PEDIATRIC INTENSIVE CARE UNIT

Policy/Procedure
TITLE: Continuous Renal Replacement NUMBER: 1625
Therapy (CRRT) Using the Prismaflex
Machine: Preparation and Management
of Equipment
Sponsor: PICU Care Team Page: 1 of 21

Approved by: Medical Advisory Committee Approval Date: Apr. 17th, 2018

Effective Date: May 24th, 2018

Applies To: PICU Registered Nurses certified in CRRT

The provision of Continuous Renal Replacement Therapy (CRRT) by

Registered Nurses is a Beyond Entry Level Competency (BELC).

TABLE OF CONTENTS

PREAMBLE ............................................................................................................................. 2
POLICY STATEMENT ............................................................................................................. 2
PROCEDURES ....................................................................................................................... 2
1. Initiation of Continuous Renal Replacement Therapy and Priming the Prismaflex ....... 2
BLOOD PRIME (required for patients under 15 kg) .......................................................... 8
DIALYZING BLOOD-PRIMED CIRCUIT ........................................................................... 8
2. Monitoring ................................................................................................................... 10
3. Blood Sampling from Continuous Replacement Therapy Circuit (Venous) ................. 10
Pre-filter venous lab draw: .............................................................................................. 11
Post-filter venous lab draw: ............................................................................................. 12
4. Fluid Sampling from the Prismaflex Circuit ................................................................. 13
5. Termination of Continuous Renal Replacement Therapy ........................................... 13
6. Effluent Bag Change ................................................................................................... 15
7. Trouble Shooting Equipment Problems ...................................................................... 15
REFERENCES ...................................................................................................................... 16
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled
and should be checked against the electronic file version prior to use.
Continuous Renal Replacement Therapy - #1625 Page 2 of 21

RELATED DOCUMENTS ...................................................................................................... 16

Policies .............................................................................................................................. 16
Appendices ........................................................................................................................ 16
APPENDIX A – DEFINITIONS .............................................................................................. 17
APPENDIX B – ALARMS AND TROUBLESHOOTING ......................................................... 18

PREAMBLE
Continuous Renal Replacement Therapy (CRRT) is a continuous extracorporeal blood
purification therapy that slowly removes fluid and/or solutes over a 24 hour period.

The IWK Health Centre will provide CRRT to appropriately selected patients who require this
type of medical treatment. CRRT care is provided by the Prismaflex machine and a critical
care team within the PICU.

Indications for CRRT in critically ill patients include (but are not limited to):
 Acute Renal Failure
 Treatment or prevention of fluid overload
 Electrolyte or acid-base disturbances
 Hemodynamically unstable patients unable to tolerate intermittent hemodialysis
 Detoxification

POLICY STATEMENT
1. CRRT management is considered an advanced critical care skill and is practiced after
the Registered Nurse (RN) has the required critical care education and has had
practical training with an appropriate clinical support person.

PROCEDURES
1. Initiation of Continuous Renal Replacement Therapy and Priming the Prismaflex

1.1. The Attending Pediatric Intensivist writes the orders for initiation of CRRT.
These orders are scanned to pharmacy by the RN who will be setting up the
Prismaflex machine and managing the treatment.

1.2. The RN ensures that the patient and family understand the treatment and that
questions are answered by the intensivist.

1.3. The RN verifies the patient's identity by comparing name and unit number on the
CRRT orders to the patient’s armband.

1.4. The RN collects and records the patient’s pre-treatment baseline values (weight
and laboratory data).
1.5. The RN ensures that central vascular access is present and functional for the
sole use of CRRT treatment. To assess vascular catheter function:
Continuous Renal Replacement Therapy - #1625 Page 3 of 21

1.5.1. Using sterile technique as per Policy #5210 – Initiating

Hemodialysis/Continuous Renal Replacement Therapy (CRRT) Using
the Fresenius 2008 K Machine, withdraw heparin from lumens and
discard waste.
1.5.2. Flush both lumens with sufficient saline to clear lines.
1.5.3. Using 10 mL syringe draw back 10 mL of blood and give back within 3
seconds (this will validate that the catheter is working and will allow the
blood flow rate needed for CRRT).
1.5.4. Heparin lock both catheters with heparin 1,000 units/mL for patients over
10 kg or heparin 100 units/ml for patients under 10 kg with the exact
amount indicated on the lumen.

1.6. Patients less than 15 kg require a blood prime, ensure cross match is drawn and
contact blood bank to prepare pre-filtered whole blood cells.

