CRRT - page 2
Our unit is being pushed to begin providing CRRT. In the last three years or so, we have only had an average of four patients each year who required it. In the past we have provided all PICU care and... Read More
Jun 5, '07The Prisma machines have a well known reputation for failing quite frequently. It is a great machine in that it tells you exactly what needs to be done for interventions, but it is not uncommon to go through several pumps during a patient's treatment history.
Jun 25, '07We run CVVH in our PICU all by the nursing staff, and it's bascially a learn on-the-job situation. Bits of teaching in orientation, but mostly learning during preceptorship and through experience. Since it isnt every day that we use it, it's basically those of us that seek out the opportunities to take those patients that become more proficient. It isnt too complicated, just takes time being exposed to it
Aug 1, '08I hope this thread is still current. We started our CRRT program nearly 5 years ago in our PICU. I kinda felt like someone who was given the task of starting a lemonade stand who had to build the stand, grow the lemons figure out how to make lemonade and recriut and train employees to make/sell it. Our program has come a long way and still has a long way to go before I can say it's a Great Lemonade Stand! Several things about the original post are alarming. But hopefully they've been resolved.
We use the BBraun Diapact machine, utilize Citrate and Calcium for anticoagulation, and use either NormoCarb or a Customized formula in 3 liter bags for dialysate/replacement fluids. CVVH is ordered and maintained by the Nephrologist (not always the best) and we have a team of 25-30 nurses trained in running a patient on CVVH as well as priming and setting up the machines 'Divas' as we like to refer to ourselves. I have found that actually, priming and troubleshooting the priming process has created nurses who are much better at troubleshooting at patient and have a fuller comprehension and understanding of the process. We always staff CVVH patients as 1:1's with an occasional 2RN's:1 when the patient is very unstable. There is always a 'Diva on Call' 24/7 and the team is great about helping each other out.
I would love to have a group of other PICU or even adult ICU nurses to talk to about CVVH or CRRT to get some insight into how things work for you.
Thanks for listening to me chat.
Aug 2, '08My unit also used CVVH quite frequently- usually for cardiac or hem/onc patients. As a new RN to the unit you received a 6 hour class on the circuit and then you were required to do 2 shifts with another RN taking care of a CVVH patient. The patients were usually 1:1 ratio depending on how "sick" they were, sometimes 1:2 with one RN for the pt and one for the circuit(knida like ECMO).
Now, years back when we switched from the old system to the new Prisma system, the Prisma rep came out and did inservices for everyone. Then a group of RNs were given a very detailed inservice with lots of hands on- they became the "trainers". Now, for the first few patients we used the new Prisma circuit on, the Prisma rep(who was a RN) came out and worked with our nurses- helping prime and set up and trouble shoot. Then we learned from each other. But we really did not have too many problems.
I think that it might be difficult if you do not use CVVH often to become familiar with things. You really have to stay on top of your ACTs and titrate that heparin every hour so you don't have any problems with your filter. The nice thing about the Prisma is that it will tell you exactly whats wrong, and if the pressure is getting high in the filter. We really haven't had too many problems with clotting or anything else. I think that alot of nurses don't really understand CVVH thinking it is comparable to dialysis.
Maybe you could get a group of RNs together and get a really good inservice on your circuit, maybe go to the adult ICU and shadow a nurse running CVVH, if you can get a couple of "experts" on your unit- you can help each other.
Good Luck to you !!!
Aug 17, '08Another thought as well, is to have the Prisma rep or whatever brand your facility uses come and do a few in-services on the machine.
Oct 20, '08Our PICU has done CRRT for many years, 14, I'd guess. The last several years we've been using the Prisma and it's worked well. Our training on our new machine begins next month.
What we have done in the past was to have a dedicated core team who takes call 24/7. They were responsible for the set up and safely seeing the patient on the circuit. In the last year or two that has changed and now all of the nurses trained on the Prisma are also supposed to be able to set it up and change the circuit as needed. To be honest, as one of the original core group, I do have concerns that the staff given a perfunctory orientation aren't familiar enough to be able to troubleshoot the system well. Kind of like reading how someone here said they went through, I think it was 14 sets in a day. Wow! That's a lot of circuits and I can't help but think they had a catheter that wasn't allowing for good flow or there was some other significant problem.
Once the patient is safely on the circuit, generally we still treat them as a 2:1. A few years ago we had some patients on for a very long time who were fairly stable, occasionally we'd pair the patient with someone else, but then the pump nurse would remain in the room with the patient 24/7. Our concern is always that the time is so limited if you have an error that needs to be immediately corrected, otherwise you have just seconds and your circuit is clotted. Not to mention the unlikely scenario that the circuit could become disconnected and rapidly exsanguinate the patient.
I'm curious to get my hands on the new machine and see how it runs.
Oct 20, '0814 in one day!!! We have standing orders to get the nephrologist to assess if we go through more than 2 in 24 hours.
Oct 20, '08Quote from tryingtohaveitallTo be honest, as one of the original core group, I do have concerns that the staff given a perfunctory orientation aren't familiar enough to be able to troubleshoot the system well. Kind of like reading how someone here said they went through, I think it was 14 sets in a day. Wow! That's a lot of circuits and I can't help but think they had a catheter that wasn't allowing for good flow or there was some other significant problem.Quote from pebblesI'm the person who posted about the 14 sets in 24 hours. (The OP is also 7 years old...) Let me explain how that came to be... The patient was 9 months old and had fallen head-first into a 5 gallon pail of human waste. At the time we tried to establish CRRT on this patient we were battling MODS, DIC, chemical pneumonitis and a host of other problems. The edema from so many issues made it difficult to do anything, and the biggest vas-cath we were able to get was an 11Fr. At the time the PICU was not running CRRT at all; if we had a kid who needed it, the adult dialysis unit or the adult MICU sent us someone. The nurses who were assigned to this patient over the 24 hour period we were attempting to get things going were both highly trained and very experienced CRRT providers. We consulted nephro several times and had someone on the unit most of the day. We had problems with the access pressure from the get-go. The filter clotted after maybe 30 minutes each time, despite our best efforts. The dialysis nurses made their views known early in the game that this wasn't going to work, the catheter was too small, the DIC would be in issue and so on. The PICU medical director and the nephrologist wanted us to keep going, and so we did. After 24 hours, it was agreed that the child was not salvageable and we finally gave up on CRRT. Death came about 5 hours later.14 in one day!!! We have standing orders to get the nephrologist to assess if we go through more than 2 in 24 hours.
Quote from tryingtohaveitallWe're using the PrismaFlex in the unit where I work now. The staff who are responsible for CRRT really like it. We've successfully dialysed an infant continuously for the last four months with it; sometimes the circuit needs to be changed after 3 days, and sometimes it lasts a week. All depends on what else is happening with the patient.I'm curious to get my hands on the new machine and see how it runs.