Transcript Document

Troubleshooting Issues in CVVH
Timothy L. Kudelka RN, BSN
Pediatric Dialysis Program
C.S. Mott Children’s Hospital
University of Michigan
Where to Begin?
• As Nephrologist, Intensivist and Nurses we all
need to address the issues of troubleshooting
• Many systems are still adapted (pieced) and
others now self-contained with simplified
operating interface and build-in software.
• Troubleshooting issues still remain.
• If you don’t have it you might as well go
• This is the most important aspect of
CVVH therapy.
Filter life.
Increased blood loss.
Staff satisfaction.
Troubleshooting Access
• How can you tell if
you have a problem
before starting?
• What if you have
problems during
• Check placement
first, then use
syringe to test
resistance and
blood return.
• Check line for kink,
then assess patients
position or need for
• Clotting or sluggish catheter.
• tPA (tissue plasminogen activator).
(Spry et al., Dialysis&Transplantation. Jan. 2001).
• Normal saline flush.
• Reason to replace catheter.
• Clotted catheter with no response to tPA.
• Exit site blood leakage with no response to pressure
• Severe kinked catheter.
• Bad re-circulation issues.
• Arterial or outflow pressures
• High negative pressure = access problem.
• High positive pressure = filter problem.
• Moderate to high positive pressure + high return (venous)
pressure = access problem.
• Venous or return pressures
• Moderate to high positive pressure + high arterial pressure =
filter problem.
• High return pressure + moderate arterial pressure = access
• None.
• Heparin.
• Bolus 10-20 units/kg then infuse at 10-20 units/kg/hr
adjust per ACT.(Heparin induced thrombocytopenia).
• Citrate.
• Initiate infusion rate at 1.5x the BFR(in mls/hr).
• Calcium chloride infusion at 0.16x the citrate rate.
(Hypocalcemia,metabolic alkalosis.
Normal saline flush.
Flashlight lines and filter.
Correct priming technique.
Maintain good BFR.
Monitor ACT levels (200-250).
Quick response to troubleshooting
• How much to ultrafiltrate?
• Net ultrafiltration should be in the range
of 1-2 mls/kg/hr.
• Neonates u/f rate 0.5-1ml/kg/hr.
U/F Issues
• Attention to intravascular volume.
• Oncotic pressures.
• U/F controllers.
– Infusion pumps up to 30% inaccurate.
(Smoyer et al, CRRT1998)
• Filter size and life.
U/F Issues
• Accurate assessment is difficult with
less room for error in smaller children.
– Bed scales.
– Frequent weights or weights of U/F in IV
controller U/F method.
– Measured volume status.
– Monitor sHct.
– Vasopressor clearance.
Membrane Reactions
• Bradykinin release syndrome
• Causes of syndrome
• ACE inhibitors
• Low blood ph
• AN-69 membranes have been
associated with “Bradykinin release
syndrome” (Brophy et al. AJKD 2001)
Membrane Reactions
• What is the common link?
– AN-69 membrane.
– Blood prime.
– Low ph. (Blood bank blood ph).
• Technique to reduce membrane
Membrane Reactions
• Correct blood from the blood bank.
• Bypassing the membrane.
• Bypass maneuver.
Bypass Maneuver
To view this
dialysis clip, go to
the Resources
References and
Procedures folder,
then the UNHS
Procedures folder
on the CD-Rom.
Thermal Issues
• Patient.
– Radiant heat methods.
• Warming blankets.
• Overhead warmer.
• Warm water bottles.
– Prevention of heat loss.
• Environmental conditions.
• Exposure. (Hats on infants, plastic wrap).
Thermal Issues
• Circuit
– Blood
• Blood warmers
•  Extracorporeal volume
•  Risk of clotting
– Dialysate or replacement fluid
• Prismatherm®
• High volume fluid warmer.
Transport Issues
• Patient that require transport while on
– Battery pack.
– Re-circulation.
• Blood prime/blood loss.
• Machine issues.
• Length of re-circulation. (1-2 hrs).
• Need for daily orders.
• Recommendations on order sheet.
• Types of solutions.
– PD are problematic r/t lactate and high glucose.
– Pharmacy made solutions risk of error and expensive.
– Bicarbonate based solution-less risk,  expense.
• Nursing orders/labs.
Nursing Report
• Standard forms for documentation.
• Review of orders.
• The key to good team work is accurate
nursing reporting of problems and
troubleshooting techniques.
Nursing Training
Basic concepts of CRRT.
Knowledge of circuit function.
Documentation and review of protocols.
Troubleshooting issues and techniques.
Simulator – for non-stressful practice.
One-on-one hands on with experienced staff.
Continuous education.
Development and implementation of QA tool.
• Forms available on your CD-ROM
Thanks To:
Dr. Timothy E. Bunchman MD
Dr. Patrick D. Brophy MD
University of Michigan Pediatric
Dialysis Team.
Pediatric Critical Care Nursing.
My Wife.