1.7. Gather the following supplies:

 Prismaflex machine and CRRT supply/stock cart

 Prismaflex filter:

Filter Set Patient Weight Priming Volume

HF 20 Less than 15 kg 60 mL
ST 60 15 – 30 kg 93 mL
ST 100 Greater than 30 kg 152 mL

 Priming solution
 Anticoagulant solution (heparin or 4% sodium citrate or NaCl 0.9% in a 20
mL syringe)
 Replacement solution
 Dialysate solution
 Medications/infusions as ordered
 Effluent bag
 4 blue clamps
 ACT machine and supplies if heparin therapy ordered

TO CONNECT:
 Mask
 Sterile gloves
 Sterile dressing tray
 Sterile towels
 5 mL syringes
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol) x 4
 10 mL prefilled sterile 0.9% NaCl syringes x 2
 Appropriate syringes for blood sampling (depending on therapy ordered)
Continuous Renal Replacement Therapy - #1625 Page 4 of 21

TO DISCONNECT:
 Mask
 Sterile gloves
 Sterile dressing tray
 Sterile towel
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol) x 2
 10 mL prefilled sterile 0.9% NaCl syringes x 2
 2 ‘Tegos’ caps
 Heparin 100 or 1,000 units/mL
 3 mL syringe x 2
 Blunt tip needle x 2
 Sterile 4 x 4 and tape

1.8. Plug Prismaflex machine in and turn machine on. The power button is located
on the right side of the Prismaflex machine. The control unit performs an
initialization test to check the system’s electronics.

1.9. Ensure both data card and manual crank are in place prior to starting the prime
procedure.

1.10. Prepare the prescribed solutions. Note: when using Prism0cal solution the bag
must be labeled that the sodium bicarbonate has been added with the date and
time. Solutions containing sodium bicarbonate are stable for 24 hours. If not
using bicarbonate pouch this must be discarded from the bag PRIOR to hanging
on the weighted scales of the Prismaflex machine.

1.11. Have emergency medications (epinephrine, calcium, bicarbonate) available for

possible cardiovascular instability during initiation of therapy (especially neonatal
or cardiac surgical patients).

1.12. Prepare emergency Clamping Tray:

Emergency Tray Contents

 2 X fluid transfer set

 Clamps X 2
 2 X 5 mL syringes for aspirating
blood
 Heparin 1000 units/mL vial X 2
 Heparin 100 units/ml vial x 2
 2 X 3 mL syringes
 2 X blunt tip needles
 10 mL sterile Normal Saline prefilled
syringes X 2
 'Dead end' caps X 2
 2% Chlorhexidine swabs X 4
 Sterile towel and clean gloves
Continuous Renal Replacement Therapy - #1625 Page 5 of 21

1.13. Press 'Therapy Info' to view therapy info screens in Prismaflex or Press
'Continue' to proceed to 'Chose Patient' screen.

1.14. Select 'New Patient' to start a new treatment. Enter patient identification (K #)
‘Enter’, weight ‘Enter’ and hematocrit and press the 'Enter' key. If patient
information is correct press ‘Confirm’.

1.15. Select 'Same Patient' to proceed to patient treatment screen.

1.16. Choose ‘CRRT’ as treatment for patient.

1.17. Select 'CVVHDF' in therapy options screen. Always start with this mode as it
allows access to all therapies once treatment has started.

1.18. Proceed to the Chose Anticoagulation Method screen. Choose 'Systemic,

Prismaflex syringe pump’ for all therapies regardless of anticoagulation. If
using citrate or no anticoagulation have a 20 mL syringe of 0.9% NaCl ready to
insert as part of the priming stage for initiation of treatment. Press ‘Confirm’.
Note: syringe pump on Prismaflex is disabled during entire treatment if 'no
syringe' option selected.

1.19. Check the expiration date on the filter set. Open the filter set. Inspect the set to
ensure that the connections are secure. Check the main four connections
(bottom of filter, top of filter, connection after return port and connection to
chamber monitoring line).

1.20. Place the filter set on the Prismaflex machine and press ‘Continue’ to set up
according to step-by-step directions indicated on the screen.

1.21. Follow the 7 steps in order on the Load Set screen. Press 'load' and once set is
loaded, confirm set loaded correctly on Confirm set loaded screen. Press
'unload' if the set is incorrectly loaded (this will give you the option to load the
set again) or 'confirm' if filter loaded and therapy selected is correct.

1.22. Proceed with step-by-step instructions on the 'Prepare and Connect Solution'
screen; follow all 6 steps in order. Note: Step 1 ‘route lines through tubing
guide’ can be done last as this is a tidy step not a functioning step. Connect and
hang priming solutions as ordered on the pre-printed CRRT order set for 1st
prime.

