CRRT and mobility

Published

So here is my question: our ICU prides itself on being pro-active with new evidence based practices. We have an aggressive "early mobility" program. One of our hospitality-CNPs insists that we attempt to walk patients while they are on CRRT. The last one coded, but she is undeterred. What are your thoughts and your hospital practices in this area? Thanks for your input!

Ah,....no. Just no! I too, have never had an CRRT patient who wasn't vented and on at least one pressor. That combination is an absolute contraindication for ambulation.

Up Vote Up Vote ×
Specializes in SICU, trauma, neuro.

Honestly I would refuse.

It's like in nursing school when they teach you never to do anything just bc "the dr says so..." you don't ambulate unstable pts with a good portion of blood outside their body (and how DO you pull the machine w you anyway?? The ones we use are huge, and must be plugged in) just bc the CNP says so.

She isn't going to take the fall when a family sues, after they find out their loved one's death was preventable.

To answer your question though, we are pretty gung ho w early mobility. As others have said though, CRRT pts are by nature of needing CRRT, going to meet several exclusion criteria. Yes EBP supports early mobility, but every decision requires a benefit to outweigh the risk.

Up Vote Up Vote ×

While the vast majority of my CRRT patients are intubated and on one or more pressors or inotropes, I have cared for relatively mobile patients who are very volume overloaded and either have failed diuresis, have an AKI from diuresis/other reason and are no longer producing urine, or have CKD (whether related to the heart failure or not) that evolves to ESRD. These patients are few and far between but as you all know, a low BP for most of these heart failure patients is usually a good thing (to a point) for afterload, however, because of this they would not tolerate normal HD at the time.

Example: I cared for one chronically on dobutamine at home that I got up to the chair x3/day and when their machine clotted off (even happened on citrate a few times!) we seized the opportunity to disconnect them and ambulate them in the hallway while we waited for the HD RN to replace the filter. The attending also requested once for us to do it solely for the purpose of ambulating the patient. Obviously they were stable enough that their lytes would tolerate being off the machine for a bit and they weren't in pulmonary edema from fluid overload (we were doing CVVH, not SCUF just to clarify).

Please NEVER unplug your CRRT machine; I learned the hard way once as a new ICU RN after an experienced RN told me it was fine to unplug it. The entire machine shuts down and I could not return their blood because the filter locked:nailbiting:! We all learned a lesson that day. Anyways, it's not impossible but I would say rare to ambulate a CRRT patient.

Also as far as the ambulating ECMO joke, I had the opportunity to go to NTI this year and there are a few centers that are ambulating their VV ECMO patients when they are cannulated with the dual lumen catheter in the IJ! It sounded like most of them were usually CF patients awaiting lung transplant. Obviously it takes an army but it is being done! Crazy but awesome :)

Up Vote Up Vote ×
Specializes in Critical care.
Also as far as the ambulating ECMO joke, I had the opportunity to go to NTI this year and there are a few centers that are ambulating their VV ECMO patients when they are cannulated with the dual lumen catheter in the IJ! It sounded like most of them were usually CF patients awaiting lung transplant. Obviously it takes an army but it is being done! Crazy but awesome :)

We mobilise patients with extracorporeal VADs. Yes, it does take an army to do it, but it makes for a shorter rehab when the patient finally gets definitive treatment. I know of centres over here (UK) that mobilise their VV ECMO patients.

Up Vote Up Vote ×
Specializes in Dialysis.

Please NEVER unplug your CRRT machine; I learned the hard way once as a new ICU RN after an experienced RN told me it was fine to unplug it. The entire machine shuts down and I could not return their blood because the filter locked:nailbiting:! We all learned a lesson that day. Anyways, it's not impossible but I would say rare to ambulate a CRRT patient.

Fresenius CRRT machines have a manual hand crank to return the blood to the patient in case of power failure. I would be surprised if other companies machines don't have a similar feature.

Up Vote Up Vote ×
Specializes in Pediatric Critical Care.

I've seen ECMO patients be ambulated and work with physical therapy......it seems that if those patients can, CRRT patients could too....technically. Obviously this is a case-by-base decision, as it would be for ECMO as well, because a lot (if not most) of these patients are just way to unstable. There would have to be a lot of support and planning, and maybe lets just work on dangling feet at the bedside first!

Up Vote Up Vote ×

No absolutly not. If a patient is too hemodynamically unstable for hemodialysis and requiring CVVHD then I do not see it being safe to get them out of bed. Sounds like the higher up's are out of touch with reality.

Up Vote Up Vote ×
No absolutly not. If a patient is too hemodynamically unstable for hemodialysis and requiring CVVHD then I do not see it being safe to get them out of bed. Sounds like the higher up's are out of touch with reality.

Yep, exactly!

Up Vote Up Vote ×

I work in a unit that ambulates patients on CRRT all the time. We also ambulate people on VA/VV ECMO, external/temporary VADs, and combinations of all these support systems. We have been known to take these people outside as well. The type of support a patient needs is not an automatic rule out, but rather how stable they are once bridged to any therapy. At least in theory a patient should become more stable once bridged to the support they need, and subsequently able to increase their activity level while awaiting recovery or definitive care.

Up Vote Up Vote ×

Yeah....

CRRT patients are on bedrest. Their blood pressure most likely is nothing to write home about.

Also Our CRRT machines are plugged in and if unplugged the machine stops.

Up Vote Up Vote ×

I had one patient who we put into a chair while on CVVHD and trached, it was always a hot mess. Some hospitals run their CRRT at night ( i think its called PIRRT therapy) and those patients are able to be OOB during the day.

Up Vote Up Vote ×

I've had patients get OOB to a regular chair (CRRT, SWAN, ART line) and I personally feel that it's A. Stupid and B. Dangerous. One little misstep and there goes all your lines and you could be up poops creek really quickly without a way to immediately fix it. Generally someone is on CRRT because they can not tolerate HD. I just feel that it's a recipe for disaster.

Up Vote Up Vote ×
+ Join the Discussion