CRRT: Who does it??

[NephRN]

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.

[zambezi, BSN, RN]

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).

[suetje]

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

Sherryg;

Sounds like a bit frustrated to me. In out unit at a large center, we have 4 hour classes about CRRT, and we also cover the essentials of how to interpret pressures on the machine, how to tell if you have a catheter problem etc. We put poeple who have attended the class on a list as mentioned above, and they are 'certified'. so to speak for it. The we have to precept them for about 4 hours to make sure they are doing fluid balance calcs properly (a huge source of error, I might add!) The machine we use is large, cumbersome and not at all intuitive.

We teach the infusion of Calcium into any other line NOT on the CRRT circuit. then the citrate is only in the circuit. Most people use the Prisma, and although it is 'easy' in many ways, I hear complaints all the time about scales needing calibration, circuits not lasting long etc. And since Gambro is so large, they tell you' 2 days inservice is enough' and then they are gone. Not my idea of good customer support!

There is a new company on the horizon which has NO SCALES and NO BAGS to dump, and the machine is as simple as the Prisma. (http://www.nxstage.com) Bottom line is: lack of knowledge and more complicated machine plus lots of nursing workload makes sad nurses in the ICU. Believe me, I do it! anything you can do to get your Educators to improve the education, may help. Also a simple machine. In our unit we do the set up on nights, holidays and weekdns, so Dialysis doesn't have to come in, so we are kind of savvy even with compicated (read :stupid!) machines.

[jiminflorida]

When you say that machine manufacturers need to provide better training, what do you mean? More frequent? More comprehensive? More illustrations? What specifically would make the training better?

[suetje]

When you say that machine manufacturers need to provide better training, what do you mean? More frequent? More comprehensive? More illustrations? What specifically would make the training better?

Better training means that a priority should be that there are a few (depends on the size of the staff) Super users who attend more than one class, maybe even help teach or do hands-on with the rep, and then can help get the program going within the institution. The institution is responsible for the frequency of the training. Remember, JACHO is going to be checking this records to see if you are competent and how you get 'certified.' There should be a 'theory' class, like the one described above, where you learn about pressures, blood rates, blood flow, how to detect clotting etc. Also how the machine works. No one will get used to the machine, no matter what it is if the docs never order the therapy. So hands on, some user guides, or flashcards to reinforce key points, maybe a video all help to keep staff educated. Also, there is an Annual CRRT conference in San Diego each year that covers ALL aspects of CRRT, and also a lot of ICU staff. It is great. In addition, usually at the National Teaching Institute for Critical Care (NTI)there are one or 2 talks on it. So plenty of stuff to learn from.

[Hellllllo Nurse, BSN, RN]

I have a close friend who is a traveling dialysis tech (I'm a traveling dialysis RN) he's working acutes in Las Vegas. He tells me that there are no nurses doing acute dialysis in Las Vegas.

The techs set up the machines, mix the baths, do the hemo, PD, the cycler, the CRRT, plasmaphoreses, give Mannitol, Albumin and even blood. He says the ICU nurses give the Epo & Ferrlecit, that's it.

They have no dialysis nurses at all.

Shocked the heck out of me.

[suetje]

I have a close friend who is a traveling dialysis tech (I'm a traveling dialysis RN) he's working acutes in Las Vegas. He tells me that there are no nurses doing acute dialysis in Las Vegas.

The techs set up the machines, mix the baths, do the hemo, PD, the cycler, the CRRT, plasmaphoreses, give Mannitol, Albumin and even blood. He says the ICU nurses give the Epo & Ferrlecit, that's it.

They have no dialysis nurses at all.

Shocked the heck out of me.

I know some years ago they were doing it (ICU nurses) because I went out there to train them..However, some ICU staff thinks this is a dialysis job. It's NOT! The ICU nurse is the one who knows precisely the pts. fluid balance, CVP etc, and can determine how well the CRRT is working. Anyway, I have a feeling that for as much as Las Vegas is growing, they may not be doing much of this. Too bad for anyone who gets renal failure there!!!

[Hellllllo Nurse, BSN, RN]

I know some years ago they were doing it (ICU nurses) because I went out there to train them..However, some ICU staff thinks this is a dialysis job. It's NOT! The ICU nurse is the one who knows precisely the pts. fluid balance, CVP etc, and can determine how well the CRRT is working. Anyway, I have a feeling that for as much as Las Vegas is growing, they may not be doing much of this. Too bad for anyone who gets renal failure there!!!

