I&O, UF rate, & CRRT

[dorimar, BSN, RN]

Hey all. When do you calculate your intake to determine your UF rate? We've always figured the intake at the end of the hour to figure what to set our UF rate at the top of the next hour. Basically, we take off this hour what we put in last hour. The other night i worked and the nurse was "estimating" what she thought would go in on the current hour (top of the hour), and setting the uf rate so she would be taking off that amount at same hour. She stated that the dialysis nurses are teling all of the floor ICU nurses to run it this way, and so that is what everyone is doing. My problem with this is, How do you really know what will go in in the hour until it is over. Especially if your dumping blood products in or doing PRN boluses or albumin and titrateing mega pressors? Plus it is very confusing in the charting. I&O has always been done as: intake charted at 8pm was what went in from 7pm to 8pm, and output is what you empied at 8pm (be it urine, ng or hemofiltration). how are you all doing it? I really would appreciate some input on input on this.

[Dinith88]

Hey all. When do you calculate your intake to determine your UF rate? We've always figured the intake at the end of the hour to figure what to set our UF rate at the top of the next hour. Basically, we take off this hour what we put in last hour. The other night i worked and the nurse was "estimating" what she thought would go in on the current hour (top of the hour), and setting the uf rate so she would be taking off that amount at same hour. She stated that the dialysis nurses are teling all of the floor ICU nurses to run it this way, and so that is what everyone is doing. My problem with this is, How do you really know what will go in in the hour until it is over. Especially if your dumping blood products in or doing PRN boluses or albumin and titrateing mega pressors? Plus it is very confusing in the charting. I&O has always been done as: intake charted at 8pm was what went in from 7pm to 8pm, and output is what you empied at 8pm (be it urine, ng or hemofiltration). how are you all doing it? I really would appreciate some input on input on this.

thats a funny post. funny because i've seen nurses do it both ways...and then a few 'ways of their own' :)

I think your way makes the most sense...especially if dumping blood products and such. HOwever, i generally calculate my input for the coming hour, then calculate my UF based on that.

I think either way would work...problem is trying to get all the nurses on the same page and doing it the same way.

I think they should have inservices on just the I&O flow-sheets as that is where most nurses running crrt have the most trouble...and screw all the numbers up.

[gradcare, LPN]

Generally we have an order for what they want of eg 50 mls/hr off at the pump, intake plus 50 mls/hr (50 ml net negative/hr) titrate every hour based on a) current intake or b) fluid in over 24hrs / 24 (including ab's and flushes. Blood products etc we generally ask the medico's if they want them included in the fluid in and adjust fluid out as appropriate. I personally do the calculate over 24 hrs thing just 'cos I've been bitten in the orifice by people drying their patient out too fast trying to get off the extra fluid from a unit of packed cells and 2 ab's in an hor (total about 400 ml) in a pressor dependent patient.

[nurseasia94]

We started CRRT recently and one of the nurses thought that reusing effluent bags would open up the system for bacterial contamination. She suggested using new effluent bags when they're full. Any thoughts?

[TennRN2004]

Generally we have an order for what they want of eg 50 mls/hr off at the pump, intake plus 50 mls/hr (50 ml net negative/hr) titrate every hour based on a) current intake or b) fluid in over 24hrs / 24 (including ab's and flushes. Blood products etc we generally ask the medico's if they want them included in the fluid in and adjust fluid out as appropriate. I personally do the calculate over 24 hrs thing just 'cos I've been bitten in the orifice by people drying their patient out too fast trying to get off the extra fluid from a unit of packed cells and 2 ab's in an hor (total about 400 ml) in a pressor dependent patient.

I agree totally. We actually do q 4 I/Os and adjust every 4 hours to help prevent this, but it is confusing. You really have to watch your numbers, and I always double check myself twice before I make flow rate adjustments. I think this way is more accurate b/c instead of guesstimating, I can show you exactly what the numbers are and where my calculations came from.

[koyeh]

I do mine at the top of the hour. You add up all the fluids going in and set that #as fluid removal if running even. 50 less if negative, 50+ if running positive. You usually know if your going to hang an antibiotic and can calculate that in, etc... If your slamming blood products in they they probably need the volume and should't have it removed. If the blood is just to pump them up hang it over 3-4 hours and dial your removal for that rate.

Yes you will crash your patient if you try to take it all off at one time. If you get ahead dial a little more but keep a close eye on their BP.

[koyeh]

What machine are you using? Are they User freindly? Our nephrologist are looking and we want a nursing freindly machine.

[km5v6r, EdD, RN]

As a dialysis nurse who used to work with the Prisma we taught that at 8:00 you added up everything put in between 7:00 and 8:00, subtracted everything put out in that same time period, added the ordered UF amount and reprogramed the machine at 8:00. The difference between what you programed and what actually happened was added or subtracted from the goal for the next hour. The hospital I work at now the docs order a set UFR for the hour. The ICU nurses do not adjust the UFR hourly. In fact when I came and mentioned the possibility the ICU nurses laughed at me and said they didn't have time for that. They weren't dialysis nurses and weren't doing it.

[koyeh]

Wow, I really like the idea of nurses adjusting per intake and would miss the freedom to adjust. Actually we just had a new nephrologist that wouldn't let us adjust and learned very quickly the nurses were unhappy with his style and now lets us do the hourly thing.

[km5v6r, EdD, RN]

These nurses don't like/want to do CRRT anyway. They particularly don't want to have to do all the additional math, empty J/P's and measure NGT output hourly. Many won't turn off the UF when the pt becomes hypotensive. The worse though are the few who won't reset after an alarm. This hospital uses the Fersenius machine for CRRT. Losing a set up means lose of app 200 ml of blood for the pt.

[koyeh]

Our hospital is currently looking at the Fersenius machine for crrt and sled. Are there any other major concerns besides the large blood loss if the filter clots?

[km5v6r, EdD, RN]

The Fersenius system for CRRT is exactly like doing hemodialysis. Everything is just slowed down. You still have to monitor the Arterial and Venous pressures, TMP, etc. Large jugs of acid and bicarb and an R/O for suppling purified water are required. On the plus side is it is a bicarb based treatment. The older style of prisma was strictly acid based. The dialysis solution and bicarb don't actually mix with the blood so don't have to be sterile. Pharmacy doesn't have to mix the special baths. No large bags to try and hang or empty. The waste go through a hose to whatever drain you designate. The same tubing is used for both hemodialysis and CRRT. Many of the same filters are also used. It is easy to access the tubing for all lab draws. No waste and no flushing after a draw. While the machine is bulky it can be moved around without triggering alarms and doesn't need to have scales rebalanced when moved. Look at the next hemo set up and see who it looks.