TATALAKSANA

ASUHAN KEPERAWATAN PASIEN DENGAN CRRT

Tandang Susanto,M.Kep
Ka. Unit Operasional Program
Inst. Diklat RSJPDHK
Instruktur BCLS/ ACLS
Fasilitator Program Pendidikan
Dan Pelatihan Div. Diklat
RSJPDHK

tandangsusanto@gmail.com

081289012656
MACHIN
E CRRT

PRISMAFLEX
 RSJHK
1285 pasien 1234 pasien 1657pasien 1380 pasien
64 pasien → CRRT 77 pasien → CRRT 82 pasien → CRRT 61 pasien →
CRRT
2013 2015 2017 2019
    
2014 2016 2018
1384 pasien 1546 pasien 1709 pasien
46 pasien → CRRT 61 pasien → CRRT 82 pasien → CRRT

Ket : Pasien Bedah Jantung

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
1 Oliguria (200ml) 5 Azotaemia
9 Hyperthermia
In 12 hours Urea > 30 mmol/L

2 Anuria (50ml) 6 10 Drug over doses

Significant organ
In 12 hours
oedema
3 Hypercalemia 7 Uraemic
potasum > 6,5 mmol/L encephalopathy

4 Severe Acedaemia 8 Severe dysnatraemia

pH < 7,1 Sodium >160 or < 115 mmol/L
KIDNEY FUNCTIONS
The kidney has several functions (CRRT deals with the first
four functions):

Fluid balance
1

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
1 Maintain fluid, electrolyte, acid/base
balance
2 Prevent further damage to kidney tissue

3 Promote healing and total renal recovery

4 Allow other supportive measures; nutritional

support
 Hypotension
Complication Bleeding &
Coagulopath
y

Inotropic support may the patient”s coagulation

be requaired to status is carefully
monitored it is importan
maintain effective
mean arterial pressures CRRT to look for other sign of
bleeding

infection Fluid ,electrolyte &

Nurses should always be monitoring for sign Acid /base
of infection imbalance
 CRRT
Transport
Mechanisms
Molecular Transport Fluid
Mechanisms 1 Ultrafiltration
Transport

}
Diffusion
Solute
Transport
3 Convection

3 Adsorption
 Ultrafiltration
• Movement of fluid through a semi-permeable membrane
caused by a pressure gradient
Ultrafiltration
Blood Out
(to patient)

Fluid Volume
Reduction

to waste Blood In
(From patient)

LOW PRESS HIGH PRESS

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.
 Hemodialysis: Diffusion

Dialysate In Blood Out

(to patient)

Dialysate Out Blood In

(to waste) (from patient)

LOW CONC HIGH CONC

 Movement of solutes from an
area of higher concentration to
an area of lower concentration.

Convection The more fluid moved through a

semi-permeable membrane, the
more solutes that are removed.

Replacement Fluid is used to

create convection
Hemofiltration: Convection

Blood Out
(to patient)

Repl.
Solution

to waste Blood In
(from patient)

LOW PRESS HIGH PRESS

 Adsorption

• Molecular adherence to the surface or interior of the membrane.

 Molecular Weights
Daltons

• Inflammatory Mediators (1,200-40,000)

“large”

“middle”

“small”
Small vs. Large Molecules Clearance

100
Kidney

80
Convection

60
Clearance in %

40

20

Diffusion
0
2.500 5.000 20.000 35.000 55.000 65.000
Urea Creatinine Myoglobin Albumin
(60) (113) (17.000) (66.000)
 SCUF CVVH

CRRT
Modes
CVVHDF CVVHD
 SCUF
Slow Continuous UltraFiltration

Primary therapeutic goal:

• Safe and effective management of fluid removal
from the patient
 SCUF

Slow Continuous UltraFiltration

Primary therapeutic goal:
 Safe and effective management of
fluid removal from the patient
 SCUF
Slow Continuous UltraFiltration
Return

Access
Blood Pump

Effluent PBP
Pump Pump

Effluent Infusion or
Anticoagulant
 CVVHD
Continuous VV HemoDialysis
• Primary therapeutic goal:
• Small solute removal by diffusion
• Safe fluid volume management

• Dialysate volume automatically removed through the Effluent pump

Solute removal determined by Dialysate Flow Rate.

 CVVHD
Continuous VV HemoDialysis
Return

Hemofilter Access
Blood Pump

Dialysate Effluent PBP

Pump Pump Pump

Dialysate Effluent Infusion or

Fluid Anticoagulant
 Dialysate Solutions
• Flows counter-current to blood flow
• Remains separated by a semi-permeable membrane
• Drives diffusive transport
• dependent on concentration gradient and flow rate

• Facilitates removal of small solutes

• Physician prescribed
• Contains physiologic electrolyte levels
• Components adjusted to meet patient needs
CVVH: Continuous VV Hemofiltration

• 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 pump

Solute removal determined by Replacement Flow Rate.