My friend tells me that the techs are mostly privately contracted thru several agencies. They often work 20-24 hrs straight. He says the nurses there are strictly ICU nurses and don't know anything about dialysis, nor does their job require them to.

I did recently read an article that shows that dialysis pts in NV have the highest morbidily/mortality rates of any other state. I wonder why!

[lake living]

We have the prisma and Gambro always comes and helps train. we looked at the NxStage but that drain taped on the floor is disgusting, how about yeats growth after 12 hours? What happens when a family member trips over the tubing. I am not sure JCAHO would accept it. Our Risk management and Infection control have ruled it out. As we can't run extension cords across the floor we can't run this drain. we utilize Gambro for 8hour classes and the we have a preceptor. Gambro has been great.

[suetje]

Interesting. How does your dialysis staff drain their effluent? In a bag? Of course not, down the drain (some even in the sink.) There are about 70 major university and academin centers that use the Nxstage that the infection control depts have not had an issue with the drain line, and this is likely because, as you know the effluent is sterile. It is filtered thru the hemofilter ports, and bacteria cannot get in or go out. Of course, if you love lugging bags, you should stick with the bag system. I am sure you also recently saw the story in Nephrology News and Issues, April 2006 that found that Gambro was linked to 9 deaths and 11 injuries with their Prisma machines (not to mention all the non reported deaths) because of the incompetant scale system. Might want to make sure your patient is not having adverse effects from those wonderful machines. The FDA has put them in a no sell, no import situation until further notice this was so severe.

[lake living]

That scale issue is the nurse not correcting alarms, effluent in the line will grow yeast within 12 hours. Our infection control vetoed the use. We just drain the effluent line in a container or toliet. I have no problem lugging. Look at NxStage they are in the hole financially, I also heard Gambro will get their import ban lifted. I am sure that NxStage and the other companies will have issues with the FDA too. NxStage is so new that they couldn't have the volume of treatments where as Gambro has done what a million? vs. 200 by NxStage? , Their scales are very accurate they are weighed where as Nxstage just dumps!! We only have specific beds used for dialysis and when they drain it is only in 4 hours not draining across for 24 hours. I also wouldn't want to lift all that weight above my head!! We also called JCAHO and they stated this was probably not acceptable. We have never had a problem with patients because we answer are alarms. I saw that NxSatges screen and you get codes I would think that would be hard to troubleshoot.

[ICU/Acute DialysisRN]

I did acute dialysis for 9 years--we set up the machines and were available 24hrs a day with a 1 hr response time to reset up the machine and to be there for the ICU RN if there were problems. I am now working again as an ICU nurse (too much CRRT call) and am seeing the other side of it. We used Prismas but now have changed to Nxstage--you still lug bags to the nxstage--and yes it's nice to not have to empty effluent bags--we put a plastic cord piece over the drain hose to stop the tripping, but my big concern that no one else seems to be worried about is the size of the Nxstage filter--240ml! vs. the Prisma's 80ml. Everytime we clot a filter we throw out 240ml of blood!!! I am doing ed classes to work on the things we as nurses can do to prevent some of the clotting but sometimes it's unavoidable and Nxstage acts like it's no big deal. ICU patients on CRRT can not tolerate that kind of blood loss AND they say there filter is so large for blood flow up to 600ml/min and for larger volume removal--what ICU/CRRT patient can tolerate 600ml/min blood flow and IF they can handle large amt of volume removed --do a hemo treatment! I'll take the Prisma back anyday!! Most of the problems with Prisma are--I hate to say this, but since I'm on both sides--are user error--the things I see done to that CRRT machine opened my eyes to why I was called in so much. More education is needed and needs to be done by ICU nurses not Gambro/Nxstage sales reps!!!

[lake living]

I agree the nurses need more training, Yes 240 cc would really drop their Hg and then think about the cost of transfusions. I know that yeast grows within 12 hours in the effluent line and that is why we opted not to use the NxStage. I think nursing as a whole has changed and that is scary. I am glad you came to ICU. dialysis does play a huge role in CVVH but often times not all the staff will come in if a circuit goes down.