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119 Continuous Renal Replacement Therapies 1055 Unit V Renal System Section Seventeen Renal Replacement PROCEDURE Continuous Renal Replacement 119 Therapies Sonia M. Astle PURPOSE: Continuous renal replacement therapies are used in the critical care unit setting for volume regulation, acid-base control, electrolyte regulation, drug intoxications, management of azotemia, and immune modulation. These methods are most often used in critically ill patients whose hemodynamic status does not tolerate the rapid fl uid and electrolyte shifts associated with intermittent hemodialysis or who need continuous removal or regulation of solutes and intravascular volume. high pressure to an area of low pressure with transport PREREQUISITE NURSING of solutes. When water moves across a membrane KNOWLEDGE along a pressure gradient, some solutes are carried along with the water and do not require a solute con- • Continuous renal replacement therapy (CRRT) is an extra- centration gradient (also called solute drag). Convec- corporeal blood-purifi cation therapy intended to substitute tive transport is most effective for the removal of for impaired renal function over an extended period of middle-molecular-weight and large-molecular-weight time for, or attempted for, 24 hours per day. 1 solutes. • CRRT can be accomplished through a variety of methods, ❖ UF: The bulk movement of solute and solvent through with either arteriovenous (AV) access or venovenous a semipermeable membrane in response to a pressure (VV) access. The VV access is used almost exclusively difference across the membrane. This movement is because of its less invasive nature. In the past, AV access usually achieved with positive pressure in the blood was used, requiring both arterial and venous cannulation. compartment in the hemofi lter and negative pressure in With AV access, the patient ’ s systemic blood pressure is the dialysate compartment. Blood and dialysate run required for blood to fl ow into the extracorporeal circuit, countercurrent. The size of the solute molecules com- making it unreliable for hypotensive patients. The newer- pared with the size of molecules that can move through generation CRRT machines have an added extracorporeal the semipermeable membrane determines the degree blood pump that pulls the patient ’ s blood into the circuit, of UF. so it is better suited to treat hemodynamically unstable ❖ Osmosis: The passive movement of solvent through a patients. 10,18 semipermeable membrane from an area of higher to • The following methods of CRRT are included as listed lower concentration. (details are outlined in Table 119-1 ): ❖ Oncotic pressure: The pressure exerted by plasma ❖ Slow, continuous ultrafi ltration (SCUF) proteins that favor intravascular fl uid retention and ❖ Continuous venovenous hemofi ltration (CVVH) movement of fl uid from the extravascular to the intra- ❖ Continuous venovenous hemodialysis (CVVHD) vascular space. ❖ Continuous venovenous hemodiafi ltration (CVVHDF) ❖ Hydrostatic pressure: The force exerted by arterial • Basic knowledge is required to understand the principles blood pressure that favors the movement of fl uid from of diffusion, ultrafi ltration (UF), osmosis, oncotic pres- the intravascular to the extravascular space. sure, and hydrostatic pressure and how they pertain to ❖ Absorption: The process by which drug molecules pass fl uid and solute management during dialysis. through membranes and fl uid barriers and into body ❖ Diffusion: The passive movement of solutes through a fl uids. semipermeable membrane from an area of higher to ❖ Adsorption: The adhesion of molecules (solutes) to the lower concentration until equilibrium is reached. surface of the hemofi lter, charcoal, or resin. ❖ Convective transport: The rapid movement of fl uid • CRRT uses an artifi cial kidney (i.e., hemofi lter, dialyzer) across a semipermeable membrane from an area of with a semipermeable membrane to create two separate 1054 119 Continuous Renal Replacement Therapies 1055 TABLE 119-1 Continuous Renal Replacement Therapies Ultrafi ltration Mode of Principles Complications/ Therapies Involved Access Indications Advantages Disadvantages SCUF (slow, Ultrafi ltration Venovenous Patients with diuretic- Continuous, gradual Anticoagulation, bleeding continuous resistant, volume- treatment (fewer Hypotension ultrafi ltration) overloaded, high and low Hypothermia hemodynamically extremes) Access complications (bleeding, unstable conditions Precise fl uid control clotting, infection) who cannot tolerate can be done in Requires strict monitoring of rapid fl uid shifts patient with low fl uid and electrolyte mean arterial replacement to avoid pressure defi cits or overload Air embolism Critical care setting only Poor control of azotemia; dialysis may be needed Minimal solute clearance Not recommended