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ICU ESSENTIALS > CRRT - Prismaflex > Flashcards

CRRT - Prismaflex Flashcards

1
Q

List indications for CRRT

A

(FWWNDOH)

  1. Fluid overload
  2. Worsening Acedemia (metabolic acidosis)
  3. Worsening Azotemia (urea >30mmol/L)
  4. Nod obstructive oliguria, anuria
  5. Organ uraemic involvement (↑ body waste product due to multi organ condition E.g - encephalopathy,neuropathy,myopathy)
  6. Drug overdose
  7. Hyperkalemia or rapidly increasing K+
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2
Q

What is the 3 principles of CRRT

A
  1. Diffusion - movement of S & M size solutes from area of high concetration to lower concentration across a semi permeable membrane (SPM).
  2. Ultra filtration (UF)- movement of water and solutes across a SPM through solvent drag (from +ve to -ve pressure area) resulted from convection and hydrostatic pressure (HP)
  3. Convection - movement of solute across SMP by HP which facilitates water flow that drags solutes along with it.
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3
Q

List common sites for VasCath

A
  1. IJ - pref R) side due to direct line to Superior Vena Cava (SVC)
  2. Subclavian - nurses preferred, easy access & cleaning, allows mobility, CXR to confirm position, may cause pneumothorax.
  3. Femoral - Prone to kinking, doesn’t allow mobility, easier insertion.

May confirm with CXR, Transducer, or ABG

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4
Q

List the 4 modes of CRRT

A
  1. SCUF - Slow Continous UF
  2. CVVH - Cont Veno-Venous Haemofiltration
  3. CVVHD - Cont Veno-Venous HaemoDialysis
  4. CVVHDF - Cont Veno-Venous HaemoDiaFiltration
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5
Q

define SCUF

A

Slow Cont UF - uses principle of UF, used when only goal is fluid removal.

Acces ————( [Filter]-Effluent )———— Return

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6
Q

Define CVVH

A

Cont Veno-Venous Haemofiltration uses convection & UF to clear water and solutes. Use to remove S, M + L solutes

Acces ——[+PBP]——( [Filter]-Effluent)——[+Post]—— Return

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7
Q

Define CVVHD

A

Continous Veno-venous Haemodialysis uses principle of Diffusion and UF. Uses dialysate fluid to facilitate diffusion gradient and remove S M sized molecules

Acces ————(-Dialysate-[Filter]-Effluent)———— Return

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8
Q

define CVVHDF

A

Continous Veno-Venous HaemoDiaFiltration uses all 3 principles of CRRT. Use to remove S, M & L molecules

Acces —[+PBP]-(+Dialysate [Filter]-Effluent)-[+Post]— Return

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9
Q

Define dialysate fluid

A

Its a synthetic solution which facilitates diffusion gradient that run through counter flow of blood

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10
Q

Define replacement fluids

A

Pre dilution replacement fluids enhances convection and UF, post dilution enhances diffusion. Replaces fluid lost as ultrafiltrate/effluent.

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11
Q

Define blood flow rate (BFR)

A

flow rate of blood accessed from patient, starts at 50-100mls/hr to 180-200mls/hr to prevent clottingy

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12
Q

Define effluent fluid

A

Waste product (solutes) and fluids (solvent) discarded from pt

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13
Q

What is the standard effluent dose?

A
  • 25mls/kg/hr
  • (50% dialysate, 200mls Post Replacement Fluid, PBP rest)
  • E.G 100kgs.
  • 25x100 = 2500mls/hr Effluent dose
  • 2500mls = 1250 dialysate, 200mls PRF, 1050 PBP
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14
Q

What are the available CRRT fluids in ICU?

A

In **mmol/L
1.) Haemosol B0 = Na+ 140/ Ca ²+ 1.75,/ Mg ²+ 0.5/ Cl 109
HCO ³ 32/ Lac 3
2.) Prism0Citrate 18/0 = Citrate 18/ Na+ 140/ Cl 86,/ Nil K+,Cal,Mg

3.) Prism0Cal B22 = HCO ³ 22/ Lac 3/ Na+ 140/ Cl 120/ K+ 4/ Mg 0.5
Glu 6.1
4.) NaCl 0.9% 1L = Replacement Fluid.

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15
Q

Why do we have to add KCL? How much do we add?

