crrt therapy in the pediatric critical care patient

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CRRT Therapy in the Pediatric Critical Care Patient

An overview of common complications and solutions for Pediatric Critical Care Patients undergoing CRRT

Therapy

By Tom MacCrae RN, BSN

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Speaker Information

2 1/2 Years experience as EMT in Santa Clara County

Graduated with BSN from Azusa Pacific University 2004

PICU RN at Lucile Packard Children’s Hospital since 2004

CRRT Clinical Coordinator in PICU since 2006

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Hungry for Knowledge?

Lets Get Ready to Learn!!!!

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ObjectivesExplanation of common catheter, filter, and pump complications with CRRT in the Pediatric Patient

Examine specific patient related complications for pediatric patients undergoing CRRT therapy.

Discuss the recommended solutions to common CRRT complications in the Pediatric Patient

Review select case scenarios from the PICU at LPCH and discuss how specific CRRT complications were addressed

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CRRT with Prisma Machine

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Catheter complications

Sluggish blood flow through the catheter

Catheter entry site complications

Patient position problems

Blood clotting complications

Blood Products / Drugs affecting catheter function

Left Femoral Catheter

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Solutions To Catheter Complications

Re-positioning the patient

TPA for clotted catheters

Infuse blood products and drugs as far away from the CRRT catheter as possible

Reversing the catheter access if necessary

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Example of Catheter Location

Tunneled Catheters

Non-tunneled Catheter

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CRRT Catheter with Pig-Tail Lumen

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Double Lumen Catheter with Dilator and Wire

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Filter / Pump Complications

Sluggish blood flow in the filter and tubing

Failing or clotting filter

Cracked filter or ruptured tubing

Filter saturation, and short filter life

Frequent air and blood leak alarms

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Filter Saturation

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Solutions To Filter / Pump Complications

Adjust blood flow rate to accommodate for rising or falling access and return pressures

Anticipate more frequent filter changes for PT in DIC

Special attention to calcium and citrate infusions can help to minimize filter and pump complications

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Solutions To Filter / Pump Complications

Careful observation for clots in the filter may warn of impending failure

Keeping machine clean will also eliminate potential alarms and reduce pump complications

Trouble shooting alarms instead of silencing them will decrease associated complications.

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Pediatric Patient Complications

Blood Pressure instability

Electrolyte imbalance

Risk of Bleeding

Decreased HCT / HGB

Kids Don’t Hold Still

Smaller kids = smaller catheters = restricted blood flow

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Solutions To Pediatric Patient Complications

Blood PrimeUsed for Small babiesand Patients with low HCT**special considerations**

Albumin PrimeUsed for Patients with B/P

instability

Saline PrimeDecreases exposure to blood products in stable patients

Pre-Medication AdministrationCACL, Albumin, isotonic

volume

Frequent Lab and VS monitoring

Chem 10, CBC, Coags

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Case Scenarios

(1) Pt J.J., a morbidly obese teenager in renal failure, fighting sepsis who is undergoing CRRT.

(2) Pt C.P., an active teenage patient undergoing CRRT and plasmapheresis simultaneously using the same catheter

(3) Pt A.M., a small infant with multi-system organ failure waiting for a liver transplant

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Case Scenario #1 (Pt. J.J.)

In addition to his underlying metabolic disorder J.J. experienced multi-system organ failure, severe respiratory distress, and sepsis.

Making things even more complicated was the fact the J.J. was morbidly obese.

J.J. experienced catheter and filter complications while on CRRT. J.J. was also very unstable and frequently dealt with B/P instability. He required multiple blood transfusions while on CRRT.

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An Overview of Complications

Larger patients require much faster blood flow rates when undergoing CRRT therapy. The faster rates increase the strain on the HD catheter and generally lead to more complications with CRRT therapy

Patients with large amounts of subcutaneous tissue generally have more frequent complications with their HD Catheter

Patients who are unstable on CRRT may require multiple blood transfusions and pharmacological interventions while undergoing therapy. These additional therapies are problematic as they often lead to clotted filters.

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An Overview of Solutions

If possible, using the largest size HD catheter in the obese patients will allow for optimum blood flow rates which will enable the CRRT therapy to be most effective

By adjusting the blood flow rates as soon as catheter blood flow becomes a problem, the associated catheter complications may be avoided

Infusing the necessary blood transfusions and drug products as far away from the CRRT catheter can minimize complications with the catheter and the filter. (opposite side of body and diaphragm)

TPA and heparin are useful tools to maintain a patent catheter. When used to lock the catheter during circuit changes TPA or heparin can un-clot an occluded catheter

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Case Scenario #2 (Pt. C.P.)

C.P. was a very unique patient in the PICU because of her mobility.

C.P. was one of the very few patients to undergo CRRT and was stable enough to sit up in bed and interact as a relatively normal teenage girl.

During the course of her CRRT it was determined that C.P. would benefit from plasma pheresis. The decision was made to run plasma pheresis and CRRT on the same catheter, thereby increasing the amount of strain on the CRRT catheter

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Active children and teenagers can often complicate CRRT therapy with frequent and unpredictable movement which can clamp off the HD catheter both internally and externally

Children with medical conditions which require additional intravenous therapies may increase the likelihood of complications with their CRRT therapy

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An Overview of Solutions

Encourage the medical / surgical team to place the HD catheter in a location which will be minimally kinked with patient movement

Proper dressing and arm board placement to extremities with HD catheters in place can minimize complications

Adjusting the blood flow rate of the CRRT during any additional intravenous therapies will help minimize any potential complications

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Case Scenario #3 (Pt. A.M.)

A.M. was one of the smallest patients that we have placed on CRRT in the PICU

While waiting for a liver transplant this patient developed renal failure

Without a functioning liver or kidney the patients body began retaining fluid and toxins

The benefit of CRRT for this patient outweighed the risks associated with using CRRT on such a small patient

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Babies often encounter unique complications with CRRT therapy because of their small size

Complications can include blood pressure instability, electrolyte imbalances, and catheter complications

Small patients require extra special attention to fluid and electrolyte removal when receiving CRRT therapy

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An Overview of SolutionsThe smaller the patient the smaller the amount of fluid that can be safely removed at a given time

(smaller patients = slower pump speed)

Special attention must be taken not to drop the blood pressure or blood volume of the small CRRT patients

When changing the CRRT machine every 3 days a “circuit to circuit prime” can lower the risk of blood pressure instability and lower the amount of exposure to additional blood products.

By administering certain medications such as CACL or albumin prior to initiating CRRT therapy, specific complications can be minimized

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Circuit to Circuit Prime

This priming process takes advantage of the circulating blood volume in the existing CRRT circuit

The dialysis RN can connect the new filter and tubing to the old filter and tubing and by running the circuits together, can use the blood from the existing circuit to prime the new one

This process benefits the patient by not requiring any exposure to new blood products. In addition the patient is benefited by lowering the potential for a drop in circulating blood volume (blood pressure)

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Conclusion

Knowing what complications to expect when running CRRT and anticipating their solutions has many benefits.

These benefits include:

● Decreasing the stresses associated with maintaining CRRT

● Providing the most efficient and effective treatment for patients undergoing CRRT

● Decreasing the amount of circuit changes due to circuit failure

● Minimizing the need for blood and electrolyte replacement during CRRT therapy

crrt therapy in the pediatric critical care patient

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