[first_lobster]

We just got the Fresinius 2008k CVVH / CRRT/ SLED/ ... machines at work, and I'm wondering if anyone else has had experience with this machine. We're working on our new protocols to go with our new machines and having a little trouble sorting through the details. I would appreciate any input that anyone can offer, even if they haven't used this machine. We are having some difficulties with figuring out the best algorythm for making hourly adjustments to the ultrafiltrate rate, as well as some other small detail problems. Any articles that anyone can point me to would be great too. Thanks Bunches!

[km5v6r]

I have done SLED with both the K machine and the older H machines with the additional CRRT chip. What kind of details are you trying to sort out? At this facility the Nephrologist orders the amount of fluid to be net UFed and the UFR set. It isn't changed on an hourly basis. Unless the doc orders to titrate the UFR it isn't changed at all. Some of the docs figure in the hourly IV rate when ordering the UFR others don't. ie. the hourly IV rate when they made rounds was 150 so a UFR of 250 is ordered. Others will write for a UFR of 100. Ask the doc how what they want done. BTW while I am a PICU nurse now working with these machines I used to be a Dialysis nurse setting them up.

[first_lobster]

Thanks alot for the input. The problem that we have is that the machines came in from the company, and NO ONE knows how to use the 100% correctly because the company has not sent any representitive to inservice us (the ICU staff), nor have they sent anyone to inservice the Dialysis nurses. We've figured out the basics, like how to clear the pumps, and turn them on, but the finer points are getting confused. How do you compensate for extra boluses (like abx or fluid boluses or gtt titrations) with the set rate, or do you just let it come out in the perverbial wash? Also, how often do you flush when you have a large amount of replacements fluids running? Does the fluid replacement compensate, or is it necassary to flush the blood all the way through every so often? I'm working my way throught the manual, but so-far I havent found teh answers yet. Any more input I can get would be great. Thanks.

[km5v6r]

Sorry to be so slow responding. I have been bogged down working.

Where would replacement solutions be running? We generally run replacement both into the arterial chamber prefilter and into the venous chamber post fluid. The theory being that the replacement solution will help to dilute the blood in the chambers in help prevent clotting. It doesn't always work that way but sometimes it does help. A complete system rinse doesn't work much better. A system flush will be done if clotting is suspected but not otherwise. IVPB and gtt titration is not dealt with on an hourly basis. Our docs look at approximately how much is given in a 24 hour period and figures the UFR. You are right you have to be aware of that volume or you won't have removed as much as expected. The other volume to consider is the prime and rinseback. The tubing and dialyzer holds about 200 ml depending on the type of dialyzer used. For example the pt is usually several kilos over dry weight when we start CRRT. In the past 24 hours they have received about another 2500 ml more then they put out. A UFR goal may be written as a net UF of 100-200 ml/hr as tol. Replacement sol is ordered both pre and post filter at a rate of 100 ml/hr. Personally I would start out with a UFR at 350ml/hr. That would be 200 ml of replacement, 50 ml for the prime and future rinseback, and a start of 100 ml/hr of net UF. As the pt tolerated the start of the treatment I would up the UFR. If they continued to tolerate, a few hours worth, it didn't look like a new system would have to be set up, and the pt is massively fluid overloaded I would call and ask about uping the UFR. I have seen systems clot in as little as a couple of hours even with replacement solutions infusing.

Another thing to keep close track of is the lytes, phos and mag levels. SLED will wipe out phos and mag completely. Conventional dialysis doesn't have that effect on phos but the long, slow dialysis of SLED will eliminate it completely. We draw a set of lytes with mag and phos every 6 hours while on SLED.

I am sure this is clear as mud but I hope it helps.

[TREBORICUNURSE]

Originally Posted by first_lobster

The problem that we have is that the machines came in from the company, and NO ONE knows how to use the 100% correctly because the company has not sent any representitive to inservice us (the ICU staff), nor have they sent anyone to inservice the Dialysis nurses.

That company has obviously "amazing professional" approach to the customers.
i just can`t belive that.....

[koyeh]

Our hospital went with Gambro and prismaflex, looks like a good move. They provide education and answere questions quickly.

[smileyRn96]

If I were in your shoes I would contact a local ICU that uses that CVVH machine and get some education and protocols. If no one local uses the machines find a hosptial anywhere that uses them and do the same. I would also raise hell with who ever purchased the machines without an education agreement from the distributer

[first_lobster]

Thanks everyone for your suggestions. We did finally get a class on how to use the machines, after we had a patient end up nine liters positive in a 12 hr shift, and after the head of nursing and our managers got together with the nephrologists and decided that until we all were properly trained, we would no longer perform CRRT, and those patients would hhave to be transferred out. It's a shame that we had to threaten them with a loss of income in order to be taught how to use the equipment. It's really good equipment, but still...I think I'm jaded now.

[koyeh]

We are getting new prismaflex machines with an external heater. The heater can ge set up to 40 C. Does anyone have a policy regarding the heater regarding what to set the temperature at? Thanks

[koyeh]

CRRT & Hypothermia:

What temp. do you consider cold and start trying to warm the patient with either a heating blanket or some other warming device? The reason why is our renal doctors want to run the patient cold so they vasoconstrict and require less pressors. They keep saying they run the inpatient dialysis patients (3 to 4 hr treatment) at 95 F.
My concern is CRRT is 24 hours a day and to be cold all day has to be discomforting.
The doctors did say if the patient starts to shiver than they will permit us to apply a warming blanket to reduce oxygen demands.

The only articles I found say, hypothermia is a side effect of CRRT but no specifics. Thanks