CONTINUOUS RENAL

REPLACEMENT THERAPY

Submitted to Submitted by

Prof. Agnet Beena Mani Nice Mathew

H.O.D Medical Surgical Nursing 2nd year M.Sc. Nursing

BMCON BMCON

Calicut Calicut
INTRODUCTION

The impact of acute renal failure on patients and families is often unexpected and despite
new technology, it remains a serious disease with high mortality rate. For the management of
acute renal failure several type of continuous renal replacement therapies are available during
recent years and are widely used in critical care units. The key aim of the therapy should be to
improve the quality of life.

DEFINITION OF RENAL REPLACEMENT THERAPY

Renal replacement delivered through a variety of means, is a process by which fluid and waste
products are filtered through a semipermeable membrane to assist in elimination from the body.
It may be done with or without the addition of dialysate solution.

Renal replacement therapy is a term used to encompass life-supporting treatments for renal
failure.
It includes:

 hemodialysis,
 peritoneal dialysis,

 hemofiltration and

 renal transplantation.

CLASSIFICATION OF RRT MODALITIES

1. Intermittent

a. Intermittent hemodialysis

b. SLED ( Sustained low efficiency dialysis) / EDD ( Extended daily dialysis)

2. Continuous

a. Peritoneal dialysis

b. CRRT

i. SCUF ( Slow continuous ultrafiltration)

 ii. CAVH and CVVH (Continuous arteriovenous hemofiltration and Continuous
venovenous hemofiltration)

iii. CAVHD and CVVHD (Continuous arteriovenous hemodialysis and continuous

venovenous hemodialysis)

iv. CAVHDF and CVVHDF (Continuous arteriovenou hemodiafiltration and continuous

venovenous hemodiafiltration)

PRINCIPLES OF RRT

 OSMOSIS- It is the process by which water moves from an area of higher solute
concentration (the blood) to an area of lower solute concentration (the dialysate bath).
 DIFFUSION- It is the process where particles move from an area of high concentration
through a semipermeable membrane to a solution of low concentration.

 ULTRAFILTRATION- It is a process of removal of fluid from the extracorporeal circuit

by creating a pressure across the membrane.

 CONVECTION- It is the process whereby replacement fluid pulls waste through the
semipermeable membrane. High flow rates of fluid ( e.g 1000-2000 ml/hr) drag more
particles across the membrane than slower flow rates.

 ADSORPTION-Molecular adherence to the surface or interior of the membrane

HEMODIALYSIS VS HEMOFILTRATION

1. hemodialysis is a method that is used to 1.Hemofiltration is the removal of waste

achieve the extracorporeal removal of waste products from the blood by using large amounts
products such as creatinine and urea and free of  ULTRAFILTRATION with reinfusion of sterile
water from the blood when the kidneys are in a replacement fluid. It is a medical procedure
state of renal failure. It requires only 4-5 hours. related to replace kidney function, for patients
It is usually performed 2-3 times wkly. with acute (sudden) kidney (renal) failure
(ARF). Hemofiltration is usually a slow
procedure, over 10-12 hours, through a central
 venous catheter. It is usually performed daily.

2.Haemodialysis removes solutes only by 2.Haemofiltration removes solutes by

diffusion. As such, it is relatively inefficient for convection along with diffusion. As such,
solutes of high molecular weight as clearance by efficiency remains more constant for all solutes
diffusion is inversely related to the molecular able to cross the semi-permeable membrane.
weight of the solute.

3. Those in favour of haemodialysis: 3. Points in favour of haemofiltration include:

 less expensive  better control of blood pressure

 technically easier  less risk of hyperlipidaemia

 toxicity of molecules of high molecular

weight has yet to be demonstrated

 haemofiltration can only reduce, not

normalise, the concentration of larger
solutes

CONTINUOUS RENAL REPLACEMENT THERAPY

Continuous renal replacement therapy (CRRT) is any extracorporeal blood purification

therapy designed to substitute for impaired renal function over an extended period, and intended
to be applied for up to 24 hours a day.

CRRT is an additional means by which fluids, wastes, and electrolytes, as well as other
small to medium size particles, can be removed from the body via ultrafiltration and dialysis in
patients with ARF.

CRRT is an alternative or adjunctive method for treating ARF. It provides a means by

which uremic toxins and fluids are removed, while acid-base status and electrolytes are adjusted
slowly and continuously from a hemodynamically unstable patients.
 CRRT is a mode of renal replacement therapy for haemodynamically unstable, fluid
overloaded, catabolic septic patients. It continuous for about 24-36 hour sometimes it may be
extending up to 72 hours.

HISTORY

CRRT was originally promoted by Kramer and associates for the treatment of
hypotensive patient. Its efficacy was later process by Peganini in 1984, who used CRRT in
haemodynamically unstable patients rendering improved survival by this modality. Traditional
intermittent hemodialysis often causes hemodynamic instability in the critically ill. Continuous
renal replacement therapy (CRRT) was developed in the 1980s in an effort to provide artificial
kidney support to patients who could not tolerate traditional hemodialysis.

CRRT VS. IHD

Several features of CRRT differ from IHD:

1. It is continuous rather than then intermittent. Large volumes of fluid can be
removed over days (24 hrs to > 2 wks) versus hours (3 to 4 hrs).
2. Solute removal can occur by convection (no dialysate required) in addition to
osmosis and diffusion.
3. It causes less hemodynamic instability(e.g hypotension)
4. It does not require constant monitoring by a specialized HD nurse but does
require a trained intensive care unit nurse.
5. It does not require complicated HD equipment, but a blood pump is needed for
venovenous therapies.
6. CRRT may be more expensive than intermittent HD.