Priming Solution Bag: 0.9% NaCl with or without heparin as ordered

PreBlood Pump: 4% sodium citrate or if using heparin anticoagulation, can either
prime with 0.9% NaCl or can consider splitting replacement fluid so that a percentage
runs pre and post filter
Dialysis Pump: prepared Prism0cal or other solution as ordered
Replacement Pump: prepared Prism0cal or other solution as ordered
'Install Syringe': either heparin 50 units/mL or 0.9% NaCl, follow install syringe screen,
then press 'confirm'
Continuous Renal Replacement Therapy - #1625 Page 6 of 21

1.23. Press “Continue'. Proceed with step by step instructions following all 5 steps in
order on the Install Syringe screen. (If using citrate or no anticoagulation
proceed to install a 20 mL syringe of 0.9% NaCl). Always install a syringe.
Use ‘auto up/auto down’ to allow the syringe to fit properly. Press ‘Continue’.

1.24. Confirm syringe installation, press ‘Confirm’. Proceed to Verify Setup screen.
Ensure the connections are correct and secure and that clamps are open on all
lines.

1.25. Press 'PRIME' and the machine should proceed to priming mode. The cycle
takes approximately 5 minutes. Once the initial prime is complete 'Priming, 1 of
1 Cycles Complete' should appear. Note: can leave the machine in this state
until ready to initiate therapy.

1.26. Hang 2nd priming solution as per pre-printed order. Press 'Reprime' and
proceed to Prepare to Reprime screen and proceed to follow the 4 steps in
order. Press ‘Reprime’, the machine will reprime. This will take approximately 5
minutes. Note: Prismaflex should not sit for more than 60 minutes following a
prime as the sterilizing agent may leach out of the plastic.

***ALWAYS reprime with 1 Litre of 0.9% NaCl if primed set has not been running
for 60 minutes!***

1.27. Inspect the circuit for air and if minimal priming is required you can use the
'Manual Prime'.

1.28. Press 'Prime Test' and wait for the machine to conduct a prime test. DO NOT
touch circuit or machine while the self-test is in progress. Once the prime
test is complete the machine ought to proceed to Prime Test Passed screen.
Adjust deaeration chamber using the ↑ and ↓ arrow keys on the screen, press
‘Confirm level” when the solution is level with the frosted line. Note: Small air
bubbles in the pods do not matter as there is an air/blood interface in the actual
pod. The presence of air on the outside of the filters hollow fibers, top or bottom,
may be seen. Additional manipulation is not needed to remove these bubbles
and attempts at clearing may damage the filter.

1.29. The Prismaflex is primed. If the machine was not primed at the bedside it is now
necessary to move the Prismaflex to the bedside, when the patient is ready to
commence CRRT. To move the Prismaflex follow these steps:

Moving the Prismaflex following initial Prime

 Determine that you are on the PRIME TEST PASSED screen
 Turn off machine and unplug
 Move Prismaflex to bedside and plug in and turn on
 Complete additional prime if machine has not run in 60 minutes or a blood
prime is required, at bedside
 Select CONTINUE and follow instructions on the machine
 If the machine was turned off and on follow the change syringe screen to
proceed, press confirm
Continuous Renal Replacement Therapy - #1625 Page 7 of 21

1.30. Select 'Continue' following prime test to proceed to 'Enter Treatment Setting'
screen. In this screen you can adjust the patient fluid loss/gain limit as per
physician order set or leave at default settings, press ‘Confirm’. Note: Low rate
is required on initiation to prevent sudden hemodynamic instability of patient
from rapid fluid shifts. Maximum excess gain/loss limit ensures safer limits of
fluid removal/gain. Maximum excess gain/loss limit cannot be changed once
entered. Prismaflex will preset to a negative access pressure range. Set
positive access range ONLY if CRRT is attached to extracorporeal life support
(ECLS) circuit. Access range cannot be changed once therapy has been
initiated.

1.31. Press 'Confirm' to proceed to the 'Enter Flow Settings' screen. Enter flow
settings as per pre-printed physicians order. Enter:
 Blood flow rate mL/min
 PBP rate mL/hour
 Dialysate rate mL/hour
 Replacement rate mL/hour
 Chose pre or post for replacement (if pre and post replacement ordered, set
this screen as post, the PBP rate will run as the pre filter solution rate). The
default setting is pre filter.
 Set patient fluid removal mL/hour
Press ‘Confirm all’.

1.32. Enter Anticoagulation Settings screen. Set rate for heparin infusion as per
pre-printed orders. If citrate or no anticoagulation has been ordered leave the
rate set at zero 0 mL/hour. Press ‘Confirm all’.

1.33. Proceed to 'Review Prescription' screen, modify choices at this time or press
‘Continue’ to accept settings. You will proceed to 'Connect Patient' screen.

1.34. Clamp Y connects; access (red) line, return (blue) line and effluent (yellow) line.
Using aseptic technique, attach return line (blue) to Y connector and attach
effluent line (yellow) to effluent bag.

