CVVHD, we need it

  1. Our hospital has a new (2 yrs old) CT surgery program, our sister hospital appx 15 miles away has a more tenured program using the same Surgons and perfusionists.

    On occasion we need to send our sick patients for cvvhd. This happens about 2 times per year. Is it worth it to provide the service in our faciliy.

    I bring this up today because of a recent case.

    55yo F, 3v cabg 2 mos ago, Presenting w/ flu like symptoms/cp/triponin up. Stat cath revealed 100% rca occlusion, patent 2 mos ago, vsd. IABP inserted, stat vsd repair with 1 om redo.

    Pt was on pump 4.5 hrs, index 1.2, on various gtts, 3 days postop renal failure, fluid overload required dialyses,

    Before transfer.
    Paced 110, 90/50, vented ac18, lungs ok, gasses ok, epi .3 mcg/kg /min, dobutrex 10mcg/kg/min. index 2.0

    Upon transfer, epi was suspended for short time, pacer was pacing on qrs, p 60-70 systolic.
    This was in my opinion due to the difference of equipment the mobile unit has.

    Upon admission to the recieving hospital, index was 1.2 with various gtts.


    Based on this single event I feel we should provide cvvhd to our patients, I would hate to see this or any other patient die because of the transfer.

    Please give any advice of which device is best

    Thanks, Chris
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  2. 6 Comments

  3. by   begalli
    I'm surprised the place doesn't have it. My goodness, to be the receiving hospital of a patient already that sick. Does the receiving hospital use the same docs as yours? I know our docs would put up a BIG HUGE stink about taking a patient like this when they were'nt the ones who did the surgery and managed the care to begin with. It would never happen. It's almost like passing the buck.

    I may be niave, but I say it's to the patient's advantage to have CVVH available if they're doing cardiac surgeries.
  4. by   oakmax
    Yep, same docs, we've only needed a couple of pts transfered. As the volume of more compromised patients rises I see the need for cvvhd rising.

    Cw
  5. by   lee1
    If you are NOT expert in providing this form of treatment I would not want you learning on me or any of my loveones.
    This is a very difficult treatment option. Totally nurse intensive, requiring 1:1 or more staffing while the CVVHD is running. If you have dialysis nurses who are 24 hr available and could at least help set it up and help you trouble shoot it would be helpful. Once started the patient generally needs a few days to help remove the fluid overload. You need staff available at all times to be able to provide this. It is worse than IABP management.
    It is also very expensive equipment to maintain and use for the few times you say you would need it.
    Also depends on which system you go with the amount of problems, the amount of attention needed by the RN.
    Believe me it is not worth your effort. Having been there, done that.
    If you can safely transfer the patient it is better for them.
  6. by   begalli
    Oakmax-

    I just realized that in the first sentence of your first post says they use the same docs. Sorry 'bout that. :imbar

    As to which device is best, I don't know, but we use the PRISMA system (at that link, drag your mouse over "Intensive Care Products" on the left of your screen and click "Continuous Renal Replacement Therapies" to see what I'm talking about). The site mentions a syringe feature for anticoagulation, but we use citrate on an IV pump.

    CVVH can be labor intensive as lee1 states, but PRISMA is an easy system to learn and maintain and the reps with the company are helpful. We implemented use of this device about 4-5 years ago. We used to use a very old Baxter system which was even more labor intensive and time consuming.

    The PRISMA system tells you when you have a problem, what the problem is, and exactly what to do about it, step by step. We don't have nearly the clotting problems as we did with the Baxter system.

    Our HD RN's come to set up the equipment and initiate treatment (and change tubing q 72/hrs and prn). The beside RN manages it from there. It's all computerized and very easy to manage. These patients are always 1:1.

    Our RN's must be CVVH certified to take a patient requiring CVVH. Certification is accomplished with classses held by either the PRISMA reps or by our unit's CNS. The classes are held a couple times/year. We renew certification once/yr with a written test and demonstration of skills.

    We frequently have patients on CVVH, sometimes many patients at once. But then again we are one of those large CTICU's that take the sickest of the sick to begin with.
    Last edit by begalli on Jan 17, '05
  7. by   lee1
    Yes you are right about labor intensity with the older Baxter system (including the constant math formulas) and that is exactly what we are still using. We are hoping to be getting the Prisma any day (thank God there was a problem with the newer Baxter system that they had been waiting 2 years for while everyone else in the state was using Prisma) now BUT the nursing management has already started hinting that you know up in so and so hopsital they can take another pt because it is supposedly easier to run. I don't why they can't seem to remember that it is the patient who ALSO needs care and if you have a shocky, intubated, or worse nonintubated patient on muliple drips, etc. there is still a great deal of 1:1 care that needs to be given along with managing the CVVHD lines, pumps, machine, etc. SWAN, Art lines, IABP, whatever. Patient positioning, bathing, assessments still take time also. Fighting with residents to give you the proper orders, etc.
  8. by   begalli
    Quote from lee1
    (including the constant math formulas)
    UGH!! I had forgotten about that!

    Prisma is just light years ahead of the old systems. But I still think the patient's require 1:1 care for all of the reasons you stated.
    Last edit by begalli on Jan 17, '05

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