ICU-CCU INSERVICE TRAINING FOR NURSES

(RECERTIFICATION)
MANAGEMENT OF CRRT
01
Mengetahui pengertian CRRT
Mengetahui tujuan penggunaan CRRT
02
Mengetahui indikasi dan kontraindikasi
CRRT
Mengetahui komplikasi penggunaan CRRT

03 Mengetahui prinsip dasar CRRT

Mengetahui macam-macam CRRT

Mampu mengatasi troubleshooting alat

04 Mengoperasionalkan alat CRRT
Mengaplikasikan alat CRRT 05 CRRT
Memberikan asuhan keperawatan pada
pasien dengan CRRT

Agenda
Continuous Renal Replacement Therapy (CRRT)

Any extracorporeal blood purification therapy

intended to substitute for impaired renal function
over an extended period of time and applied for or
aimed at being applied for 24 hours/day.

Bellomo R., Ronco C., Mehta R, Nomenclature for

Continuous Renal Replacement Therapies, AJKD, Vol 28,
No. 5, Suppl 3, Nov 1996
 WHY CRRT?
CRRT closely mimics the native kidney in treating
ARF and fluid overload

Removes large amounts of fluid and waste products

over time

Tolerated well by hemodynamically unstable patients

Indication for CRRT
oliguria (200 ml) In 12 hours
Significant organ oedema

Hypercalemia > 6,5 mmol/L Uremic Ensephalopaty

Severe Acidemia pH < 7,1 Severe dysnatraemia

Sodium >160 or < 115 mmol/L
Anuria (50ml) In 12 hours
Drug over doses

Azotaemia (Urea > 30 mmol/L)

Hyperthermia
 KIDNEY
FUNCTIONS
The kidney has several functions (CRRT deals with the
first four functions):

1 Fluid balance

2 Electrolyte balance

3 Acid-base balance

4 Excretion of drugs and by-products of metabolism

5 Regulation of blood pressure

6 Synthesis of erythropoietin
 CRRT Treatment Goals

Allow other supportive

measures; nutritional
Promote healing support
and total renal
Prevent further recovery
damage to kidney
Maintain fluid,
tissue
electrolyte,
acid/base balance
 COMPLICATION
Hypotension Bleeding &
Coagulopathy
Inotropic support may be
requaired to maintain The patient”s coagulation
effective mean arterial status is carefully
pressures monitored, it is important to
look for other sign of
CRRT bleeding

Nurses should always

be monitoring for Fluid, electrolyte &
sign of infection Acid /base imbalance
Infection
 Nursing Management
• Weight the patient daily to Check blood urea nitrogen and
assess fluid removal creatinine levels at least daily to assess
• Monitoring for hemodinamic CRRT efficacy
• Monitor for sign infection
• Monitor for aritmia

Routinely monitor the patient”s

Monitor for signs and symtoms of
Complete blood count to check For
bleeding in the oral msucosa,
unintended blood loss in
gastric aspirate, stool & injection site,
case The CRRT circuits
check coagulation regulary
suddenly clots

Take step to prevent hypothermia, Check routine electrolyte levels &

manufactures provide warmer BGA
blanket.
 Infographic Style
CRRT
Transport Mechanisms Add Title
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 Daltons
Molecular
Weights
Ultrafiltration 1
Fluid

Diffusion
Solute

}
3

Convection
4

Adsorption
 Ultrafiltration
Movement of fluid through a semi-permeable membrane
caused by a pressure gradient
 Diffusion
Movement of solutes from an area of higher concentration to an area of
lower concentration

Dialysate is used to create a

concentration gradient across a semi-
permeable membrane.
 Convection
Movement of solutes with water flow, "solvent drag".

The more fluid moved through a

semi-permeable membrane, the
more solutes that are removed

Replacement Fluid
is used to create convection
Adsorbtion
 SCUF

CVVHDF
CRRT CVVH
MODES

CVVHD
Primary therapeutic goal:

Safe and effective management

of fluid removal from the SCUF
patient
Primary Therapeutic Goal:
• Removal of small, middle and large sized
solutes
• Safe fluid volume management

• Replacement solution is infused into

blood compartment pre or post filter
• Drives convective transport
• Replacement fluid volume
automatically removed by effluent CVVH
pump
Solute removal determined by
Replacement Flow Rate
 Primary therapeutic goal:
• Small solute removal by diffusion

CVVHD
• Safe fluid volume management

Dialysate volume automatically

removed through the Effluent pump

Solute removal determined by Dialysate Flow Rate

 • Flows counter-current to blood flow
• Remains separated by a semi-permeable
membrane
• Drives diffusive transport

DIALISAT • Dependent on concentration gradient and

flow rate
SOLUTION • Facilitates removal of small solutes
• Physician prescribed
• Contains physiologic electrolyte levels
• Components adjusted to meet patient
needs
Primary therapeutic goal :
• Solute removal by diffusion and convection
• Safe fluid volume management
• Efficient removal of small, middle and large molecules
• Replacement and dialysate fluid volume automatically
removed by effluent pump

Solute removal determined by

Replacement + Dialysate Flow Rates.
• Infused directly into the blood at points along the
blood pathway
• Drives convective transport
• Facilitates the removal of small middle and large
solutes
• Physician Prescribed
• Contains electrolytes at physiological levels
• Components adjusted to meet patient needs
Pre-Dilution Replacement Solution

•Decreased risk
of clotting
•Higher UF
capabilities
•Decreased
Hct. In filter
 Post-Dilution Replacement Solution

•Consider lowering replacement rates

(filtration %)

•Higher anticoagulation

•More efficient clearance (>15%)

Component of CRRT
• Macine
• Hemofilter
• Solutions
• Vascular Access
• Anticoagulation
• Warmer
 Prismaflex M100 sets

PRIMSMAFLEX M100

Characteristics:
 Membrane: AN 69
 Priming volume: 152 ml
 QB Range: 50 - 400 ml/ min
 Application: ≥ 30 kg
 Validated to use for: 72 hours
Solutions
Purpose
• Dialysate and/or Replacement – provide diffusion and/or
convection
• Depends on mode of therapy
• Removal of unwanted solutes
• Restores electrolyte and acid/base balance to patient’s
blood.

Buffer
• Normalize blood pH
• Treat underlying metabolic
acidosis/alkalosis
• Replace bicarbonate lost during CRRT
Vascular
Access
 Vascular Access - CRRT

Jugular Subclavian
Long term access  Easy to insert
Patient comformt  Risk of stenosis &
kinking

Femoral
 Easy to insert
 Good blood flow condition
 Risk of stenosis & infectious
 Vascular Access - CRRT

Access:
Important
Considerations
• Refer to and follow the hospital protocol for
specific guidelines
• Vascular Access recommendations:

• Aspirate and discard heparin before

flushing
• 20 to 30 CC syringe to assess patency
• Check for kinks/ clamps
Anticoagulation
THANK YOU