LEARNING MODULE

for

CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)

Beyond Entry-Level Competency

for

Registered Nurses - CVICU/MSNICU and MSICU - Central Zone

BEL-UN-020

Developed by: Debrah White - Clinical Nurse Educator

Date: January 2016

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BEL-ND-020 Continous Renal Replacement Therapy Learning Module Page 2 of 14

Table of Contents
PREREQUISITE NURSING KNOWLEDGE .................................................................................................... 2
OBJECTIVES ............................................................................................................................................... 2
LEARNING AND CLINICAL RESOURCES FOR CRRT ..................................................................................... 3
PHYSICIAN ORDERS ................................................................................................................................... 3
EQUIPMENT ............................................................................................................................................ 4
ANTICOAGULATION AND CRRT................................................................................................................. 5
ECMO {Refer to CC 45-074 Pump Assisted Oxygentation Therapy (POAS)} ............................................ 6
REFERENCES .............................................................................................................................................. 6
RELATED DOCUMENTS ............................................................................................................................. 6
Policies ................................................................................................................................................ 6
Forms .................................................................................................................................................. 6
Appendices ........................................................................................................................................ 7
POST-TEST ................................................................................................................................................. 8
ANSWERS ................................................................................................................................................ 13

PREREQUISITE NURSING KNOWLEDGE

Chronic Renal Replacement Therapy (CRRT) is a Beyond Entry Level Competency

(BELC) for Registered Nurses in CVICU/MSNICU and MSICU – Central Zone and
requires demonstration of competency prior to performing this treatment. To
achieve certification:

 Attend a CRRT workshop consisting of theory and practice prior to caring for a
patient using CRRT ( 7.5 hrs - 15.0 hrs).

 Complete the post-test in this Learning Module

 Complete a minimum of two 12 hour clinical shifts with a RN certified to care

for CRRT

OBJECTIVES
1. After attending an approved education session and reviewing resource material
the RN will be able to:
1.1. Identify indications for CRRT.
1.2. Describe the function of the semi-permeable membrane in CRRT.
1.3. Describe the vascular access and extracorporeal circuit used for CRRT.

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1.4. Discuss the use of replacement fluids and dialysate in CRRT.

1.5. Name the four treatment modalities available when using CRRT.
1.6. Outline medical and nursing management during initiation and maintenance
of CRRT.
1.7. Discuss options for anticoagulation during CRRT therapy.
1.8. Discuss potential complications of CRRT.
1.9. Discuss essential components of nursing care for patients receiving CRRT
including vascath care. (Gambro 2004,Orlando Health, CC 50-049 Care
of Non-Tunnelled Hemodialysis CVC )

LEARNING AND CLINICAL RESOURCES FOR CRRT

1. Operator’s Manual and at the back of the Prismaflex machine. (If not
available call customer clinical support)
1.1. Provides installation, operating, maintenance, and troubleshooting
instructions, as well as general information.
1.2. Provides information about the Prismaflex therapy and the Prismaflex.
2. Instructions (machine step by step set-up and operating Instructions)
2.1. Detailed operating instructions are incorporated in the software of the
Prismaflex Machine. The instructions are available on-line and through the
interactive display.
http://www.baxter.ca/en/healthcare_professionals/therapies/gambro_thera
pies/crrt/index.html
2.2.
2.3. Instructions include the following screens:
2.3.1. Operating screens (step-by-step instructions the operator follows
2.3.2. Alarm screens (instructions if an alarm situation occurs).
2.3.3. Help screens (additional information about an Operating or Alarm
Screen).
3. Assistance from other RN’s who have CRRT experience
4. Gambro clinical support

Baxter Corporation – 7125 Mississauga Rd, ON L5N 0C2

Sans Frais (Toll Free): 1-855-588-8775 | Mobile 1-514-249-5966

5. CRRT Prismaflex tutorial

(https://gateway.gambro.semcon.com/content/prismaflex-tutorial-4929.html )
6. Gambro Learning Modules in Unit Resource Binders

PHYSICIAN ORDERS
Preprinted physician orders are used for CRRT.

