CRRT: Who does it??

What we do is exactly what you are doing in your hospital. But there is always conflicts between ICU staff and dialysis nurses when it comes to this question. Some nurses will be very happy to take up the responsibility while some nurses don't. We all know that it is impossible for us to stay in ICU and monitor the patient and the machine round the clock. ICU staff has to do it. A clear hospital policies on who does what will help to prevent conflicts.

We do everything ourselves, with minimal backup. The ICU nurses in our TSICU (trauma/surg/burn) and MICU takke classes on prisma and from then on run the therapy and do all of the things you mention. Matter of fact, the MICU stores the prisma machines when not in use. We are responsible for orderingour own supplies and dealing with the renal docotors. Our patinets are usually only made one to one when stable, but if they are on high dose pressors, then they are two to ones.

one other thing to add, pharmacy mixes all the dialysate, and replacement fluids.

In the CVICU where I work, the nurses do everything with the CRRT. But first you have to attend inservice classes, and then your name goes on the list of nurses in the unit who can do CRRT. (We do the same for IABP and VADs.) If we have problems we can't handle, which is a rare occurence, we call the Prisma rep. We always nurse the patients 1:1. When we first started using the Prisma, in the early 90's, we would have 2:1, but that didn't last long!!! If and when the patient is stable enough for hemo, the dialysis nurses take over, and bring their portable equipment, which we have nothing whatsoever to do with.

The nurses in my ICU who've been trained in CRRT with the Prisma machine, set up and all that other Jazz with the machines. Pharmacy sends up KCL to inject into the dialysate. I've not been trained on it yet...probably within the next 6 months or so....

I work acute HD and thank god we don't do CRRT, for the reasons mentioned above. We are contract workers and it always ends up in a big mess about who is supposed to do what, even with a clear hospital policy. Doctors don't know/care what hospital policy is. They ask us to do all kinds of things that we aren't "credentialed" to do at our hospitals. I hate having to explain this to a nurse, especially when we tell them that they have to come to the unit to check BG'S. We do not even have a BG monitor!! all we are "credentialed" to do is dialysis and dialysis related procedures. We aren't even supposed to suction a pt in ICU when we are doing a treatment!! Ya know that us good nurses do it anyway!!!

p.s. Our docs don't like CRRT. They have the mindset that if the ICU pts cant tolerate a slow, gentle HD, they don't need CRRT.

Hi

You say "first you have to attend inservice classes." Can you tell me about your training regimen? How many sessions do you get? How many hours per session? An overview of what comprises the training? Have you heard of any incidents resulting from insufficient training?

We have one 4-hour session for ICU indivual CRRT dialysis.

Thanks.

Nancy

:uhoh21:

my colleagues and I don't have any conflict with ICU staff as our roles a fairly clear. Long term patients that the Renal Unit hs not seen or heard of are generally looked after by the ICU staff and are dialysed on CVVHD. Personally I have no idea what a CVVHD looks like! One of us renal nurses is on call, after hours 356 days a year. If a patient in ICU needs acute dialysis then we wil be called in and will perform dialysis in ICU.

If a patient crops up on a Sunday (the only day the dialysis unit is closed) we will still have to dialyse the patient in ICU, as we need expert nursing help around in case the s**t hits the fan.

My ICU colleagues are nothing but helpful in the times i have had to "encroach" on their turf to do my job. Their machines scare the hell out of me and my machine scares the hell out of them!!

Dear neph:

I also work in an acute setting where we have one Prisma machine. We have had numerous problems with it (computer wasn't functioning correctly, etc)

which clotted the catheter where we couldn't give them their blood back.

The nurses in the units were very reluctant to attempt to run them after we went home on call.

WHERE do you give the Calcium chloride back if you use citrate as a anticoagulant? We have a Quinton with a third port and was told by the Prisma inservice personnel to put the Calcium chloride there; but when I called the help desk about multiple clotting (which was the machine by the way)

I was told that this is not recommended.

VERY frustrating. NEED MORE INSERVICES. These are slow in coming from the gambro company

Sherryg

I am a dialysis nurse working in an inpatient, acute care setting. Where I work, the dialysis staff sets up the CRRT (PRISMA), provides teaching to the critical care staff, changes the set-up when the sytem clots, makes the changes when there is a change in modality ordered (ie: SCUF to CVVHD), on call for problems, and discontinues the treatment when so ordered. Please tell me how it is handled where you work. I would also like to know what area you work in (ie: ICU, CCU, SICU, TICU, CVRR, Dialysis, etc.) and how you feel about your CRRT resonsibilities. Thanks in advance.

Dear neph:

I also work in an acute setting where we have one Prisma machine. We have had numerous problems with it (computer wasn't functioning correctly, etc)

which clotted the catheter where we couldn't give them their blood back.

The nurses in the units were very reluctant to attempt to run them after we went home on call.

WHERE do you give the Calcium chloride back if you use citrate as a anticoagulant? We have a Quinton with a third port and was told by the Prisma inservice personnel to put the Calcium chloride there; but when I called the help desk about multiple clotting (which was the machine by the way)

I was told that this is not recommended.

VERY frustrating. NEED MORE INSERVICES. These are slow in coming from the gambro company

Sherryg

We give the CaCl in the same port as the return to patient via a 3-way stopcock.

In our institution, we do a lot of CRRT in the SICU. The Dialysis staff have been setting it up and then hooking it up, we handle it from there. But their overtime got so bad (you are supposed to do CONTINUOUS therapy..) they taught us to prime, hook up etc: everything. We troubleshoot and it is with a dog of a machine, the Braun. Set up takes about an hour, and hourly fluid balance is not intuitive.

My experience throughout the US is that Dialysis usually set up the equipment (even the Prisma!) and ICU monitors. But the problem is that the ICU, IF they do it often enough, becomes the expert, and as one RN complained to me a week ago "we're the experts. All they do is set it up." It would be great if the Dialysis staff was 'user expert' too. But more and more ICU's are doing the whole thing. That's smart, 'cause Dialysis has enough work with out that added burden.

Our calcium for the citrate is hooked up immediately at the end of the venous line, and seems to work well. Overall, if you don't do the therapy, you'll never be good at it, no matter if you are Dialysis or ICU. The best thing seems to be the new machine out now that dumps the UF down the drain, and you can hang all your bags for the shift ONCE...Many nurses using this machine (the Nxstage) LOVE the simplicity of it and totally love not dumping drain bags! And for those of you like us, who work with the scale system, and have to haul 2 8Liter UF bags every 3-4 hours, that is the best. (Aren't nurses the only ones who think 100lbs. is light???) Remains to be seen what happens when ICUs besome more intensivist-driven, too.

We also do CRRT in our ICU and CCU. The dialysis RN comes to initially set the machine up and does filter changes...we do the hourly numbers, make changes, and troubleshoot/return blood, etc. IF the machince clots off in the middle of the night, we either wait until morning to restart (I don't know why since the point is continuous replacement therapy...) or call the dialysis rn to come in and change the filter set out. Currently we are still using heparin but I have heard rumor of changing to calcium citrate. OUr pharmacy fixes up all of the replacement bags and bicarb and kcl solutions...In order to become checked off we attend and 8 hour class and have a four hour session with another trained RN to show us the ropes so to speak...then we are on our own...unless we don't feel ready and then they will train us further. We also have yearly competency classes that we have to complete (approx. 4hour refresher class).