for emergently treating hyperkalemia or acidosis CVVH (continuous Ultrafi ltration Venovenous Patient with volume- Precise fl uid control Anticoagulation, bleeding venovenous Convection overloaded, can be done in Hypotension hemofi ltration) Solute removal hemodynamically patients with low Hypothermia unstable condition with mean arterial Access complications (bleeding, azotemia or uremia pressure clotting, infection) Ease of initiation Requires strict monitoring of fl uid and electrolyte replacement to avoid defi cits or overload Air embolism Critical care setting only Recommended 1 : 1 nurse/ patient ratio Metabolite removal not as effi cient as CVVHDF CVVHD (continuous Ultrafi ltration Venovenous Patients with volume- Precise fl uid control Same as CVVH venovenous Diffusion overloaded, can be done in Hyperglycemia hemodialysis) Solute removal hemodynamically patients with low Hypernatremia unstable conditions mean arterial Hypophosphatemia with azotemia or pressure uremia Ease of initiation CVVHDF (continuous Ultrafi ltration Venovenous Patient with volume- Precise fl uid control Same as CVVH venovenous Convection overloaded, can be done in Hyperglycemia hemodiafi ltration) Diffusion hemodynamically patient with low Hypernatremia Solute removal unstable conditions mean arterial Hypophosphatemia with azotemia or pressure uremia, catabolic Better solute acute renal failure, clearance than electrolyte imbalances/ CVVH/ CVVHD metabolic acidosis Ease of initiation Adapted from Giuliano K, Pysznik E: Renal replacement therapy in critical care: implementation of a unit-based CVVH program, Crit Care Nurse 18:40–45, 1998. compartments: the blood compartment and the dialysis solution but is impermeable to larger molecules (e.g., red solution compartment. The semipermeable membrane blood cells, plasma proteins). allows the movement of small molecules (e.g., electro- • Each dialyzer has four ports: two end ports for blood lytes) and middle-size molecules (e.g., creatinine, vasoac- (blood fl ows in one end and out the other) and two side tive substances) from the patient ’ s blood into the dialysis ports for dialysis solution ultrafi ltrate (dialysate solution 1056 Unit V Renal System fl ows in one end and out the other). In most cases, the blood and dialysate run through the dialyzer in opposite or countercurrent directions. • Hollow-fi ber dialyzers are used almost exclusively for CRRT. The blood fl ows through the center of hollow fi bers, and the dialysis solution (dialysate) fl ows around the outside of the hollow fi bers. The advantages of hollow- fi ber fi lters include a low priming volume, a low resis- tance to fl ow, and a high amount of surface area. The major disadvantage is the potential for clotting as a result of the small fi ber size. • All dialyzers have a UF coeffi cient; thus, the dialyzer 2–6,8,9 selected varies in different clinical situations. The UF drain bag higher the UF coeffi cient, the more rapid the fl uid removal. 12,16,19 UF coeffi cients are determined with in vivo measurements done by each dialyzer manufacturer. • Clearance refers to the ability of the dialyzer to remove Figure 119-1 Slow continuous ultrafi ltration (SCUF). Fluid metabolic waste products or drugs from the patient ’ s removal, no fl uid replacement. (Copyright Rhonda K. Martin. All blood. The blood fl ow rate, the dialysate fl ow rate, and the rights reserved. Used with permission.) solute concentration affect clearance. Clearance occurs by the processes of diffusion, convection, and UF. • The dialysate (when used during CRRT) is composed of Replacement fluid water, a buffer (i.e., lactate or bicarbonate), and various electrolytes. Most solutions also contain glucose. The buffer helps neutralize acids that are generated as a result of normal cellular metabolism. The concentration of elec- trolytes is usually the normal plasma concentration, which helps to create a concentration gradient for removal of excess electrolytes. The glucose aids in increasing the Blood pump oncotic pressure in the dialysate (thus aiding in fl uid removal) and in caloric replacement. Although glucose comes in various concentrations, it is usually used in normal plasma concentrations to prevent hyperglycemia. • Heparin or citrate are often used during CRRT to prevent clotting of the extracorporeal circuit during treatment. Saline solution fl ushes can be used alone or with other 31,33 anticoagulants to maintain circuit patency. UF drain bag • An anticoagulant may be used to maintain vascular access patency when CRRT is not in use. 4,18,33 • If the patient is taking angiotensin-converting enzyme (ACE) inhibitors, contact with certain fi lters or mem- Figure 119-2 Continuous venovenous hemofi ltration (CVVH). branes in the CRRT system can cause an anaphylactic Fluid removal and fl uid replacement. (Copyright
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