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1. Citrate Anticoagulation
 PPO 00213MR Prismaflex CRRT orders Citrate /Calcium Chloride regional
Anticoagulation
 PPO 00238MR Calcium Chloride Infusion
PLEASE NOTE: Calcium chloride drip must be infused through a central
line
 PPO00239MR 4% Sodium Citrate Anticoagulation
 PPO 00363MR Citrate Toxicity may happen and is treated using the citrate
toxicity order set
2. No Anticoagulation
PPO 0214MR Prismaflex CRRT orders No Anticoagulation for patients with
contraindication to citrate anticoagulation only
Basic knowledge is required of the principles of diffusion, ulrafiltration (UF),
osmosis, oncotic pressure, hydrostatic pressure, and how each of these pertains
to fluid and solute management during dialysis.

EQUIPMENT
The Prismaflex Machine
 Loads and primes the Prismaflex Set automatically.
 Pumps blood through the blood flow path of the Prismaflex Set.
 Delivers anticoagulant solution(if used) into the blood flowpath.
 Controls fluid removal/plasma loss from the patient.
 Pumps sterile infusion solution into the blood access line with the pre-blood
pump (PBP)
 Pumps sterile replacement solution/fluid and/or sterile dialysate.
 Pumps effluent.
Dialysis Filters and Warmer Tubing
NSHA – Central Zone - stocks 2 types of filters and warmer tubing:
1. ST 100 used for most patients
2. HF 1000- used with the patient population who have been or are taking
angiotension-converting enzyme (ACE) inhibitors.
2.1. Contact with certain filters or membranes in the CRRT system can cause an
anaphylactic reaction and severe hypotension. Contact with chemicals in the
system can produce bradykinin which acts as a potent vasodilator. Ace

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inhibitors are recommended to be withheld for 48-72 hours before starting

CRRT treatments if possible.
All filters are set up with the warming unit added inline. In some cases the warmer
may not be turned on.

ANTICOAGULATION AND 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.
Advantages of longer filter life include:
 educed time off therapy,
 reduced nursing time for filter changes, and
 reduced cost.
1. Any form of anticoagulation has its risks. When considering anticoagulation the
guiding principle is “Losing the filter is better than losing the patient.” (Bellomo &
Ronco).
The physician must consider the relative risks of anticoagulation and choose the
safest option for the patient. Options for anticoagulation include:
1. Systemic unfractionated Heparin- administered intravenously and titrated to
achieve an activated partial thromboplastin time (aPTT) as 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. This method of anticoagulation would be used with extra-corporeal
membrane oxygenation (ECMO) where the CRRT circuit is placed into the ECMO
circuit.
2. Citrate - Regional anticoagulation of the filter can be achieved through the use
of Citrate.
 Citrate inhibits clotting by binding calcium, a key factor in many steps of the
clotting cascade. Citrate is infused pre-filter (pre blood pump) A calcium
chloride infusion is administered to the patient to replace the calcium bound
by the citrate via another central line.
 Anticoagulation is monitored using ionized calcium levels. Citrate is
comparable to heparin in maintaining filter patency.
 Use of citrate eliminates the risk of Heparin-induced
thrombocytopenia/thrombosis (HITT), and does not cause systemic

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anticoagulation. Risks include hypocalcaemia and metabolic alkalosis. Citrate

is broken down in the body into bicarbonate ions.
 Citrate is available at NSHA – Central Zone - as 4% Trisodium Citrate (TSC)
in one liter bags.
 When citrate anticoagulation is used, dialysate and replacement fluids must
be calcium free. (Gambro Training Manual)
3. 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.

ECMO {Refer to CC 45-074 Pump Assisted Oxygentation Therapy (POAS)}

 When the CRRT circuit is attached to the ECMO circuit it will be located
between the pump and the oxygenator.
 A Perfusionist will attach the stop cocks in the ECMO circuit and attach the
primed CRRT to the stop cocks. NURSES ARE NOT TO ACCESS THE ECMO
CIRCUIT. A Perfusionist must be contacted to begin and terminate CRRT
tubing from ECMO. This includes CRRT circuit changes.

