Should CVVHD be 1:1

oregonnurse2007 · Jan 24, 2011

CRRT at my hospital is a 1:1, on occasion if we are holding an overflow med/surg pt or a not-medically-cleared psych pt it will be paired up with that. IABP are 1:1, but not vents. I routinely have two vent patients, and it is very manageable. Also if we have someone on frequently titrated pressors that pt is 1:1. If we have a pt that's on 3 or more machines then it is a 2:1, ie vent, CRRT, IABP, ECMO, VAD. Sorry that your manager does not see this. Would the AACN have any literature on best practice for CRRT patients? If it supports 1:1, maybe you could bring this up to him/her?

s_elliott52 · Jan 26, 2011

It may be wrong to tell you guys this but the UK the recommendations are that vent, CRRT, IABP all 1:1 even if they are not sedated. Any HDU/ward patient can be 1:2 but normally on my unit 1:1. Any patient on ECMO/VAD are always strictly 2:1, with once of these being an experiences and trained ECMO specialist....Tell me again why I want to move to USA!!!

xtine618 · Feb 21, 2011

I have only taken care of CRRT patients on a citrate gtt and even those patients who are stable are still busy! Our protocol requires us to draw labs q 2 hrs and depending on the settings, I could be changing dialysate and replacement bags every 1.5 hrs. And those don't usually fall on the same schedule. I am usually doing something every 15-30 minutes. And that's if they're stable. I would not feel comfortable having a second patient. Luckily in my facility they are 1:1.

Ruby Vee, BSN · Feb 21, 2011

i have only taken care of crrt patients on a citrate gtt and even those patients who are stable are still busy! our protocol requires us to draw labs q 2 hrs and depending on the settings, i could be changing dialysate and replacement bags every 1.5 hrs. and those don't usually fall on the same schedule. i am usually doing something every 15-30 minutes. and that's if they're stable. i would not feel comfortable having a second patient. luckily in my facility they are 1:1.

our cvvhd patients are usually on insulin drips -- blood draws every hour. what are you drawing every two hours?

xtine618 · Feb 21, 2011

our cvvhd patients are usually on insulin drips -- blood draws every hour. what are you drawing every two hours?

ours are routinely on insulin gtts also, but i don't usually count those as lab draws since sometimes they are finger sticks. our patients on crrt either get heparin or citrate for anticoagulation. those on citrate gtts get ionized calciums drawn q 2 hrs. and each time they are drawn from 2 different sites. one from the patient and one from the machine. after it's resulted, we titrate the calcium and citrate gtts according to the protocol. and the most common mistake made in this process is the blood being mislabeled since both ionized calciums are being drawn at the same time.

not to mention serial chemistries being drawn q 4-6 hrs and needing replacement. sometimes it's hard to find time to go to the bathroom let alone find time to care for another patient. sure there are times that i could take another patient, provided that they were very stable and not on the call light every 30 minutes, but our policy (and luckily our staffing) supports 1:1 crrt.

sister s · Mar 2, 2011

Australia

aking2157 · Jan 5, 2012

WOW! A vented patient on a 1:1? That's nuts in my opinion. An intubated patient is all apart of being an ICU nurse! We are always 2:1 except if our patient is on CVVHD, Aquaphoresis, has a balloon pump, or is in the CVU and is less than 24 hrs post op open heart sx regardless of stability. Theses patient are ALWAYS on a 1:1. Even the most stable patients can become unstable at any time.

ShaunES · Jan 6, 2012

Theses patient are ALWAYS on a 1:1. Even the most stable patients can become unstable at any time.

That's why they're 1:1.

What's the difference between an intubated patient and someone on CRRT?

If you lose an airway that's a lot bigger deal than your circuit clotting.

I don't understand.

Biffbradford · Jan 6, 2012

With CRRT you're constantly changing bags, adjusting removal rates, and the charting is time consuming.

Someone on a vent ... well, you just watch them. *Yawn* :yawn:

ShaunES · Jan 7, 2012

If the argument is that it's time consuming, then I agree, it can be time consuming. On the other hand, changing bags takes a minute or two at most, and fluid removal is simple.

As for charting, I'm not sure how you guys do it, but it's pretty simple for us, just bang in the pressures and the fluid removed and you're done; when compared to the other hourly stuff you do it's not a big deal at all.

Simply put if acuity is the reason you 1:1 these patients then I would reasonably expect ventilators to be 1:1.

ckh23, BSN, RN · Jan 14, 2012

Simply put if acuity is the reason you 1:1 these patients then I would reasonably expect ventilators to be 1:1.

I understand the point you are trying to make, but it is not all encompassing. For example, there is no need for a drunk that was combative in the ER and then tubed to be a 1:1 when he will be extubated in the AM. I really think 1:1 should be on a case by case basis except for those that are immediately 1:1 due to their condition such as liver tx and fresh hearts.

I also agree that the CVVH is not that time consuming for me either, unless you are running into clotting issues and catheter issues. I think it depends on what equipment you are using and what flow sheet/charting your facility has in place.

Piglet08 · Jan 19, 2012

Well, CVVHD is different from a ventilator in that it carries with it the risk of rapid - pump-driven! - exsanguination, and I've as yet seen no alarm system against THAT. And a nurse who thinks a clotted circuit is the "big problem" in cvvhd has not been sufficiently prepared to care for a patient on cvvhd.

In our ICU, when a patient is on dialysis, the dialysis nurse stays at the bedside. So we're 1:1 for cvvhd, too. I hope that doesn't change.