COMPARISON OF HEMODIAYSIS, CRRT AND PERITONEAL DIALYSIS

 HEMODIALYSIS CRRT PD
Access AV fistula or graft; AV fistula or graft; Temporary or
dual lumen venous dual lumen venous permanent peritoneal
catheter catheter. catheters.
Anticoagulation Systemic Systemic May only need
requirements heparinization or anticoagulation with heparin
frequent saline heparin or trisodium intraperitoneally
flushes. citrate may be Not absorbed
indicated depending systemically.
on patient’s
coagulation studies
before starting
therapy.
Length of treatment 3-4 hr, three to five Continuous through Continuous (cycled)
times per wk, day; may last as many or intermittent
depending on patient days as needed. excahanges; time
acuity. between
exchanges=1-6hrs.
Advantages Quick, efficient Best choice for patient Continuous removal
removal of metabolic who is of wastes and fluids.
wastes and excess hemodynammically Better hemodynamic
fluid. unstable b’se less stability.
Useful for drug blood is outside body Fewer dietary
overdose and than with restrictions.
poisonings. hemodialysis and
blood flow rates are
slower; amount of
fluid removed can still
be achieved but over a
much longer period of
time.
Good for
 hypercatabolic
patients who receive
large amounts of IV
fluid.
Disadvantages May require frequent Requires vascular Contra indicated after
vascular access access procedures; abdominal surgery or
procedures. potential blood loss in presence of many
Places strain on a from clotting or scars.
compromised CVS. equipment leaks; uses Waste products may
Potential blood loss an extra piece of be removed too
from bleeding or equipment. slowly in a catabolic
clotting lines. Requires specially patients
Requires specially trained staff to Danger of peritonitis.
trained staff to perform therapy.
perform therapy.

INDICATION

 CRRT is indicated in any patient who meets criteria for hemodialysis therapy but
cannot tolerate intermittent dialysis due to hemodynamic instability. CRRT is
better tolerated by hemodynamically unstable patients because fluid volume,
electrolytes and pH are adjusted slowly and steadily over a 24 hour period rather
than a 3 – 4 hour period. This pattern more closely mimics the native kidney and
prevents abrupt shifts in fluid, electrolyte and acid-base balance. In patients with
a high risk of hemodynamic instability who do not tolerate the rapid fluid shifts
that occur with hemodialysis, in those who require large amounts of hrly IV fluids
or PRN, and in those who need more than the usual 3-4 hrs hemodialysis
treatment to correct the metabolic imbalances of renal failure.
1. Acute or chronic renal failure
2. Clinically unstable patients for haemodialysis
3. Patients with fluid overload secondary to oliguic renal failure.
 4. Patients whose kidneys cannot handle their acutely high metabolic\ nutritional needs
5. To maintain electrolyte, acid – base and solute homeostasis
6. Refractory pulmonary edema
7. Drug overdose
8. Major burns with compromised renal function
9. Poisonings with a dialyzable toxin and severe rise in blood urea and serum creatinine.

CONDITION THAT WARRANT THE INITIATION OF CRRT

Clinical Condition Assessment Findings

Oliguria Urine output <200 mU12 h

Anuria Urine output <50 mU12 h
Severe acidemia due to metabolic acidosis pH <7.1
Azotemia (urea) >30 mmol/L
Hyperkalemia or rapidly rising serum Serum potassium >6.5 mEq/L
potassium levels
Suspected uremia organ involvement Pericarditis, encephalopathy, neuropathy,
myopathy
Severe alterations in serum sodium levels Serum sodium> 160 mmol/L or < 115 mmol/L
Clinically significant organ edema Pulmonary edema
Drug overdose with dialyzable toxin Aspirin overdose
Coagulopathy requiring large amounts of Disseminated intravascular
blood products in patient at risk of
pulmonary edema or acute respiratory
distress syndrome (ARDS)

PRINCIPLES OF CRRT CLEARANCE

• CRRT clearance of solute is dependent on the following:
• The molecule size of the solute
• The pore size of the semi-permeable membrane
• The higher the ultrafiltration rate (UFR), the greater the solute clearance.
• Small molecules easily pass through a membrane driven by diffusion and convection.
 • Middle and large size molecules are cleared primarily by convection.
• Semi-permeable membrane remove solutes with a molecular weight of up to 50,000
Daltons.
• Plasma proteins or substances highly protein—bound will not be cleared.
• Sieving Coefficient;;;The ability of a substance to pass through a membrane from the
blood compartment of the hemofilter to the fluid compartment.
• A sieving coefficient of 1 will allow free passage of a substance; but at a coefficient of 0,
the substance is unable to pass.
.94 Na+
1.0 K+
1.0 Cr
0 albumin will not pass

CONTRA INDICATIONS

Contraindications to CRRT include:

1. Once the patient become hemodynamically stable.
2. Advance directives indicating the patient does not desire dialysis, or that the
patient does not desire life-sustaining therapy
3. Patient or family refusal of therapy
4. Inability to establish vascular access in coagulopathies

REQUIREMENTS FOR CRRT

• CRRT requires:
• A central double-lumen veno-venous hemodialysis catheter
• An extracorporeal circuit and a hemofilter
• A blood pump and a effluent pump.
• With specific CRRT therapies dialysate and/or replacement pumps are required.