REFERENCES
Dirkes,S.&Hodge,K. (2007)Continous renal replacement therapy in the adult
intensive care unit-history and current trends, Critical care nurse 27(2)p 61-81.

Gambro Clinical Website for CRRT

Prowle, J.R. & Bellomo,R. (2010) Continuous renal replacement therapy: recent
advances and future research, NEPHROLOGY.MacMillan Publishers Limited,
p521-529.

Bellomo & Ronco. www.thelancet.com/journals/lancet/article/PIIS0140-

6736(11)61454-2

RELATED DOCUMENTS
Policies
CC 50-049 Care of Non-Tunnelled Hemodialysis CVC

Forms
CD2081MR CRRT NURSING NOTE (DAYS)

CD2082MR CRRT NURSING NOTE (NIGHTS)

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Appendices
Appendix A – short form for assessment and completion of CRRT initation and
discontinuing

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POST-TEST
1. CRRT is performed over a
a. 3-4 Hours
b. Continuously
c. 8-12 hours
d. Up to 8 hours
2. The advantages of CRRT versus hemodialysis done intermittently include
a. better hemodynamic stability
b. effective systemic anticoagulation
c. continuous control of fluid intake and output as well as electrolytes and PH
d. a and c
e. all of the above
3. SLED (Slow Low Efficiency Daily Dialysis) and IHD (Intermittent hemodialysis)
require a larger filter and higher blood flow rates in order to achieve their time
requirements re fluid removal. SLED is usually run over 4 to 6 hours and IHD
over 3 to 4 hours
a. True
b. False
4. The use of citrate as an anticoagulant requires the following:
a. Citrate is run into the circuit at the preblood pump point of the circuit
b. Citrate blocks calcium in the clotting cascade
c. A calcium infusion to replace citrate is not required
d. Calcium is added to the replacement bags
e. a and b
f. a, b and d

5. Dialysis treatment based solely on diffusion and small amounts of convection

is called
a. SLED
b. CRRT
c. IHD
d. a and c

6. The use of citrate requires that the physician write orders using
a. The citrate PPO

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b. The calcium chloride PPO

c. The PPO for regional anticoagulation using citrate
d. The citrate toxicity PPO
e. All of the above except d

7. The CRRT nurse (critical care nurses) at NSHA – Central Zone - are taught how
to set-up and run CRRT using which mode? (Other modes may be ordered and
the nurse should call Gambro clinical support for guidance on these modes.)
a. CVVH
b. SCUF
c. CVVHD
d. CVVHDF

8. The term Qb refers to

a. The dialysate flow rate
b. The replacement rate
c. The return flow rate
d. The blood flow rate

9. The transport mechanisms used in CVVHDF to remove plasma water and

solutes are convection, diffusion and ultra filtration.
a. True
b. False

10. The movement of solutes from a higher concentration gradient to a lower

concentration is called
a. Diffusion
b. Convection
c. Transport
d. Ultra filtration

11. The use of the handle to manually give the blood back is meant to be used
a. Only during a power failure
b. When the machine alarms” filter is clotting
c. When the clamp closes on the return line

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d. Whenever the blood needs to be returned to the patient.

12. Examples of small molecules that may easily pass through the CRRT filter
include
a. Urea, creatinine, potassium and phosphate
b. Albumin and insulin
c. Glucose ,uric acid and Vitamin B 12
d. All of the above

13. If the blood leak alarm should go off when your patient is receiving CRRT
therapy you should:
a. Silence the alarm and continue therapy
b. Stop the CRRT machine, disconnect the patient from therapy and flush
all lines/ports appropriately
c. Send a sample of effluent to the lab to be tested for red blood cells
d. Check the tubing for loose connections

