CRRT: Who does it?? - page 2

by NephRN 23,779 Views | 29 Comments

I am a dialysis nurse working in an inpatient, acute care setting. Where I work, the dialysis staff sets up the CRRT (PRISMA), provides teaching to the critical care staff, changes the set-up when the sytem clots, makes the... Read More


  1. 0
    Quote from sherryg0
    Dear neph:
    I also work in an acute setting where we have one Prisma machine. We have had numerous problems with it (computer wasn't functioning correctly, etc)
    which clotted the catheter where we couldn't give them their blood back.
    The nurses in the units were very reluctant to attempt to run them after we went home on call.
    WHERE do you give the Calcium chloride back if you use citrate as a anticoagulant? We have a Quinton with a third port and was told by the Prisma inservice personnel to put the Calcium chloride there; but when I called the help desk about multiple clotting (which was the machine by the way)
    I was told that this is not recommended.
    VERY frustrating. NEED MORE INSERVICES. These are slow in coming from the gambro company
    Sherryg
    We give the CaCl in the same port as the return to patient via a 3-way stopcock.
  2. 0
    In our institution, we do a lot of CRRT in the SICU. The Dialysis staff have been setting it up and then hooking it up, we handle it from there. But their overtime got so bad (you are supposed to do CONTINUOUS therapy..) they taught us to prime, hook up etc: everything. We troubleshoot and it is with a dog of a machine, the Braun. Set up takes about an hour, and hourly fluid balance is not intuitive.
    My experience throughout the US is that Dialysis usually set up the equipment (even the Prisma!) and ICU monitors. But the problem is that the ICU, IF they do it often enough, becomes the expert, and as one RN complained to me a week ago "we're the experts. All they do is set it up." It would be great if the Dialysis staff was 'user expert' too. But more and more ICU's are doing the whole thing. That's smart, 'cause Dialysis has enough work with out that added burden.
    Our calcium for the citrate is hooked up immediately at the end of the venous line, and seems to work well. Overall, if you don't do the therapy, you'll never be good at it, no matter if you are Dialysis or ICU. The best thing seems to be the new machine out now that dumps the UF down the drain, and you can hang all your bags for the shift ONCE...Many nurses using this machine (the Nxstage) LOVE the simplicity of it and totally love not dumping drain bags! And for those of you like us, who work with the scale system, and have to haul 2 8Liter UF bags every 3-4 hours, that is the best. (Aren't nurses the only ones who think 100lbs. is light???) Remains to be seen what happens when ICUs besome more intensivist-driven, too.
  3. 0
    We also do CRRT in our ICU and CCU. The dialysis RN comes to initially set the machine up and does filter changes...we do the hourly numbers, make changes, and troubleshoot/return blood, etc. IF the machince clots off in the middle of the night, we either wait until morning to restart (I don't know why since the point is continuous replacement therapy...) or call the dialysis rn to come in and change the filter set out. Currently we are still using heparin but I have heard rumor of changing to calcium citrate. OUr pharmacy fixes up all of the replacement bags and bicarb and kcl solutions...In order to become checked off we attend and 8 hour class and have a four hour session with another trained RN to show us the ropes so to speak...then we are on our own...unless we don't feel ready and then they will train us further. We also have yearly competency classes that we have to complete (approx. 4hour refresher class).
  4. 0
    Quote from sherryg0
    Dear neph:
    I also work in an acute setting where we have one Prisma machine. We have had numerous problems with it (computer wasn't functioning correctly, etc)
    which clotted the catheter where we couldn't give them their blood back.
    The nurses in the units were very reluctant to attempt to run them after we went home on call.
    WHERE do you give the Calcium chloride back if you use citrate as a anticoagulant? We have a Quinton with a third port and was told by the Prisma inservice personnel to put the Calcium chloride there; but when I called the help desk about multiple clotting (which was the machine by the way)
    I was told that this is not recommended.
    VERY frustrating. NEED MORE INSERVICES. These are slow in coming from the gambro company
    Sherryg
    Sherryg;
    Sounds like a bit frustrated to me. In out unit at a large center, we have 4 hour classes about CRRT, and we also cover the essentials of how to interpret pressures on the machine, how to tell if you have a catheter problem etc. We put poeple who have attended the class on a list as mentioned above, and they are 'certified'. so to speak for it. The we have to precept them for about 4 hours to make sure they are doing fluid balance calcs properly (a huge source of error, I might add!) The machine we use is large, cumbersome and not at all intuitive.