SEMIPERMEABLE MEMBRANES
 Semipermeable membranes are the basis of all blood purification therapies. They allow
water and some solutes to pass through the membrane, while cellular components and other
solutes remain behind. The water and solutes that pass through the membrane are called
ultrafiltrate. The membrane and its housing are referred to as the filter. There are two types of
membranes used in renal replacement therapy, cellulose and synthetic. Synthetic membranes
allow clearance of larger molecules and are the primary type used in CRRT. Filters are changed
when they become contaminated, clogged or clotted, and when institutional policies dictate they
be changed. With anticoagulation techniques filters can stay patent longer than they remain safe
to use
VASCULAR ACCESS AND THE EXTRACORPOREAL CIRCUIT

 There are two options for vascular access for CRRT, venovenous and
arteriovenous. Venovenous access is by far the most commonly used in the
modern ICU. A veno-venous double lumen hemodialysis catheter or two single
lumen venous hemodialysis catheters may be used.

 Access location; -
Internal Jugular Vein- Primary site of choice due to lower associated risk of
complication and simplicity of catheter insertion.
Femoral Vein- Patient immobilized, the femoral vein is optimal and constitutes
the easiest site for insertion.
Subclavin Vein- The least preferred site given its higher risk of
pneumo/hemothorax and its association with central venous stenosis.
 Venovenous access is generally achieved with the use of a large-bore (11.5 – 13.5
French) dual lumen dialysis catheter placed in a large central vein. Only one
puncture is required. The patient’s blood will be removed from one lumen of the
catheter, directed through the pump, and returned through the other lumen. By
convection blood is usually removed through the red port and returned through
the blue port. Venovenous access requires the use of a blood pump in conjunction
with the dialysis filter and tubing. Use of the pump provides reliable, adjustable
blood flow through the filter. The constant blood flow provided by the pump
lessens the risk that the filter will clot. The adjustability allowed by using a pump
 means that the flow rates can be fine tuned to suit the needs of the patient. The
pump also alarms if the system clots, becomes disconnected, or if an air bubble is
detected in the blood line. Throughout this packet we will use the Gambro
PRISMA ™ as an example. Arteriovenous access was the first method of access
for CRRT. It may still be used in facilities that do not have access to a blood
pump. To perform CRRT in this way, two punctures are required, one in an artery
for blood removal and one in a vein for blood return. The “pump” is provided by
the difference between the patient’s mean arterial pressure (MAP) and the venous
pressure. Because critically ill patients often do not have a high MAP, it is
important to remove as much resistance from the circuit as possible. Because of
this, large short catheters, short blood lines and short filters are used. Despite
these attempts to increase efficiency, arteriovenous access tends to fail at a very
high rate. The patient is also exposed to the additional risk of the large-bore
arterial access, and the lack of alarms on a system of this type.

 Dialysate
Dialysate is any fluid used on the opposite side of the filter from the blood during blood
purification. As with traditional hemodialysis therapy, the dialysate is run on the opposite side of
the filter, countercurrent to the flow of the patient’s blood. The countercurrent flow allows a
greater diffusion gradient across the entire membrane, increasing the effectiveness of solute
removal. Dialysate is a crystalloid solution containing various amounts of electrolytes, glucose,
buffers and other solutes. The most common concentrations of these solutes are equal to normal
plasma levels. The concentration of solutes will be ordered by the physician based on the needs
of the patient.
Typical dialysate flow rates are between 600 – 1800 mL/hour. There are several options for
dialysate in CRRT:
• Commercially prepared pre-mixed dialysates (Normocarb, Prismasate).
• Commercially prepared peritoneal dialysate (Dianeal). Peritoneal dialysates contain high
concentrations of glucose. When using this type of dialysate close monitoring of the patient’s
blood glucose and appropriate insulin coverage is essential.
• Custom dialysate compounded by the pharmacy.
• Commercially prepared dialysates with additives.
Replacement Fluids
Replacement fluids are used to increase the amount of convective solute removal in
CRRT. It is very important to understand that despite their name, replacement fluids do not
replace anything. Many professionals new to CRRT mistakenly believe that if replacement
fluids are added to the therapy, fluid removal rates are decreased or eliminated. This is not the
case. Fluid removal rates are calculated independently of replacement fluid rates. The most
common replacement fluid is 0.9% Normal Saline. Other crystalloid solutions may also be used
as replacement fluid. Sometimes an additive will be added to the replacement fluid bag to aid in
correction of electrolyte or acid-base balance. An additive incompatible with the dialysate
solution can sometimes be safely added to the replacement fluid. The decision to infuse
replacement fluids before or after the filter is made by the physician. Replacement fluids
administered pre-filter reduce filter clotting and can be administered at faster rates (driving
higher convection) than fluids administered post-filter. The downside of pre-filter replacement
fluids is that they invalidate post-filter lab draws; the lab results will show the composition of the
replacement fluid rather than that of the effluent. Some physicians use labs drawn in this way to
gauge the efficiency of the filter, and thus prefer post-filter administration of replacement fluids.
Follow the physician’s orders when setting up replacement fluids.
Anticoagulation & CRRT
Anticoagulation is needed in CRRT because the clotting cascades are activated when the
blood touches the non-endothelial surfaces of the tubing and filter. CRRT can be run without
anticoagulation, but filters last much longer if some form of anticoagulation is used. Options for
anticoagulation include Heparin, Prostacyclin, Citrate, and no anticoagulation. Direct thrombin
inhibitors are also being investigated for use in CRRT.