14. Mrs.Thomas is receiving CRRT for acute renal failure associated with septic
shock. The intensivist has ordered a dialysate bag with a very low
concentration of potassium to help correct her serum potassium of 7.0
mg/dL. Safe administration of this dialysate requires
a. Monitoring of the serum potassium every hour
b. Calling for a change in the dialysate formula order when the serum
potassium approaches normal.
c. Use of Citrate anticoagulation rather than Heparin
d. Decreasing the frequency of serum potassium measurement

15. Select the statement that is most appropriate regarding intake and output
(I&O) calculations in patients receiving CRRT
a. All patient I&O calculations are performed by the CRRT machine
b. The nurse must always manually calculate dialysate and replacement
fluid use
c. I&O calculation by hand is not necessary for these patients
d. The nurse must calculate all intake and output functions not done by
the CRRT machine, but related to the patient, in order to calculate fluid
removal as per physician orders.

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16. The physician has ordered a fluid removal of 50 mLs per hour. In order to
carry out this order
a. I dial 50 mLs into the machine every hour
b. I calculate all my intake from all non Prismsflex souces and subtract all
output from Non Prismaflex sources. The physician should determine if
fluids such as blood products will be considered intake or not. Then I
add 50mLs to that amount to determine what the amount is that I dial
in.
c. I add my non Prismaflex intake to my and than subtract 50mls from
that amount.
d. I subtract my non-Primaflex out put from my non Prismaflex intake and
subtract another 50 mLs
17. Mrs. Thomas is going to start CRRT today. She received a liver transplant 3
days ago and was the recipient of multiple transfusions and is in acute renal
failure. She has had an intra-op inferior MI. The following questions pertain to
her care. The intensivist has written the order set for “no anticoagulation”
The following are “true” or “false “questions related to the scenario above.

A. I will need to mix a calcium drip using this order set. T or F

B. The replacement fluid is divided so that half of it is delivered T or F

pre-blood pump

C. I am not allowed to add anything to the Prismocal bags T or F

D. I always add Compartment A to Compartment B in my T or F

Prismocal bags.

E. The calculations for the amount of dialysate and T or F

replacement that will be run are based on ideal body weight
for those pts greater than 100kg

F. I will need to closely monitor my pressure readings since my T or F

filter may clot easier than if I was using an anticoagulant

G. Sometimes using this order set I run 0.9%saline and T or F

alternating D5.45%saline one liter bags instead of Prismocal
bags for my replacement fluid

H. Increasing transmembrane pressures may indicate that my T or F

filter is getting clogged with waste products

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I. All my replacement and dialysate bags have calcium T or F

Gluconate added to them

.
18. The filter has clotted twice in the last 6 hours and a decision is made to trial
the citrate orders

A. The physician must complete the 3 new order sets T or F

B. I always add the same extras to the Prismocal bags for Tor F
replacement and dialysate

C. I must remember to discontinue my calcium chloride drip if I T or F

stop my CRRT. This drip is run in a separate central line.

D. I must follow both the citrate and the calcium nomogram in T or F

order to safely deliver CRRT and adjust the rates of both
drips.

E. If I am trying to lower an electrolyte in the pts blood, that T or F

electrolyte(potassium) will not be into the dialysate or will
be at a lower level and will be removed by diffusion.

F. I must start the CRRT over again beginning with a new filter. T or F

19. The CRRT machine is alarming with an air in blood alarm. This means that
a. I will have to give the blood back right away
b. I will not be able to give the blood back since the return clamp is closed
c. The machine may give the patient a lethal dose of air into the vein
d. I will have to check the deaeration chamber more closely
e. I must concentrate on saving the vascath
f. b and e

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ANSWERS
1. B

2. D

3. A

4. E

5. D

6. E

7. D

8. D

9. A

10. A

11. A

12. A

13. C

14. B

15. D

16. B

17. First Part of Patient Scenario

A-F

B-T

C-F

D-F

E-T

F-T

G-T

H-T

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I-T

18. Second part of the patient scenario

A-T

B-F

C-T

D-T

E-T

F-T

19. F

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