1.35. For Pediatric patients less than 15 kg and using the HF 20 filter, blood priming is
required – unless the patient is on ECLS. For patients requiring a blood prime
continue to prime circuit following the steps in blood prime. If a blood prime is
not required continue to step #1.36.
Continuous Renal Replacement Therapy - #1625 Page 8 of 21

BLOOD PRIME (required for patients under 15 kg)

Blood prime is done immediately pre-therapy initiation and is done at the patient bedside.
Blood prime is required on all patients under 15 kg with HF 20 filter set.

1. Verify flow rates are at the default settings of zero and that the blood flow rate is at 10
mL/minute.

2. Whole blood is used for blood prime. Order red cells and FFP and in comment
section state “whole blood needed to prime CRRT machine please, filter prior to
issuing”.

3. Check blood as per hospital guidelines.

4. Hang the prepared blood product on the priming hook where the priming solution was
hung.

5. Clamp the access (red) line and the limb of the Y line and the effluent (yellow) line,
spike the blood bag using fluid spike. Continue to the Connect patient screen and
press ‘Blood prime’ to prime the circuit. Press and hold ‘manual prime’ to blood
prime the circuit, stop blood priming when blood has reached effluent bag.

6. Press ‘Continue’ to proceed to verify patient connection screen. Clamp the access,
return and effluent lines. Place the effluent (yellow) line on the effluent bag. Place the
return (blue) line on the limb of the Y line connected to the blood bag. Unclamp all the
lines and press 'Start'.

We are now ready to dialyze the blood prior to treatments if this has been ordered (not
required).

DIALYZING BLOOD-PRIMED CIRCUIT

1. Clamp Y line, access line, return line and effluent line.

2. Connect Y line to a 100 mL bag of 0.9% NaCl, this will circulate while you dialyze the
blood to prevent hemoconcentration due to forced ultrafiltration.

3. Unclamp the Y line, access (red) line, return (blue) line and the effluent (yellow) lines.

4. To Dialyze Blood Primed Circuit: Set blood flow rate at 10 mL/minute, Dialysate
Flow is 1000 mL/hour and all other flow rates are zero. Press ‘Enter’ to go to ‘Review
Flow Rate’ screen. Press ‘Continue’ if correct. ‘Connect Patient’ screen will appear.
Press ‘Start’. A bolus of heparin may be given at this time if ordered by a physician,
through the access (red) line. Dialyze blood for 15 minutes. Send blood sample as
ordered. Continue dialyzing until sample results have been approved by physician.

5. Once approved, go to ‘Flow Rates’ screen and ensure that the blood flow rate is 10
mL/minute and dialysate flow rate is zero.

6. Press stop. Clamp access, return and effluent lines. Prepare to connect to patient.
Continuous Renal Replacement Therapy - #1625 Page 9 of 21

1.36. Verify that the patient is ready for the initiation of therapy.

1.37. Ensure effluent (yellow) line is unclamped and that the access (red) and return
(blue) lines are clamped. Place the access (red) and return (blue) circuit lines on
a sterile towel near the vascular access catheter leaving attached to the priming
bag (or blood prime).

1.38. For patients receiving *CITRATE ANTICOAGULATION,* ensure that a Calcium

Chloride infusion is connected to a separate central access device, clamped and
ready to infuse (via a separate central line, not the CRRT vascular access).

1.39. Remove tape, gauze and labels from the CVAD catheter.

1.40. Ensure emergency medications and fluid boluses are available at the bedside.
Physician must be present during initiation of CRRT.

1.41. Perform hand hygiene (see Policy #205.2 – Hand Hygiene) and don personal
protective equipment.

1.42. Prepare and place a sterile dressing tray near the vascular access catheter, this
will be the sterile working field.

1.43. Open 4 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol) and place on
sterile field. Open sterile syringes, sterile 0.9% NaCl syringes X 2 and
appropriate supplies (for pre-initiation blood work as per pre-printed physician
order), place on sterile field. Don sterile gloves.

1.44. Verify that the catheter clamps are closed. Perform a vigorous 30 second scrub
of the hub of each vascular access device and allow to dry for 30 seconds (see
Policy #735E – CVAD Blood Withdrawal, Indirect and Direct). Place on sterile
drape.

1.45. Attach a 5 mL syringe to the arterial lumen, unclamp the lumen and withdraw
waste greater than the filling volume of the catheter. Remove syringe and
discard. At this time collect any blood labs as per pre-printed orders, (see Policy
#1753 – Arterial Line, Blood Sampling and Removal) asking a second nurse to
label and send to the lab. Do not heparin lock the lumen. Saline lock with sterile
0.9% NaCl syringe, clamp lumen and leave syringe attached.

1.46. Attach a 5 mL syringe to the venous lumen, unclamp the lumen and withdraw
waste greater than the filling volume of the catheter. Remove syringe and
discard. Do not heparin lock the lumen. Saline lock with sterile 0.9% NaCl
syringe, clamp lumen and leave syringe attached. Note: Do not delay in
connecting the circuit and initiating therapy at this stage as these lines can clot
very quickly.

