New adequacy calculation

Trauma Columnist · Oct 30, 2011

Residual function only allows the pt to be a little looser with fluid. It has no effect on the filtering of toxins. CMS has decided that a URR of 65 is adequate. That's actualy barely adequate. The higher the kT/V is (>1.4) the better for the pt.

Any pt on HD has a GFR of

just keep swimming · Oct 30, 2011

Residual function only allows the pt to be a little looser with fluid. It has no effect on the filtering of toxins. CMS has decided that a URR of 65 is adequate. That's actualy barely adequate. The higher the kT/V is (>1.4) the better for the pt.
Any pt on HD has a GFR of
Thank you for your response but i guess I'm still confused about something...if residual function only allows the patient to be looser with fluids, what about those patients who only run once or twice a week because they still have some function? I understand KT/V and URR and the implications of poor results, just wasn't sure where residual function came in. If I'm not mistaken, it was calculated into the KT/V and produced a higher number. Should this not be part of the KT/V?

Trauma Columnist · Oct 31, 2011

Hmm - I'm with a large nephrology practice and we have no one running once/twice/week. If they only need dialysis once per week, they don't need dialysis.

Wonder what their GFR is? CMS is coming down hard on providers that try to do HD for other than ESRD.

just keep swimming · Oct 31, 2011

I have patients who only come a couple times each month and we have no record of them going to any ER in the area to dialyze. Those who are only scheduled once/twice/week are usually expected to regain function but are going to need dialysis too long to be considered acute (one lost function while on chemo but regained it within a few months). As for the patients who are non compliant, they must have a significant amount of residual function to be able to come so infrequently. Some do not even reach a KT/V of 1.2 because their pre BUN is not high enough. Do you think that maybe these people are being started too early? Eventually, they almost all end up 3/week or very ill, however I have some who have been doing it for many months, some close to a year.

I work in a very large, inner city unit. We get all the difficult patients and all of the non compliant patients...

Trauma Columnist · Nov 1, 2011

lol - my biggest clinic is 130 pts of noncompliant, inner city, tough as nails pts.

I too have several that only come intermittently, they haven't urinated in years! Don't know why they survive.

My own theory is that they have lived very hard lives and have had to survive many difficulties so surviving w/o working kidneys isn't so bad.

My other thought is that they have been so sick for so long that they don't realize what feeling good is anymore.

just keep swimming · Nov 2, 2011

Sounds like you work in my world! I love it but it sure is challenging sometimes. I hope you don't mind me picking your brain...I'm always looking for new things to learn and unfortunately, the NP I work with has been there 3 years and is still asking about when to schedule a fistulogram or how we know when to adjust EDW.....grrrrr! But I'll save that rant for another day. Luckily, I have some great docs who are great teachers! I'm in school for my BSN right now and hope to continue to be a NP eventually (when my kids give me time that is). I read your thread about "how much do you want to take off today". What do you do with those patients who chronically put on 8 or more kg and then crash when trying to pull the fluid, especially with those whose cardiac function is poor?

Trauma Columnist · Nov 3, 2011

Well, I refuse to allow >6% EDW (not the weight they come in at) to be pulled.

The other issue is that I work for 17 docs and they all have their own way of managing pts. I always error on the safe side and the newest literature says that removing 11ml/kg/hr is the best way to decrease the cardiac stress.

So, I've been using that. I provide lots of education to my pts. Plus, the one unit, where the most noncompliant pts are, have seen pts die in the chair and that scares them....usually.

Trauma Columnist · Nov 3, 2011

BTW - I've only been doing this 5 1/2 years. My nursing background is ER/ICU.

The reason I was hired was that it was felt I could handle the attitudes of the pts.

lol

msnmbahcm · Nov 3, 2011

I am a traveler and am currently in Arizona. It has been my experience that using PUF (sequential dialysis) for the 1st hour, to take off 2L has been positive, no cardiac issues nor any b/p issues. I worked in an acute setting where we did CRRT, PUF, SLED, etc and I have conferenced with docs all over and they like the fact we can decrease EDWs effectively with this mode in the OP setting.

just keep swimming · Nov 4, 2011

BTW - I've only been doing this 5 1/2 years. My nursing background is ER/ICU.
The reason I was hired was that it was felt I could handle the attitudes of the pts.
lol

LOL! That's the same reason they assign me all the "difficult" patients! Keeps it interesting. Thanks for you input. I have one patient that I think it may be good to try the 11ml/kg/hr on. As for your experience, the 5 1/2 half years are more than adequate as it appears you put the work into knowing what you are doing. When I was complaining about the NP I work with I was trying to point out that he doesn't care to put the work in and relies only on what the nurses tell him. It's awesome when docs and NP's listen to us but, if they do not put in the effort to learn the field they are practicing in, I have a hard time giving them the respect they "deserve". Maybe I'm being a little hard on him, but if I saw any effort from his side, I wouldn't be so harsh....

just keep swimming · Nov 4, 2011

I am a traveler and am currently in Arizona. It has been my experience that using PUF (sequential dialysis) for the 1st hour, to take off 2L has been positive, no cardiac issues nor any b/p issues. I worked in an acute setting where we did CRRT, PUF, SLED, etc and I have conferenced with docs all over and they like the fact we can decrease EDWs effectively with this mode in the OP setting.

I agree that this works well for some patients and have used it many times in the past. The difficult part is getting those patients who are so non compliant already to sit in the chair an extra hour!