Heparin
Most medical professionals caring for CRRT patients are well-acquainted with Heparin.
It is a common parenteral anticoagulant that works by inhibiting clot formation. When used for
anticoagulation in CRRT, Heparin can be used in several ways. Regardless of how it is
administered, Heparin carries with it the risk of Heparin-induced thrombocytopenia and
thrombosis (HITT). Platelet counts must be monitored, and HITT should be suspected if the
platelet count drops by more than 50% from the patient’s baseline after Heparin therapy is
begun. If HITT is suspected, all forms of Heparin must be discontinued immediately.
• Low-dose pre-filter unfractionated Heparin: any dose less than 5 units/kg/hour. This dose is
common in many institutions and is reported to have minimal effect on the activated partial
thromboplastin time (aPTT). The Heparin may be administered using a pump integrated into the
CRRT machine, or via a separate volumetric pump
• Medium-dose pre-filter unfractionated Heparin: a dose between 8-10 units/kg/hour. This
dose reportedly mildly elevates the aPTT and can be used for patients with minimal risk of
bleeding. The Heparin may be administered using a pump integrated into the CRRT machine, or
via a separate volumetric pump.
• Systemic unfractionated Heparin is administered intravenously and titrated to achieve an
activated partial thromboplastin time (aPTT) ordered by the physician. The Heparin is usually
administered using a separate volumetric infusion pump. This dose is typically reserved for
patients who have another indication for Heparinization, such as deep vein thrombosis or cardiac
valve replacement.
• Regional unfractionated Heparin: a pre-filter dose of 1500 units/hour of Heparin combined
with administration of Protamine post-filter at a dose of 10-12 mg/hour. This approach is
monitored with the aPTT, keeping the patient’s aPTT as close to normal as possible. Protamine
can have serious side effects in some patients, including hypotension, cardiovascular collapse
and acute pulmonary hypertension. The Heparin is administered via a separate volumetric pump,
as is the Protamine. There is some scientific evidence supporting this approach.
Low-molecular-weight Heparins (LMWH): These agents can be used to prolong filter life.
They have not been shown superior to unfractionated Heparin for this use, but they are less likely
to cause complications such as Heparin-induced thrombocytopenia (HITT). Even though LMWH
are less likely to cause HITT, they are contraindicated for patients who have developed HITT
because of cross-reactivity. LMWH are administered subcutaneously. Anticoagulation is
monitored with Factor Xa levels which may not be readily available in all hospitals, and
Protamine results in only partial reversal of LMWH.
Prostacyclin
Prostacyclin is a very effective platelet antagonist and there is evidence to show that it can
prolong filter life. Prostacyclin is extremely expensive and can induce hypotension, it is rarely
used.
Citrate
Regional anticoagulation of the filter can be achieved through the use of Citrate. Citrate inhibits
clotting by binding Calcium, a key cofactor in many steps of the clotting cascade. Citrate is
infused pre-filter using a volumetric infusion pump. A Calcium Chloride infusion is administered
to the patient to replace the Calcium bound by the citrate. Anticoagulation is monitored using
ionized calcium levels. Risks include hypocalcemia and metabolic alkalosis. When Citrate
anticoagulation is used, dialysate and replacement fluids must be calcium free.
No Anticoagulation
Many critically ill patients are at increased risk of bleeding. In these patients
anticoagulation may not be needed to achieve adequate filter life, and avoiding anticoagulation is
safer for the patient. The following types of patients probably do not require anticoagulation:
• Platelet count < 50,000/mm3
• INR > 2.0
• aPTT > 60 seconds
• actively bleeding or with an active bleeding episode in the last 24 hours
• severe hepatic dysfunction or recent liver transplantation within 24 hours post cardiopulmonary
bypass or extra-corporeal membrane oxygenation
(ECMO)
A trial of CRRT without anticoagulation may be tried if there is concern about the risk of
bleeding for these or other reasons.

ADVANTAGES

1. CRRT by its lower rate of removal of fluid can lead to steady state fluid equilibrium in
haemodynamically unstable, critically ill patients.
2. It provides excellent control of azotemia, electrolyte and acid base balance.
3. It is effective in removing fluid in special circumstances- post surgery, pulmonary edema
ARDS etc.
 4. Haemofiltration modality is effective in lowering intracranial tension. Prevention of rapid
shift in intracerebral water. Sometimes in routine intermittent hemodialysis which can
sometimes raise intracranial tension
5. Better tolerated by critically ill patient
6. CRRT is a slow procedure, so only 150-200 ml may be filtered in one hour so chance of
hypotension is low.
7. Control of phosphate and calcium balance.
8. Ability to provide protein rich nutritional support while achieving excellent uremic
control.
9. Minimal risk of infection
10. High level of biocompatibility.

DISADVANTAGES OF CRRT

1. It is expensive
2. It requires regular monitoring of hemodynamic status and fluid balance
3. Regular infusion of dialysate
4. Continuous anticoagulation
5. Ongoing alarms

TYPES OF CRRT

1. Continuous haemofiltration
a. Continuous arteriovenous haemofilration
b. Continuous venovenous haemofiltration
2. Continuous haemodiafiltraiton
a. Continuous venovenous haemodiafiltration
b. Continuous arteriovenous haemodialysis
3. Continuous haemodialysis
a. Continuous arteriovenous haemodialysis
b. Continuous venovenous haemodialysis
c. Slow low efficiency Diffusion haemodialysis
4. Slow continuous ultra filtration
 1. CONTINUOUS HAEMOFILTRATION
a. Continuous arteriovenous haemofilrtaion(CAVH)

It is the first used method of CRRT in 1977.This procedure provides a simple method of
removing fluid from the patient and at the same time convective removal of solutes.