1.47. If heparin therapy is the chosen method of treatment and a heparin bolus has
been ordered, administer it now.
Continuous Renal Replacement Therapy - #1625 Page 10 of 21

1.48. Disconnect the priming bag (or red cells (RC)) from the access (red) line and
remove the syringe from the arterial lumen. Attach the arterial port of the
vascular access device to the access (red) line and secure connections.
Disconnect the priming bag (or RC) from the return (blue) line and remove the
syringe from the venous lumen. Attach the venous port of the vascular access
device to the return (blue) line and secure connections. Ensure the warming
sleeve is wrapped around the return (blue) line. Note: CRRT is attached to
ECLS circuit for patients receiving extra-corporeal membrane oxygenation
(ECMO) therapy.

1.49. Open the clamps on both the arterial and venous lumens of the vascular access
catheter. Open clamps on the access (red) and the return (blue) circuit tubing.
PLEASE NOTE: IF ATTACHING TO ECMO CIRCUIT THE ECLS
SPECIALIST/PERFUSIONIST WILL HOOK CRRT LINES TO ECMO CIRCUIT.
ALWAYS ASK IF BLOOD PRIME IS REQUIRED REGARDLESS OF
PATIENT WEIGHT.

1.50. Begin with blood flow pump SET at 2-3 mL/kg/minute, press ‘start’. As blood
moves through the circuit, increase blood flow rate every 2 minutes as tolerated
until the prescribed rate is reached.

1.51. Commence calcium chloride infusion to patient as per pre-printed physician

orders. *ONLY WITH CITRATE ANTICOAGULATION THERAPY*

1.52. Ensure that all monitor alarms are on and parameters are set. Secure lines to
bed using blue clamps.

2. Monitoring

2.1. Monitor vital signs every 5 minutes for the first 15 minutes, then every 15
minutes for the first hour and then hourly or as patient condition requires.

2.2. Document as per Continuous Renal Replacement Therapy Flow Sheet for the
Prismaflex CRRT system, in the PICU. Document on flow sheet every hour and
monitor fluid balance hourly or more often as patient condition requires.

3. Blood Sampling from Continuous Replacement Therapy Circuit (Venous)

3.1. Ensure child and family understand the procedure and questions have been
answered.

3.2. Verify correct patient using two patient identifiers.

3.3. The therapy/treatment prescribed for CRRT will dictate the frequency and labs
that are drawn and sent as per the pre-printed physician orders. All labs are
sent from the pre filter access (red) port for entire CRRT therapy. Other labs
can also be added and sent with this lab work as indicted by the physician and
RN caring for the patient, rather than perform a second draw from a separate
arterial/venous line. **When patient is on citrate anticoagulation iCa will be
monitored POST FILTER** as ordered on the pre-printed physician order.
Continuous Renal Replacement Therapy - #1625 Page 11 of 21

If citrate is infusing pre and post filter; the labs will continue to be drawn pre filter
through the stopcock that has been added to the access line. Citrate will be
infusing through this port so the infusion must be stopped for the time it takes to
draw the labs.

Pre-filter venous lab draw:

Gather supplies
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol)
 1 mL syringe
 5 mL syringe
 ABG syringe x 1
 Clean gloves
 23 or 25 gauge needle x 2
 4 x 4 sterile gauze

PROCEDURE for pre-filter venous lab draw

1. Don clean gloves. Place 4 x 4 gauze under access port.

2. Perform a vigorous 30 second scrub with Soluprep antiseptic swab of the port of the
access (red) line and allow to dry for 30 seconds.

3. If the patient is on a citrate infusion that is running through an added stopcock

on the access line a discard of 2 mL is required for a clean sample to be sent.
The citrate infusion should not be running while labs are being drawn. Attach a 23 or
25 gauge needle to a 2 mL syringe and withdraw a 2 mL discard.

4. Attach a 23 or 25 gauge needle to a 5 mL syringe. Withdraw the required amount of

arterial blood from the access port; divide into ABG syringe/CBC tube/Coag tube as
ordered. Label and send to the lab. *ENSURE the specimen is ordered and
labeled as venous blood gas*.

5. Dispose of used supplies appropriately. Remove gloves and perform hand hygiene.
Continuous Renal Replacement Therapy - #1625 Page 12 of 21

Post-filter venous lab draw:

Gather supplies
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol)
 1 mL syringe x 2
 ABG syringe x 1
 Clean gloves
 23 or 25 gauge needle x 2

PROCEDURE for post-filter venous lab draw

1. Don clean gloves.

2. Perform a vigorous 30 second scrub with Soluprep antiseptic swab of the post-filter
port of the return (blue) line and allow to dry for 30 seconds.

