve an air embolusAir can also occur if the access cannot provide the bloodflow programmed: the blood pump will run but a vacuum is created causing air to movethrough the circuitContinually assess the circuit tubing for the presence of air

SummarySafety checks at the start of the shiftUse the prescription chart – it’s really useful!If you’re not sure – ask!!

Questions?

Fluid Management Most patients undergoing CRRT are oliguric, anuric or volume overloaded. Fluid management typically involves calculation of patients intake ( infusions, feed etc) fluid loss via filter. (Also - insensible losses - e.g. loss of circuit, sweating, GI losses.) Fluid loss and Fluid balance aims should be stated explicitly on