It is rarely used today as more advanced techniques have been developed. It mainly used
to treat fluid overload.

Procedure: (Femoral artery- Femoral vein)

Blood flows from the femoral artery by an arterial catheter to the hemofilter. Mainly
using the patients arterial pressure than that of blood pump as used in haemodialysis. A pressure
gradient is necessary for optimal filtration. (cannulation of femoral artery and vein provides the
necessary gradient in arterial and venous pressure).The filtered blood returns to the patients
circulation through a venous catheter. intravenous fluid may be administered to replace the fluid
removed by the procedure. In CAVH, there is no concentration gradient. So only fluid is filtered.
Electrolytes are eliminated only as they are pulled along and removed with the fluid. ultra filtrate
is collected in drainage bag measured and discarded. It is mainly set up and initiated by trained
dialysis staff and maintained and monitored by critical care personnel 50-200ml blood is filtered
in one hour
.

Advantages

 Simple to use
 Does not require mechanical blood pump. Because the mean arterial pressure
drives the blood in to the filter.
 Well tolerated
 Effective clearance of excess of free water
 Simple technology
 Retains most of nutrients and proteins.

Disadvantages

 Risk of bleeding from puncture site in artery

 Chance of disconnection during the procedure
 Recurrent clotting problems
 Spasm of the artery cannulated
 The patient has to remain in bed fill the catheter in situ
 only fluid is filtered.
 Fluctuations in blood pressure
 b. CONTINUOUS VENOVENOUS HAEMOFILTRATION (CVVH)

Continuous haemofiltration with the aid of blood pump provides solute removal by
convection. If offers high volume ultrafilrtation using replacement fluid. The pump guarantees
adequate blood flow to maintain required ultra filtration rates. The addition of a blood pumb to
the circuit removes the necessity for arterial access, and provides a more reliable and controllable
method of delivering treatment.

Procedure:-

A double lumen catheter is inserted into a large vein. Internal jugular vein is proffered
over femoral vein and femoral vein is opted over subclavion vein. Blood from a double lumen
venous catheter is pumped using a small blood pump through a haemofilter and then returned to
the patient through the same catheter. It provides continuous slow fluid removal by ultra
filtration.

Advantages

 Hemodynamic effects are mild and better tolerated by patients with unstable conditions
 No arterial access is required
  Critical care nurse can set up, initiate, maintain and terminate the system .
 It has rapid and constant blood flow rate.
 Most frequently used method in ICU because its ease of cannulating a central vein and
use of a pump in the circuit and greater removal of urea, metabolic wastes and fluids by
adjusting the pump speed..

Disadvantages: Air embolism , hemorrhage, central vein thrombosis , hematoma

B. CONTINUOUS HAEMODIAFILTRATION

a. CONTINUOUS VENOVENOUS HAEMODIAFILTRATION

In this method mainly uses both convection and diffusion to remove fluid, waste
particles, and other toxins. Like dialysis a dialysate solution runs counter to the blood, and
particles are removed by diffusion. Dialysis solution is for increasing the efficiency of small
molecule clearance. Small molecule (urea) clearance by diffusion is more efficient . It is possible
to use standard blood monitor for the extra corporeal circuit and then use infusion pumps to
administer dialysate and replacement fluid. In addition, an electrolyte solution is pumped into the
blood to promote convention. It has the best clearance but more expensive and technically
challenging.

Diagram – CVVHOF
CONTINUOUS ARTERIO VENOUS HAEMODIAFILTRATION

It is same as continuous venovenous hemo diafiltration. Only the change is access

line is artery and returning blood to vein. It also has high permeability dialyzer with
countercurrent flow through dialyzer compartment. In excess of patients weight loss
solute clearance by both diffusion and convection.

b. CONTINUOUS HAEMODIALYSIS
a. Continuous arteriovenous haemodialysis

It has the many of the characteristics like. The blood flows through the system depends
on the patients arterial pressure. Blood pump is no needed. But it offers the advantage of a
concentration gradient for faster clearance of urea. This is accomplished by the circulation of
dialysate on one side of the semi permeable membrane.

b. Continuous venovenous haemodialysis

It is similar to CVVH. Blood is pumped from a double venous catheter

through a haemofilter and returned to the patient through the same catheter. Here no need for
replacement fluid. It facilitates the removal of uremic toxins by the help of concentration
gradient. Haemodynamic effects are usually mild as critical care nurse can set up initiate,,
maintain and terminate the system. In this method uses the same principle in intermittent
haemodialysis but operates at a greatly reduced rate. It has fully automated systems which
provides a reliable and easy method of monitoring the fluid balances of patients who are
critically ill..
 An example of integrated system for continuous fluid management and
automated renal replacement therapy is the prisma machine. This plasma machine has a basic
blood module with blood pump venous and arterial pressure monitoring and an air detector. The
fluid monitor has 2 integral pumps. One to remove the fluid from filter and the second to pump
replacement fluid to the patient. The replacement fluid and ultra filtrate are suspended on a
weigh scale, which calculates and controls a liner patient weight.

The main advantage of this machine is due to accurate fluid control, the nurse does not need
to constantly to ensure and record fluid loss and replacement.

5.SLOW CONTINUOUS ULTRA FILTRATION

It is also used to remove the fluid. It involves convection through a process

called ultra filtration. In this fluid removal is the therapeutic goal, while some urea is also
removed. It has the lower solute clearance.