3. Attach a 23 or 25 gauge needle to 1 mL syringe. Withdraw the required amount of

venous blood from the return port, place into ABG syringe. Label and send to lab.
*ENSURE specimen is ordered and labeled as venous blood gas and dialysis is
noted in the comment section*.

4. Dispose of used supplies appropriately. Remove gloves and perform hand hygiene.
Continuous Renal Replacement Therapy - #1625 Page 13 of 21

4. Fluid Sampling from the Prismaflex Circuit

If there is reason to question the presence of blood through the effluent line (as
indicated by the blood leak detector in the Prismaflex or through visual observance),
effluent fluid can be sent to the lab. This fluid would be treated as a body
fluid/peritoneal dialysis sample.

Fluid sampling:

Gather supplies:
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol)
 3 mL syringe x 1
 Sterile orange top sample bottle x 1
 Clean gloves
 23 or 25 gauge needle x 1

PROCEDURE for collecting fluid sample

1. Don clean gloves.

2. Perform a vigorous 30 second scrub with Soluprep antiseptic swab of the yellow
effluent port of the effluent (yellow) line (just past the blood leak detector) and allow
to dry for 30 seconds.

3. Attach a 23 or 25 gauge needle to 3 mL syringe. Withdraw 2-3 mL of fluid from the

effluent port and place into the orange top sterile container.

4. Label and send specimen to the lab. *ENSURE the specimen is ordered as
micro cell count for whole red blood cells, effluent fluid is captured under
body fluid/PD sample, dialysis should be typed in the comment section*.

5. Dispose of used supplies appropriately. Remove gloves and perform hand hygiene.

5. Termination of Continuous Renal Replacement Therapy

5.1. Verify that order has been written to terminate treatment.

5.2. Gather supplies:

 Mask
 Sterile gloves
 Sterile dressing tray
 Sterile towel
 Soluprep antiseptic swabs (2% chlorhexidine/70% alcohol) x 2
 10 mL pre-filled sterile 0.9% NaCl syringes x 2
 2 ‘Tegos’ caps
 Heparin 1,000 units/mL or heparin 100 units/mL (based on patient’s
weight)
Continuous Renal Replacement Therapy - #1625 Page 14 of 21

 3 mL syringe x 2
 Blunt tip needle x 2
 Sterile 4 x 4 and tape

5.3. Perform hand hygiene and don mask.

5.4. Remove any tape or labels from the vascular access lumens.

5.5. Prepare sterile field. Open dressing tray and add Soluprep antiseptic swabs,
0.9% NaCl syringes, 10 mL syringes, 3 mL syringes, blunt tips and sterile caps.

5.6. Press ‘Stop’ on Status screen. On the Stop screen you will have the choice to
recirculate through the circuit or to return blood to the patient. Press
‘recirculate’ to temporarily disconnect from the patient, choosing either to
recirculate with 0.9% NaCl (follow the 4 steps) or to recirculate with blood (follow
the 6 steps). If treatment is complete press ‘End Treatment’.

5.7. If the physician has ordered that the blood be returned to the patient press
‘return blood’. Follow the 3 steps in order and press ‘continue’. Choose ‘auto
return’ or ‘manual return’, watch the circuit set closely for air bubbles, this
process takes approximately 2 minutes. Press ‘continue’ when blood return is
complete.

5.8. Proceed to the Disconnect Patient screen. Clamp all lines. Place a sterile
green towel close to the vascular access catheter.

5.9. Don sterile gloves.

5.10. Vigorously scrub the access lumen with Soluprep antiseptic swabs for 30
seconds and place on sterile field. Repeat scrub for return lumen and place on
sterile field, allowing lines to dry for 30 seconds.

5.11. Disconnect the circuit tubing and attach 10 mL 0.9% NaCl syringe to the
vascular access lumen. Aspirate slightly to ensure absence of air in lumen.
Flush lumen with 5 mL of 0.9% NaCl to ensure lumen is cleared of blood. Clamp
lumen. Have bedside nurse hold heparin vial while sterile nurse uses 3 mL
syringe and blunt tip to withdraw heparin from vial. Attach to vascular access
lumen, unclamp and flush lumen with the exact amount indicated on the vascular
access lumen. Clamp lumen and attach sterile cap. Repeat procedure for
return lumen.

5.12. Wrap vascular access lumens with a 4 x 4 gauze and tape around gauze. Label
with ‘Do Not Flush, For Dialysis Only’, date, time and initial.

5.13. Press ‘unload’ to release and remove the filter set from the Prismaflex machine.
Discard circuit. Remove gloves and mask.

5.14. Perform hand hygiene.

Continuous Renal Replacement Therapy - #1625 Page 15 of 21

5.15. Document patency of vascular access catheter, fluid balance, the patient’s
tolerance of termination of therapy, reason for termination, circuit assessment,
and amount and strength of heparin flush.