    We teach the infusion of Calcium into any other line NOT on the CRRT circuit. then the citrate is only in the circuit. Most people use the Prisma, and although it is 'easy' in many ways, I hear complaints all the time about scales needing calibration, circuits not lasting long etc. And since Gambro is so large, they tell you' 2 days inservice is enough' and then they are gone. Not my idea of good customer support!
    There is a new company on the horizon which has NO SCALES and NO BAGS to dump, and the machine is as simple as the Prisma. (www.nxstage.com) Bottom line is: lack of knowledge and more complicated machine plus lots of nursing workload makes sad nurses in the ICU. Believe me, I do it! anything you can do to get your Educators to improve the education, may help. Also a simple machine. In our unit we do the set up on nights, holidays and weekdns, so Dialysis doesn't have to come in, so we are kind of savvy even with compicated (read :stupid!) machines.
  5. 0
    When you say that machine manufacturers need to provide better training, what do you mean? More frequent? More comprehensive? More illustrations? What specifically would make the training better?
  6. 0
    Quote from jiminflorida
    When you say that machine manufacturers need to provide better training, what do you mean? More frequent? More comprehensive? More illustrations? What specifically would make the training better?
    Better training means that a priority should be that there are a few (depends on the size of the staff) Super users who attend more than one class, maybe even help teach or do hands-on with the rep, and then can help get the program going within the institution. The institution is responsible for the frequency of the training. Remember, JACHO is going to be checking this records to see if you are competent and how you get 'certified.' There should be a 'theory' class, like the one described above, where you learn about pressures, blood rates, blood flow, how to detect clotting etc. Also how the machine works. No one will get used to the machine, no matter what it is if the docs never order the therapy. So hands on, some user guides, or flashcards to reinforce key points, maybe a video all help to keep staff educated. Also, there is an Annual CRRT conference in San Diego each year that covers ALL aspects of CRRT, and also a lot of ICU staff. It is great. In addition, usually at the National Teaching Institute for Critical Care (NTI)there are one or 2 talks on it. So plenty of stuff to learn from.
  7. 0
    I have a close friend who is a traveling dialysis tech (I'm a traveling dialysis RN) he's working acutes in Las Vegas. He tells me that there are no nurses doing acute dialysis in Las Vegas.

    The techs set up the machines, mix the baths, do the hemo, PD, the cycler, the CRRT, plasmaphoreses, give Mannitol, Albumin and even blood. He says the ICU nurses give the Epo & Ferrlecit, that's it.

    They have no dialysis nurses at all.

    Shocked the heck out of me.
  8. 0
    Quote from Hellllllo Nurse
    I have a close friend who is a traveling dialysis tech (I'm a traveling dialysis RN) he's working acutes in Las Vegas. He tells me that there are no nurses doing acute dialysis in Las Vegas.

    The techs set up the machines, mix the baths, do the hemo, PD, the cycler, the CRRT, plasmaphoreses, give Mannitol, Albumin and even blood. He says the ICU nurses give the Epo & Ferrlecit, that's it.

    They have no dialysis nurses at all.

    Shocked the heck out of me.
    I know some years ago they were doing it (ICU nurses) because I went out there to train them..However, some ICU staff thinks this is a dialysis job. It's NOT! The ICU nurse is the one who knows precisely the pts. fluid balance, CVP etc, and can determine how well the CRRT is working. Anyway, I have a feeling that for as much as Las Vegas is growing, they may not be doing much of this. Too bad for anyone who gets renal failure there!!!
  9. 0
    Quote from suetje
    I know some years ago they were doing it (ICU nurses) because I went out there to train them..However, some ICU staff thinks this is a dialysis job. It's NOT! The ICU nurse is the one who knows precisely the pts. fluid balance, CVP etc, and can determine how well the CRRT is working. Anyway, I have a feeling that for as much as Las Vegas is growing, they may not be doing much of this. Too bad for anyone who gets renal failure there!!!
    My friend tells me that the techs are mostly privately contracted thru several agencies. They often work 20-24 hrs straight. He says the nurses there are strictly ICU nurses and don't know anything about dialysis, nor does their job require them to.
    I did recently read an article that shows that dialysis pts in NV have the highest morbidily/mortality rates of any other state. I wonder why!
  10. 0
    We have the prisma and Gambro always comes and helps train. we looked at the NxStage but that drain taped on the floor is disgusting, how about yeats growth after 12 hours? What happens when a family member trips over the tubing. I am not sure JCAHO would accept it. Our Risk management and Infection control have ruled it out. As we can't run extension cords across the floor we can't run this drain. we utilize Gambro for 8hour classes and the we have a preceptor. Gambro has been great.


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