It has lower blood flow and dialysate flow rate. it takes 6 and 8 hours. Because of lower
blood flow special attention for anticoagulation of circuit to prevent clotting.

5. CONTINUOUS PLASMA FILTRATION – ADSORPTION

 Therapeutic plasma exchange is an extracorporeal blood purification technique, for the
removal of large molecular weight substances form the plasma. Plasma is separated from the
whole blood and then a replacement fluid is infused in equal volume to the plasma has been
removed. Diffusion is the process used in this method, where movement of solutes occur a
semipermiable membrane. For the replacement fresh frozen plasma, and albumin alone or with
normal value can be used. Albumin has the advantage that there is no risk of viral transmission
and minimum risk of anaphylaxis.

DIFFERENCES

Sl. Specialties Continuous Continuous Continuous Slow

No hemofiltratin haemoidia filtration haemodialysis continuous
ultra
filtration
1. Arteriovenous(AV) AV/VV AV/VV AV/VV AV/VV
orVenovenous(VV)
1. Blood flow 50-200 50-200 50-200 50-200
(ml/min)
2. Dialyzate flow - 10-20 10-20 -
( ml/Min)
3. Clearance (L/24 hr) 12-36 12-40 14-36 -
4. ultra filtration 8-25 8-12 2-4 2-5
rate(ml/min)

5. Blood filtrate Highly High permeability Low permeability Highly

permeable dialyzer with dialyzer with permeable
filter countercurrent flow countercurrent filter
through dialyzer flow through
compartment dialyzer
compartment
6. Ultra filtrate Replaced in In excess of patients Corresponds to Corresponds
part or weight loss, solute weight loss; solute exactly to
completely clearance by both clearance by patients
to achieve diffusion and diffusion weight loss
 purification convention
and volume
control
7. Replacement fluid Yes yes: to achieve fluid None None
balance
8. Efficiency Clearance for Extends from small to Limited to small Used only for
all solutes large molecules molecules fluid control
equals ultra in
filtration overhydrated
states

COMPLICATIONS

A. Technical
 Vascular access malformation
o Vascular spasm(initial BFR too high)
o Movement of catheter against vessel wall
o Improper length of hemodialysis catheter inserted
 Air embolism-
 Leaks or faulty connections in tubing
 Line separation.
 Circuit blood clotting and decreased blood flow
 Fluid electrolyte imbalance
 Excessive fluid removal without appropriate fluid replenishment
 High ultrafiltration rates (high clearance)
 Inadequate replenishment of electrolytes by intravenous infusion,
 Inadequate replenishment of bicarbonate loss during CRRT

B. Clinical
 Bleeding :-
 Ineffective anticoagulation therapy
 Clotting of hemofilter
  Inadvertent disconnection in the CRRT system
 Hemorrhage due to over-anticoagulation
 Blood filter leaks
 Thrombosis
 Infection/Sepsis
 Bioincompatibility of membrane
 Hypothermia
 Nutrient losses
 Hypotension- Intravascular volume depletion
Underlying cardiac dysfunction
 Cardiac arrest
 Hypotension/hypertension
 Hemolysis
 Air embolism
 Circulatory overload
 Arrhythmias

CRRT is a complex invasive therapy and can cause complications. The most common
complications encountered include bleeding, infection, fluid & electrolyte imbalances,
hypothermia, and hemodynamic instability.
Bleeding
Bleeding complications related to CRRT can be local or systemic. Local bleeding can
occur at the vascular access site and may or may not be visible. Visible bleeding includes
external bleeding, hematoma and ecchymosis. The site should be monitored hourly for these
changes. Vascular access sites can also bleed in areas that are not visible. Subclavian and
femoral lines in particular may cause internal bleeding that is not immediately apparent. Monitor
the hemoglobin and hematocrit for decreases that may indicate hidden bleeding. Inadvertent
disconnection of the CRRT blood circuit could lead to significant blood loss. Modern CRRT
machines are equipped with alarms and cutoff switches to minimize this risk.
 Generalized bleeding complications can occur as a side effect of anticoagulation or as a
result of critical illness itself. Monitor the platelet count for thrombocytopenia. Monitor the
patient and lab data for signs of disseminated intravascular coagulation (DIC). Check all skin
surfaces for petechiae and ecchymosis, and monitor wounds and punctures for oozing. Keep in
mind that not all bleeding can be seen. Bleeding that is not visible externally is called occult
bleeding,. Hypotension is usually a late sign of bleeding. If sudden hypotension occurs, consider
the possibility that the return lumen may have slipped out of the vessel. Though rare, this event
results in the patient’s blood volume being pumped into the extravascular space. All symptoms
of hypovolemia will be noted. Other symptoms are dependent on the location of the return
catheter.
Hypothermia
Causes
• Patient’s blood in extracorporeal circuit at room temperature
• Administration of large volumes of room temperature fluids (replacement and
dialysate)
Signs and Symptoms
• Hemodynamic instability
• Chilling, shivering,Skin pallor, coolness and cyanosis
Treatment measures
• Warming blankets
• Prismatherm™ II Blood Warmer
• Prismaflo® Blood Warmer

