I was taking care of patient who is under CVVHDF. I am new at it and want to share to improve. Thanks.
The 57 year old man was initially admitted for DKA, sepsis, chronic renal failure. Was ventilated and had his medical condition corrected. After extubated and transfer to medical ward, he was found later have hidden abscess at his Rt thigh, and drug-induced abnormal LFT- undergone op and came back to ICU and ventilated overnight. His BP dropped, given blood products, commerced inotrops and CVVFDF with zero extraction. Extubated the next day and on o2 FM.. The first post-op day, UF started at 50, then increased to 80 due to postive balance thousand plus with no unrine output and the BP is stablized. Input is 1L perday plus IV med. Predictably, he was shown to have hypoalbuminemia with anasarca. Third day with wheezing, put on HFM o2 12L, started prn Neb and increased UF to 120. The BP and CVP gradually came down with constant dopamine support and thus UF cut down to 100. As through out the few hours of removal of fluid, the wheezing and his upper limbs edema subsided.
Question here :
1. He was always hypothermic 34c due to the CVVHDF..
-but he is not complaining of it cold or any sort. Why?
-Should I put warmer-blanket for him? Why?
-The orthopedic surgeon doesn't want us to involve warming the surgical site. Why?
Apr 21, '08
Are you sure the 34 deg was due to the CVVHDF? It's unusual to get that much of a drop. Did you have a blood warmer in the filter circuit?
If it was truly just due to that, I would add a blood warmer to the circuit +/- foil to the rest of the circuit. Can add heating blanket if still <35 deg.
What surgical site? You didn't mention one.
Generally surgeons dislike hypothermia as it tends to make you susceptible to bleeding.
Apr 22, '08
No warmer circuit. It is the conventional prisma dialysis machine.
We are pretty sure that the hypothermia was due to the dialysis. His temperature picked up to above 36 deg after the completion.
The surgical site is at the anterior Rt thigh.
It should be hyperthermia the surgeon dislike right?
Apr 22, '08
Surgeons dislike hypothermia because it can increase bleeding issues. Clinically relevent hypothermia (generally defined as less than 35 degrees Celsius) can mimic severe clotting factor deficiencies. Of course, the lower it goes, the worse it will get. Couple this with the anticoagulant used in the circuit and you could have some trouble. It sounds like your patient was just scraping by on the temperature front.
It is not uncommon for CRRT patients to have dialysis-induced hypothermia. At our facility, it is fairly usual to have these patients under lights and a Bair Hugger.
Knowing that hypothermia is common for these patients should also make you very wary of fever. If the dialysis can lower the core temp by two degrees, you can picture what the patient's actual response is if his temperature is reading 37.7!
Last edit by -MNC_RN- on Apr 22, '08
Apr 22, '08
We used the bair hugger. Light? what light? you mean the infra-red?
Apr 23, '08
Heating lights. We have them above every ICU bed to assist in active external rewarming.
Apr 23, '08
Ok, we don't equip any heating device in every bed, probably because Malaysia is hot and humid and the ICU is always regulated in room temperature. Thanks MNC_RN for your info. I just knew about it.
Apr 29, '08
I have a question in regard to BiLevel mode of ventilation on Bennet. On wich patients can I use it? I have difficulty in understanding how it works (ie. high PEEP/lowPEEP)can somebody give some hints on how to look after a patient that is on it.
Apr 30, '08
That patient was so sepsis that he had to put back on CVVHDF again. Despite on various antibiotics namely cravit, fortum, cloxa, superazone.. His TWDC was still very high.. As the INR is 4.25 and the platelet only 29, the prisma was run without heparin..
During the priming, I saw column of air was trapped in the bottom of filter. The line was perfectly prime. My preceptor taught me to hit the filter gently to expel the air.
Firstly, we would used the heparin 10k unit in 1L N/saline to prime, the we reprime with N/saline. But I still see the column of air there, not moving. And my seniors said is all rite. Isn't it that we need to see the whole filter being filled with the priming solution?
Please Advise. Thanks
Apr 30, '08
I'd call the Gambro help line on that one. The circuit primes in reverse so, while it is not uncommon for air to be trapped in the filter, any air should be at the TOP of the filter and not likely to get into circulation. Air trapped in the bottom of the filter seems unusual and dangerous to me.
Gambro reps who have done education at my hospital have always taught that it is not necessary to tap the filter or to expell all air; however, that is because of the reverse prime.
Again, with air in the bottom of the filter, I would call the help line--and probably start a new circuit anyway.
Now keep in mind that it's been quite a long while since I've done hands-on CRRT... the info I'm spewing is purely from memory and may not be accurate. Current users may have more helpful input.