 CVVH
Continuous VV Hemofiltration
Return

Access
Blood Pump

Replacement Effluent Replacement PBP

Pump 2 Pump Pump 1 Pump

Replacement 2 Effluent Replacement 1 Infusion or

Anticoagulant
 Pre-Dilution Replacement Solution
Return

Hemofilter Access
Blood Pump

•Decreases risk of clotting

Effluent Replacement PBP
Pump Pump Pump
•Higher UF capabilities

•Decreases Hct. In
filter
Effluent Replacement Infusion or
Fluid Anticoagulant
 Post-Dilution Replacement Solution
•Consider lowering
replacement rates (filtration
Return
%)

Access
•Higher BFR (filtration %) Hemofilter
Blood Pump

•Higher anticoagulation

Replacement Effluent Replacement PBP

•More efficient clearance Pump Pump Pump Pump
(>15%)

Replacement Effluent Replacement Infusion or

Fluid Fluid Anticoagulant
 Replacement
Solutions
• 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
 CVVHDF
 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.
 CVVHDF
Continuous VV HemoDiaFiltration
Return

Access
Blood Pump

Dialysate Effluent Replacement PBP

Pump Pump Pump Pump

Dialysate Effluent Replacement Infusion or

Fluid Fluid Anticoagulant
Basic Components in CRRT

n
solutio

Hemofilter

Solutions

Mesin CRRT
CRRT

Anticoagulation Vascular access Blood Warmer

 Access: Location
A veno-venous double or two single lumen venous catheters

• Internal Jugular Vein

• Lower risk of complication
• Simplicity of catheter insertion
• Femoral Vein
• Optimal site for immobilized patient
• Easiest site for insertion
• Subclavian Vein
• Higher risk of pneumo/hemothorax
• Associated with central venous stenosis
 Access:
• Refer to and follow the hospital protocol for Important
specific guidelines Considerations
• Vascular Access recommendations:
• Aspirate and discard heparin before flushing
• 20 to 30 CC syringe to assess patency
• Check for kinks/ clamps

*
Anticoagulation

Commonly utilized:
• Heparin
• Citrate
 Purpose of Warmers in CRRT

• Prevent heat loss

• Minimize calorie loss
• Patient comfort
 Solutions for CRRT
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
PrismaSol
Solutions ®

Composition
 Nursing CARE

Stage One
1 Stage Four
ASSESSMENT
4 IMPLEMENTATION

Stage Two

DIAGNOSIS 2
CRRT Stage Five

5 EVALUATION
Stage Three

PLANNING 3

Nursing Process
Tammy J. Toney-Butler; Jennifer M. Thayer.
General assessment

Cardiovascular Neurology

Respiratory Gastrontestinal

Renal Integument
  Fluid loss Total
 Hourly fluid loss (fluid loss total for last hour
subtracted from this hour)
 Post-dilution rate (ml/hr)
 Dialysate rate (ml/hr)
 Heparin infusion rate (ml/hr) if used
 Pre-filter pressure
 Blood pump rate These values can be found
PRISMAFLEX either on the main Aquarius screen or if you
key into the “More” tab. On the next
Nursing Diagnosis
 Risk of electrolytic & Acid /base imbalance

 Risk of infection

 Risk for imbalanced fluid volume

 Risk of bleeding

 Impaired skin integrity

 Initiation of Therapy

• Assess and record the patient’s vital signs

and hemodynamic parameters prior to
initiation of therapy.
• Review physician orders and lab data
• Prepare vascular access using unit protocol.
• Set fluid removal, dialysate and
replacement solution flow rates as
prescribed.
• Administer anticoagulant and initiate
infusion if applicable.
• Document patient’s hemodynamic stability
with initiation of therapy.
 Intratherapy Monitoring
The critical care nurse must continuously monitor
the following parameters during CRRT

• Blood pressure • Blood flow rate

• Patency of circuit
• Hemodynamic stability
• Level of consciousness
• Acid/base balance
• Electrolyte balance
• Hematological status
• Infection
• Nutritional status
• Air embolus
• Ultrafiltration flow rate
• Dialysate/replacement flow
rate
• Alarms and responses
• Color of ultrafiltrate/filter
blood leak
• Color of CRRT circuit
 Termination of Therapy
The decision to terminate CRRT is made by the
nephrologist or an intensivist based on the patient’s
renal recovery or the patient’s status-recovery or
decision of the patient and family.

• Extracorporeal circuit will be discontinued as per

established protocol.
• Vascular access care administered as per unit
protocol
 Nurse Education
To ensure effective CRRT, nurses who care for patients receiving this therapy
should attend classes on this specialized therapy and demonstrate clinical
competency on a regular basis. Classes typically include education on :

 How To Use The CRRT Machine

 Identify Machine Alarms
 Perform Troubleshooting
Current
FAQs
How much replacement and
dialysate do you use?

Ronco’s research
 Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00

• Prospective study on 425 patients - 3 groups:

• Study:
• survival after 15 days
• recovery of renal function

306100135
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00

100
p < 0.001
90

80
Survival (%)

70 p < 0.001 p n..s.

60

50

40

30

20 41 % 57 % 58 %
10

Group 1(n=146) Group 2 (n=139) Group 3 (n=140)

( Uf = 20 ml/h/Kg) ( Uf = 35 ml/h/Kg) ( Uf = 45 ml/h/Kg)
TIMING GFR Criteria Urine Output Criteria
Increased creatinine x 1.5
or GFR decrease >25% UO <,0.5ml/kg/hr x 6 hours
Risk
Increased creatinine x 2 or
UO <0.5 ml/kg/hr x 12 hours
Injury GFR decrease >50%

Increased creatinine x 3 or
GFR decrease >75% or UO <0.3 ml/kg/hr x 24 hours
Failure Serum Creatinine > 4mg/dl or anuria x 12 hours Early
Initiation
Persistent ARF= complete loss of
Loss renal function >4 weeks

End-stage renal disease (>3

ESRD months)
 Evidenced Based Research reports that
patient survival is improved by:

• Early initiation:
• Utilization of RIFLE Criteria

• Minimum dose delivery of 35 ml/kg/hr

• eg. 70 kg patient = 2450 ml/h

Effects of different doses in CVVH on outcomes of ARF – C. Ronco M.D., R. Bellomo

M.D. Lancet 2000; 356:26-30.
THANK YOU