Electrolyte Imbalances
Most patients who are receiving CRRT have baseline electrolyte abnormalities.
Sometimes though, CRRT results in overcorrection of an imbalance, and these abnormalities are
considered complications of therapy.
Be especially vigilant for over-correction of electrolytes when non-physiologic solutions are
used as dialysate or replacement fluids, or when electrolytes are added to these fluids. Glucose
rich peritoneal dialysate fluids used for CRRT can cause hyperglycemia. If blood sugars become
very high electrolyte balance can also be affected. Although all electrolytes can be affected, keep
a close watch on potassium levels because potassium is carried into the cell with glucose. Most
CRRT protocols call for monitoring of electrolytes every 4 to 6 hours during the first 24 hours of
therapy and whenever dialysate or replacement fluids are changed. After the electrolyte levels
become stable and there are no changes to the fluid prescriptions the frequency of lab testing can
be safely reduced. The exact frequency used will depend on your hospital’s protocols and
physician preferences.
Acid-Base Imbalances
CRRT complications that result in acid-base abnormalities usually result from over-
correction of metabolic acidosis. If bicarbonate is used at greater than physiologic levels large
pH shifts can occur. The pH must be trended so that fluid prescriptions can be adjusted to more
physiologic solutions as the pH approaches normal. Most critical care references recommend that
metabolic acidosis not be treated with bicarbonate until the pH is less than 7.1. Remember that
CRRT effectively treats metabolic acidosis related to renal failure, not acidosis related to
inadequate tissue perfusion or respiratory acidosis. Electrolyte balance and pH balance are
closely linked, so monitor electrolytes closely as pH is corrected. Plan to monitor the pH at the
same frequency as electrolytes are monitored, at least initially.
Infection
CRRT is an invasive process that increases infection risk. Patients receiving CRRT are
already vulnerable to infection due to their renal failure, critical illness, and other invasive lines
and procedures. These patients must be monitored closely for signs and symptoms of infection so
treatment can be instituted rapidly should infection occur. Infections caused by CRRT may be
local to the vascular access site or systemic (septicemia). When CRRT is in progress fever may
be masked due to the cooling effect of extracorporeal circulation. Monitor for other signs of
infection such as elevated white blood cell count, increased numbers of immature white blood
cells, and local symptoms like redness, swelling and purulent drainage. All connections and
vascular access sites must be handled with meticulous aseptic technique to prevent infection.
Standard nursing interventions to reduce infection risk also apply to CRRT patients. These
techniques include, but are not limited to, handwashing, aggressive pulmonary hygiene,
meticulous and frequent oral care, as much mobility as hemodynamics will allow, frequent
position changes, and meticulous skin care.
NURSING MANAGEMENT OF PATIENT WITH CRRT

BEFORE THE PROCEDURE

 Psychosocial Assessment- The most important psychosocial assessment for the patient
receiving CRRT should take place before the therapy.
 Check the criteria that warrant the initiation of RRT.

 The basic preparation like all the other procedure

 Take the consent from the patient and ralatives.

 Assess and record the patient’s vital signs and hemodynamic parameters prior to
initiation of therapy.

 Review physician orders and lab data

 Prepare vascular access using unit protocol.

 Set fluid removal, dialysate and replacement solution flow rates as prescribed.

 Administer anticoagulant and initiate infusion if applicable.

 Document patient’s hemodynamic stability with initiation of therapy.

 There is chance for hyperkalemia so avoid potassium rich foods

 Provide normal supine position. If the patient is hypotensive provide trendlenberg
position
 Check the weight of the patient
 Antihypertensive drugs should be avoided before RRT to avoid hypotension
 Set realistic expectations and reinforce them frequently.
 Teach the patient through actions and words that all alarms are promptly and
appropriately acted upon.
 The presence of the nurse will help alleviate many of the fears families have.
DURING THE PROCEDURE
1. Care of clot formation
  The puncture site check the site for infection such as redness
 Swelling, drainage from the site, fever and chills.
 Infection control measure must be used
2. Take precautions during intravenous therapy
 It should be controlled by volumetric infusion pump and should be slow. Rapid
administration will result in pulmonary edema because the patient cant excrete
 Maintain strict intake output chart
3. Monitor symptoms of uremia
4. Monitor Blood flow rate, Ultrafiltration flow rate, Dialysate/replacement flow rate,
Alarms and responses, Color of ultrafiltrate/filter blood leak, Color of CRRT circuit.
5. Detect the cardiac and respiratory complications, it should be assess frequently
6. Controlling electrolytes levels
 Electrolyte alternations are common. .
 Assess serum electrolytes daily
 Hypoalbuminemia is an indicator of malnutrition.
7. Manage discomfort and pain
Keep the skin clean and well moisturized
Apply lotion to the skin
Always keep the nail trimmed.
8. Monitoring blood pressure and HR
 Hypotension is common
 Check for fluid overload
 Should teach the purpose and side effects of antihypertensive therapy.
9. Presenting infection
 Renal failure patient is commonly have low WBC, RBC, and impaired platlet
function so chance for infection is high
10. Administering medication
 All medication during the procedure should be closely monitored
 Administer ionotropic drugs and vasopressors according to condition of the
patient.
 Medication containing K+ Mg+ should be avoid,
 11. Provide psychological support
 Nurse provide opportunity for patients to express the feeling.
12. Nutritional support
 Protein, fluid, and electrolyte restrictions are not necessary during CRRT.
 Protein requirements during CRRT have ranged between 1.5 and 2.5 g/kg
reference weight.
 Although the enteral route is preferred for nutrition support, PN may be
indicated in the presence of gastrointestinal dysfunction or hemodynamic
instability.
 Water-soluble vitamin supplementation is necessary for patients treated with
CRRT.
 Standard multivitamin and trace element levels are appropriate with PN.
 Uninterrupted CRRT leads to a dramatic decline in serum magnesium,
potassium, and phosphorus levels secondary to intracellular shifting and
increased losses with ultrafiltration. Anticipation of these abnormalities can
yield appropriate supplementation and electrolyte repletion.
 The safest approach to treat severe hyperglycemia in CRRT patients is
through the use of a: continuous regular insulin infusion. 62
 The nutrition regimen should be based on the changes that occur in the
patient's clinical and metabolic status.