6. Effluent Bag Change

 When we start a treatment two effluent bags will be used on the patient,
alternating between them.
 We will use two new effluent bags when we change out the filter, a minimum of
every 72 hours (with a perfectly working filter or more often if the filter is clotting
and requires changing sooner).
 A whole new set up should have a completely clean start, including effluent bags.

7. Trouble Shooting Equipment Problems

To support the CRRT nurse to treat clinical problems see Appendix B – Alarms and
Troubleshooting.
Continuous Renal Replacement Therapy - #1625 Page 16 of 21

REFERENCES

Baxter Gambro (2013). Prismaflex Tutorial – SW 7.10. Lundia, Alberta.

British Columbia Children’s Hospital (2012). Continuous Renal Replacement Therapy

(CRRT), Policy and Procedure Manual. Vancouver, British Columbia.

Kellum, J., Bellomo, R. and Ronco, C. Continuous Renal Replacement Therapy (2010).
Oxford University Press. Oxford, New York.

London Health Sciences Centre Children’s Hospital (2012). Pediatric Resource Manual for
Prismaflex, Preparing the Prismaflex Circuit for PCRRT. London, Ontario.

Monroe Carell Jr. Children’s Hospital at Vanderbilt (2013). CRRT Procedures and
Guildelines. Guidelines for the utilization of CRRT at Monroe Carell Jr. Children’s Hospital at
Vanderbilt. Nashville, Tennessee.

Vancouver Coastal Health, Providence Health Care (2014). Continuous Renal Replacement
Therapy (CRRT), Professional Practice Policy. Vancouver, British Columbia.

RELATED DOCUMENTS
Policies
Clinical Policy # 205.2 – Hand Hygiene
Clinical Policy # 735 E – Blood Withdrawal, Indirect and Direct
Clinical Policy # 1753 – Blood Specimen Collection from Arterial Lines
Clinical Policy # 5208 – Discontinuing Hemodialysis/ Continuous Renal Replacement
Therapy (CRRT) Using the Fresenius 2008 K Machine
Clinical Policy # 5210 – Initiating Hemodialysis/Continuous Renal Replacement Therapy
(CRRT) Using the Fresenius 2008 K Machine

Appendices
Appendix A – Definitions
Appendix B – Alarms and Troubleshooting
Continuous Renal Replacement Therapy - #1625 Page 17 of 21

APPENDIX A – DEFINITIONS
Adsorption: removal of molecules by means of binding to the filtering membrane or artificial
surface.

Convection: the removal of solutes due to the pressure difference between blood and fluid,
“solvent drag”.

Continuous Renal Replacement Therapy (CRRT): is a continuous extracorporeal blood

purification therapy that slowly removes fluid and/or solutes over a 24 hour period.

CRRT Modalities:

1. Slow Continuous Ultrafiltration (SCUF): the removal of fluid without the need for
substitute fluid replacement.

2. Continuous Venovenous Hemofiltration (CVVH): removes large volumes of fluids

and waste from the patient using replacement fluids, to maintain electrolyte and acid
base balance.

3. Continuous Venovenous Hemodialysis (CVVHD): primarily uses diffusion along

with a dialysate solution to boost the removal of waste products.

4. Continuous Venovenous Hemodiafiltration (CVVHDF): large volumes of fluids and

waste are removed from the patient using dialysate and replacement fluids to replace
the “dirty plasma” with clean fluid. This allows for the removal of large volumes of
toxin-filled plasma, while still maintaining electrolyte balance.

Diffusion: the movement of solutes from a higher to a lower concentration.

Filter: device containing the fibers of the semi-permeable membrane within it.

Ultrafiltration: the movement of fluid through a semi-permeable membrane driven by a

pressure gradient.
Continuous Renal Replacement Therapy - #1625 Page 18 of 21

APPENDIX B – ALARMS AND TROUBLESHOOTING

1. Alarms

(A) Type of Alarm

Latched Requires correction, will not reset, use alarm silence

Unlatched Self correction, then reset without intervention
Advisory Message to operator, future intervention
Alarm
Warning Message to operator, intervention now
Alarm
Crisis Alarm Message to operator, machine will stop

(B) Understanding Alarms

Warning - Patient hazard: immediate attention, blood pump, syringe pump

and fluid pumps stop
- Access extremely negative: immediate attention, all pumps stop
including the blood pump, clotting can occur
Malfunction - System hazard: immediate attention, blood pump, syringe pump
and fluid pumps stop
- Air detector, machine is not working as it should, all pumps will
stop, clotting can occur
Caution - Fluid pumps stop, treatment is suspended, blood and syringe flow
continues
- Bag empty: fluid pumps stop, treatment is suspended, blood
pump and anticoagulation continue
Advisory All pumps continue to run