A
    • DO NOT ADD IF K+ >5.0 as per ICU Protocol**
  • to maintain homeostasis K+ target range = 3.5-5.0 mmol/L
  • in Haemosol B0 = add (20mmol/L in 5L bag) total concetration of 4mmol/L in all the bags of fluid.
  • in Citrate, Add 20mmols in PBP fluid bag (Prism0Citrate 18/0 - 5L) total concentration of 4mmol/L. Dialysate solution has preadded 20mmols/5L Hence theres no need to add more K+
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16
Q

Demonstrate how to calculate flow rates & setting using non-citrate CRRT.

A
  • 25mls/kg/hr
  • (50% dialysate, 200mls Post Replacement Fluid, PBP rest)
  • E.G 100kgs.
  • 25x100 = 2500mls/hr Effluent dose
  • 2500mls = 1250 dialysate, 200mls PRF, 1050 PBP
  • Heparin infusion concentration (15000u in 50mls NaCl) run through coagulation port. Commence at 5-10u/kg/hr
  • E.G 70kg * 10u = 700u/hr = approx. 2.3mls/hr w/ above concentration
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17
Q

Demonstrate how to calculate flow rates and settings using Citrate anticoagulation CRRT

A

**Citrate dose = Q Cit (PBP flow rate in ml/min) x C cit (18mmol/L) ÷ BFR (default 150mls/hr)

E.G. = BFR 150

1500 ÷ 60 x 18 / 150 = 3 mmol/hr

**Citrate flow rate (Qc) (mls/min) = Dose of Citrate (3mmol/L) x BFR (150mls/hr) ÷ Citrate Concetration (18mmols/L)

3x 150 ÷ 18 = 25mls/min x 60 (1hr) = 1500

18
Q

Describe the purpose of anticoagulation in CRRT

A
  • anticoagulation in CRRT = improve CRRT efficiency
    (CRRT stimulates coagulation cascade when blood is in contact with artificial filters and tubing)
  • most commonly used anticoagulation in ICU
  • Heparin w/ Haemosol B0 - inhibits factor IX,X,Thrombin= inc clotting time
  • Citrate w/ Prism0Citrate 18/0 - binds with Ionised Cal = inhibit clotting cascade.
19
Q

Differentiate regional and systemic anticoagulation in CRRT.

A
  • Regional = Circuit Anticoagulation = less interruption of therapy
  • Systemic = Pt Systemic Coagulation
20
Q

Indications for CRRT

A 
Pt at risk of bleeding (SHHIC) 
• recent Surgery or trauma
• Haemorrhagic disorder i.e Leukemia, dec PLT
• HITS
• Intracranial Lesions
• uncontrolled Coagulopathy
21
Q

Explain how Citrate functions as regional coagulant in CRRT

A
  • Blood accessed from pt mixed w/ Citrate during Pre dilution (PBP) which then prevents clotting in the circuit (regional)(by binding to calcium-impedes clotting cascade)of CRRT machine.
22
Q

Describe fluids that are required during citrate anticoagulation

A

(OBS)

  • Prism0Citrate 18/0 - PBP (Orange)
  • Prism0Cal B22 - Dialysate (Black)
  • NaCl 0.9% - Post dilution replacement fluid (Saline)
23
Q

Explain how CRRT machine controls citrate anticoagulation

A

Machine calculates the Citrate dose in accordance to BFR & PBP flow rate.

24
Q

Explain the importance of frequent monitoring of blood electrolytes and acid base balance in pt requiring citrate anticoagulation CRRT

A
  • CRRT may cause acid base and electrolyte imbalance due to clearance of small and mid molecules
25
Q

Explain Citrate toxicity and how to monitor it.

A

Citrate toxicity occurs when liver can not metabolise citrate which manifest as decreased in Ionised Cal
**Monitor for Citrate Triad
• metabolic acidosis
• increased in anion gap
• high total to ionised calcium ratio (>2.5)

  • hypercalcaemia
  • increasing cal replacement requirement

Q4H - Q6H EUC + ABG to check ionised cal

26
Q

Explain why Calcium replacement is necessary and how to administer and monitor it.

A
  • Cal is metabolised when binded by Citrate therefore need to be replaced
  • Commence at 100% replacement then perform ABG 1 hour post commencement Q4H afterwards.
27
Q

Why is Ionised Cal being measured in Citrate CRRT?

A

• monitoring via ABG, decreasing iCal level can be an indication of Citrate toxicity and also to avoid Hypercalcaemia.

28
Q

Describe how Heparin function as anticuagulation agent in CRRT

A

Heparin binds and activate circulating antithrombin III → inhibits thrombin, factor IX & X → results in ↑ clotting time.

  • most commonly used
  • inexpensive & widely available, easy to monitor & reversed (protamine)
  • optimal regime available
  • must be administered by cautious balance b/w therapeutic benefits of preventing clot of the CRRT circuit & risk of systemic bleeding
29
Q

State the types of fluids used w/ non-citrate anticoagulation Tx.