13. Neurological assessment

 Monitor the neurologic status of the patient at least hourly for changes in level of
consciousness, seizure activity, and neuromuscular function appropriate to the
patient’s diagnosis and coexisting conditions.
 Improvements in pH balance, electrolyte balance and uremia should produce slow
improvement.
 Pay particularly close attention to sodium balance in patients with cerebral edema.

14. Pulmonary Assessment of Fluid Overload

Assessment findings that may indicate improvement of fluid overload include:
• Decrease in adventitious lung sounds, particularly crackles.
• Reduced appearance of pulmonary congestion on chest x-ray.
• Reduced tachypnea, related to improved pulmonary compliance and reduced work of breathing.
• Improved oxygen saturation and/or decreased requirement for supplemental oxygen.
• In mechanically ventilated patients, look for decreased peak-inspiratory pressures, reduced
need for oxygen and lower positive end-expiratory pressure (PEEP) requirements.
• In patients with pulmonary artery catheters, look for decreased PA pressures and a lower
pulmonary vascular resistance (PVR).
Pulmonary Assessment of Metabolic Acidosis
Pulmonary assessment findings that may indicate improvement of metabolic acidosis:
• Decrease in respiratory rate and depth.
• ABG changes including:
o Increased pH, bicarbonate and PaCO2.
o Decreased base deficit.

Signs and Symptoms of Uremia

• Decreased attention span, lethargy, peripheral neuropathy

• Nausea, vomiting, stomatitis, gastritis, constipation, carbohydrate intolerance
• Weight loss, muscle wasting
• Itching, dry skin, ecchymosis, edema
• Pericarditis, friction rubs
• Platelet dysfunction, anemia, decreased immune response
• Hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia
• Pleuritis, pulmonary edema

AFTER CARE

 Patient will be in ICU after the CRRT

 Check for the complications of CRRT and proper correction of complications
 Check the weight of the patients if possible
 strict IO chart should be maintain
 Maintain the normal vital signs
 Administer prescribed medications
 .
RESEARCH STUDY

Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is
applied early vs. late

L. G. Gettings,  H. N. Reynolds,  T. Scalea

Abstract

Objective: To determine whether the timing of initiation of continuous renal replacement therapy
(CRRT) affects outcome in patients with post-traumatic acute renal failure (ARF). Design: The
medical records of patients treated with CRRT for post-traumatic ARF were retrospectively
reviewed. Chi-square testing was used to test frequencies between groups, and Student's t -test
was used to compare means. Setting: A Level I trauma center. Patients: 100 Adult trauma
patients treated with CRRT for ARF from 1989 to 1997. Patients were characterized as “early”
or “late” starters, based upon whether the blood urea nitrogen (BUN) was less than or greater
than 60 mg/dl, prior to CRRT initiation. Results: The mean BUN of the early and late starters
was 42.6 and 94.5 mg/dl, respectively (p < 0.0001). CRRT was initiated earlier in the hospital
course of early starters compared to late starters (hospital day 10.5 vs 19.4, p < 0.0001).
Creatinine clearance prior to CRRT did not differ statistically between the two groups. No
significant difference was found between early and late starters with respect to Injury Severity
Score, admission Glasgow Coma Scale, presence of shock at admission, age, gender distribution,
or trauma type. Admission laboratory values including BUN, serum creatinine, lactate, and
bilirubin as well as fluid and blood requirements in the first 24 h were statistically the same for
the two groups, suggesting a similar risk of developing renal failure. Survival rate was
significantly increased among early starters compared to late starters (39.0 vs 20.0 %,
respectively, p = 0.041). Conclusions: This retrospective review indicates that an earlier
initiation of CRRT, based on pre-CRRT BUN, may improve the rate of survival of trauma
patients who develop ARF.

CONCLUSION
 A careful understanding of the particular benefits limitations and potential complications
of each modality is much important for the selection of dialysis therapy. In certain
circumstances, the more conventional intermittent therapies are sufficient, where as in other
setting, CRRT techniques are advantageous. ARF patients are secondary to multiple organ
dysfunction syndrome, post surgical patient , PTA patients is having various co-morbid condition
are in mechanically ventilation and various use supporting modalities which do not merit the
dialysis procedure to be corrected out in routine dialysis set up. Being catabolic they require
continuous clearance of waste products and adequate need for infusion of nutritional and
inotropic agents for good vital parameters which is continuously needed in the management.
CRRT can meet all those challenging in ICU settings and saved many lives across the world.

BIBLIOGRAPHY

1. Thomas Nicola, (2008), Renal Nursing, Elsevier publications, 3 rd edition, P.N. 116-
121
2. Base G Brenda, Smeltzer C Suzanne (2009). Brunner and suddarth’s medical surgical
nursing Lippincott Williams publishers, 11th editions 9. N 1542-1544.
3. Black M. Joyce (2005) Text book of medical surgical nursing, Saunders publications,
7th edition, P.N 947.
4. Bellomo R, Ronco.C (1999) continuous renal replacement therapy in intensive care
unit. P.N. 781-789.
5. Philips (1999) a nursing process approach 3rd edition P.N. 1578.

WEB REFERENCE
1. www.wikipedia.crrt.com