(C) Types of Alarms

Pressure Alarms: related to patient
safety
Access extremely negative: check access
line
Access extremely positive: check access
and return lines
Machine will try to self clear for 15 seconds
Rule out other causes (clots, patient
moving, patient being suctioned, blood
flow rate too high)
Continue treatment, check flow settings:
change if required, ‘Continue’ will open
return clamp, reset and clear alarms
This alarm will NOT self clear
Rule out other causes (clots, patient
moving, patient being suctioned, blood
flow rate too high, return pressure sensor
fail)
Press release clamp
Check flow settings: change if required,
Continuous Renal Replacement Therapy - #1625
Return extremely positive: Return clamp
closes
Return disconnection: alarms when return
pressure is lower than +10mmHg
Return Pressure Dropping: If return
pressure is 50mmHg below operating point
Check return advisory: If return pressure is
greater than 50mmHg above operating
point
Can not detect run: When return pressure
operating patient is below +10mmHg
Filter extremely positive: if filter pod
pressure is ≥450mmHg
Set disconnection: if filter pressure is lower
than +10mmHg when operating point
above +10mmHg
Clotting
Advisory: filter is clotting
Warning: filter is clotted
Other
Bag empty/full caution alarm
2. Trouble shooting
(A) Trouble shooting: P – A – C – E
Patient Assess patient, coughing, repositioning, patient movement
Access Related to catheter, is there blood return, catheter patency, kicks,
check clamps
Circuit Related to filter and tubing, check for clots or gas bubbles
Equipment Equipment failure or power outage
Page 19 of 21
‘Continue’ will open return clamp, reset
and clear alarms
‘Release clamp’ opens the return clamp
and allows treatment to continue
‘Release clamp’ opens the return clamp
and allows treatment to continue
‘Release clamp’ opens the return clamp
and allows treatment to continue
‘Release clamp’ opens the return clamp
and allows treatment to continue
‘Release clamp’ opens the return clamp
and allows treatment to continue
Return clamp closes, ‘Release clamp’
opens the return clamp and allows
treatment to continue
Over ride goes back to ‘status’, alarm is
not clear
Resistance through filter, the filter pressure
drop will increase
If internal filter pressure
increases(increase in transmembrane
pressure (TMP)/pressure drop is
100mmHg higher than last value
calculated) ensure adequate
anticoagulation (decrease ultra filtration
rate or increase blood flow rate)
Adapt settings, may need self test
Inadequate anticoagulation is most likely
the cause, most likely will need to change
filter set
Fluid pumps will stop and treatment will
discontinue, change bags and continue
Continuous Renal Replacement Therapy - #1625 Page 20 of 21

(B) Troubleshooting Checklist

Alarm/Problem Possible Causes Actions

Too low arterial 1. Kinked or clamped line
pressure alarm 2. Clotted line
3. Access device against vessel wall
4. Hypovolemia
High venous 1. Kinked or clamped line
pressure alarm 2. Clotted line
3. Positional vascular access
obstruction
Arterial (or 1. Line separation or disconnection
venous) line from patient (very rare)
disconnection 2. Circuit kinked or clamped before
alarm pressure sensor
3. Clot excluding pressure sensor
4. Blood pump speed relatively too
slow with respect to catheter
performance
Increasing TMP 1. Clogging hemofilter
2. Kinked or clamped
hemofiltration/dialysis line
3. Blood flow to slow for UF setting
Air in circuit 1. Presence of small air bubbles
(often due to bicarb - CO2 coming
form hemofiltration bag)
2. Line disconnection at arterial
access
3. Turbulence close to air sensor
Fluid balance 1. Effluent or hemofiltration/ dialysis
error bags moving or incorrectly hung
2. Kinking in effluent or hemofiltration/
dialysis bags
3. Machine occasional error
4. Machine systematic error (if more
than 10 times without reason in 3
hours)
1. Remove kinking
2. Declot access
3. Consider limbs switching
4. Stop UF, decrease blood
flow rate
1. Remove kinking
2. Declot access
3. Consider limbs switching
1. Check circuit and patient
and, if no disconnection is
present, override alarm
2. Declamp line
3. Evaluate for circuit
change
4. Increase set blood flow
rate
1. Evaluate for circuit
change
2. Declamp line
3. Increase blood flow
speed, check UF setting
1. Follow instructions for
de-gassing
2. Stop session
3. Override alarm
1. Wait for bags, stop or
reposition them on the
scales
2. Remove line kinking
3. Override
4. Change machine and do
not reuse it before technical
assistance

***
Continuous Renal Replacement Therapy - #1625 Page 21 of 21

District Health Authority/IWK Policies Being Replaced

(Please List)

Version History
(To Be Completed by the Policy Office)

Major Revisions (e.g. Standard 4 year Minor Revisions (e.g. spelling correction,
review) wording changes, etc.)