A

CRRT circuit primed using 1L 0.9% NaCl w/ 5000u of Heparin.
- additional Heparin infusion through Anticoagulation port to maintain APTT (30-40secs-sample collected from pt Artline)

Haemosol B0 - PBP,Dialysate & Post Replacement Fluid

30
Q

Describe method of monitoring and adjusting heparin Tx in pt requiring heparin CRRT

A

Dose commence at 5-10u/kg/hr approx 3.3mls/hr (15k U/50mls)

Maintain APTT 30-40secs-blood sample collected from pt Artline

Recheck in 4-6 hours post commencement

31
Q

Describe how to safety connect CRRT machine to a patient.

A
  1. Use asceptic technique + sterile gloves when connecting lines to pt.
    - Aspirate and discard 5mls ea line to remove heparin from line
    - Further aspirate 10mls ea line, flush 10mls NaCl 0.9%- check ease of blood flow
    - Connect RED port - ACCESS, BLUE port - RETURN, Cal syringe - CVC
    - Follow PRISMAFLEX instruction - Ensure to unclamp circuit lines then press START.
    - Check iCa 1 hour post commencement
32
Q

Describe safely returning blood in case of cessation of CRRT or temporary stopping of Tx (OT, changing circuit, no longer needed)

A
  • use asceptic technique w/ sterile gloves
  • press STOP → Auto Return or Saline Recirc → d/c red access fr Vascath → connect to a 3 way tap which is spike to 1L NaCl 0.9%
  • flush return line 10mls NaCl 0.9%
  • Heparin lock the Vascath (5k U/ml - inject as per lumen indication), label the Vascath ‘Heparin locked’
33
Q

Explain the possible causes for the following alarms

  • Access Pressure (normally -ve)
  • Return Pressure (normally +ve)
  • Filter Pressure
A

• Access pressure extreme -ve pressure alarm

  • Line clamped, kinked, obstructed
  • VasCath obstructed
  • pt movement, coughing or being suctioned
  • BFR too high

• Access extremely +ve

  • Red clamp is closed
  • obstructed/kinked VasCath or Access Line
  • Pt coughing, moving, positioning.
  • BFR too low

• Return Pressure

  • Blue clamp is closed
  • Obstructed/kinked VasCath or Access Line ? Clot
  • Pt coughing, moving, positioning.
  • BFR too high
  • High Airway Pressure
  • Filter clotting/clotted

• Filter Pressure
- Filter clotting/clotted

34
Q

Explain strategies to improve filter life.

A
  • Ongoing TMP monitoring
  • Regular Check of APTT
  • Increase BFR, PBP rate
35
Q

Explain Strategy to improve clearance

A
  • Increase BFR - utilises UF
  • Increase PBP - Utilises Convection
  • Increase Effluent Dose.
36
Q

Describe the possible complications of associated with CRRT

A

HHATCHI
• Hypothermia
• Hypomagnesaemia, HypoKalaemia, Hypophosphataemia
• Anemia
• Thrombocytopaenia
• Coagulopathy - Bleeding (overheparinisation) regular check of APTT
• HITS - Heparin induced thrombocytopaenia
• Infection

37
Q

Discuss Nx Strategy in managing pt requiring CRRT

A
  • Hourly Obs (Haemodynamics, RR, SpO2)
  • CRRT hourly monitoring, OBS (BFR, Fluid removal, & Line Pressures)
  • Monitoring APTT / iCa as per protocol + regular EUC CMP.
  • Monitoring for any signs of Citrate Toxicity. (Triad Cit Tox)
  • Appropriate documentation
  • Monitor for complications (HHATCHI)

have metaraminol + NaCl 0.9% pump set ready when starting CRRT

38
Q

What are the signs of the Triad of Citrate Toxicity?

A 
• Metabolic Acidosis w/ high Anion Gap
• Increasing totCal/iCal ration (>2.5:1) 
• Cal Gap phenomenon 
 - ↓ iCal 
 - ↑ Calcium replacement requirement
 - HyperCal
 -
39
Q

Discuss the importance of regular monitoring of blood electrolytes and acid-base balance

A
  • Regular check of EUC/CMP can minimise risk of arrhythmia

* Also help early identify Citrate toxicity

40
Q

Why do we need to have pt temperature monitored?

A

CRRT can induced hypothermia due to blood being exposed to extracorporeal circuit outside the body.
- use active warming and/or warming blanket when required is suggested.

ICU ESSENTIALS (1 decks)

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