Objectives
By the end of the presentation the CRRT-trained RN will
be able to:
1. Recall how electronic CRRT orders are placed
2. View or print a CRRT prescription
Starting April 10th, orders for CRRT will be provided
electronically. To enter an order, from the patient’s home
page the provider will:
• Select “Add order” &
• Search “CRRT”
• 3 ordersets will appear (they will select the
appropriate orderset):
1. NEPH- CRRT Heparin
2. NEPH- CRRT No anticoagulation or other
anticoagulation
3. NEPH- CRRT Citrate (VH)
Entering Electronic Orders
Ordering Heparin via CRRT
• Prior to ordering CRRT, there needs to be communication
between the Nephrology and CCTC physicians:
– To determine whether heparin can be used
– To review fluid removal goals
• If heparin cannot be used, orders for “no anticoagulation”
should be initiated
• Continue with subcutaneous VTE prophylaxis during
CRRT heparin to ensure that VTE prophylaxis is
maintained during CRRT downtime
Recommended Orders: NEPH- CRRT Heparin
• Solution is PrismaSoL 4
• Flow rates
– Dialysate 1,000 mL/hr
– Predilultion hemofiltration (PBP) 1,000 mL/hr
– Postdilution hemofiltration (POST replacement pump) 200
mL/hr
• Prime with heparin 5,000 units then reprime with saline
• Potassium replacement protocol enabled
• Electrolyte replacement orders activated
• Heparin titration protocol enabled
** Higher flow rates may be required if there is inadequate
clearance or extreme acidosis, but we should start at these rates
for most patients.
NEPH- CRRT Heparin
• Note: most orders are preselected
• When “initiate” is selected, the Powerform with the
CRRT prescription appears for the physician to
complete.
Note dropdown menus:
• Can only select ST150 filter & can only select CVVHDF
• Can only select blood flow rate to start at 150 mL/min & increase to 250 mL/min
Recommended Prescription for Heparin via
CRRT (alternate orders if desired, can be typed
into the box)
Note dropdown menus:
• 2 priming options: (1) 2 liters of plain saline or (2) 1 liter saline with heparin & 2nd liter plain saline
• Dialysate solution & PBP solution: can only choose PrismaSol 0 or PrismaSol 4
• Post Replacement solution: can select PrismaSol 0, PrismaSol 4 or normal saline (although it is
preferred to use either PrismaSol 0 or PrismaSol 4)
Clicking the green check mark takes us back to this screen where the
physician needs to click the “orders for signature” and then “sign”
Clicking on the missing detail (the blue
circle with an “X”) takes the physician
to the following screen…..
• Once the Reason/Clinical History is completed the
physician will be prompted to “sign” and “refresh”
Potassium Titration Change
Effective April 10, 2017, the potassium titration protocol
will be used to maintain the same potassium
concentration in ALL dialysis and hemofiltration
solutions.
This change will reduce the risk for error through
standardized practice.
Go to “Results Review” Menu and find the tab
along the top menu for Dialysis Treatment.
You can print this screen.
• Any powerforms completed for the patient
will be found here
• This patient only has the CRRT Heparin
Prescription VH
• Double clicking over the prescription will
open the prescription in a new window
Unfortunately we cannot
print from this screen. You
can print from the Dialysis
Treatment Tab (slide 23-
26).
Select the appropriate printer from the drop
down menu & click ok (RP 863 is at the front
desk & RP 864 prints to the RT area)
• Right click over the prescription to
get the “print” option
Printing the Prescription
Other CRRT Ordersets
• For a physician to place an order for CRRT using citrate or
no/other anticoagulant, the process is the same
• The steps for printing the prescription are also the same
• The electronic
prescription is your
source of truth
• If there is a printed
prescription at your
bedside, make sure it
matches the electronic
version before using it
Remember:
Summary of Recommended Orders:
Patient on Systemic Anticoagulation
• If a patient is receiving systemic anticoagulation at a therapeutic rate, they do not require additional filter anticoagulation
• Use the same flow rates as Heparin but without any filter anticoagulation
• If the systemic anticoagulation is going to be stopped electively, start filter anticoagulation with heparin or high flow prior to discontinuing systemic anticoagulation
• If the systemic anticoagulation is stopped urgently, immediately increase the PBP to high flow rates and stop dialysate (switch to NEPH- CRRT no anticoagulation protocol)
Summary of Recommended Orders: No
Anticoagulation
• Solution is PrismaSoL 4
• Flow rates – Dialysate 0 mL/hr (if dialysate is zero you can prime with saline
as flow rate will be turned to off)
– Predilultion hemofiltration (PBP) 2,000 to 2,500 mL/hr
– Postdilution hemofiltration (POST replacement pump) 500 mL/hr
• Prime with heparin 5,000 U and reprime with saline if no HITT
• Potassium replacement protocol enabled
• Electrolyte replacement orders activated
• AIM TO INCREASE BLOOD FLOW RATE AS HIGH AS 250 mL/min or as tolerated
**Higher flow rates may be required if there is inadequate clearance but the default should be these flow rates
Summary of Recommended Orders: Citrate
• Solution is Prism0CAL
• Prism0CAL has zero potassium, therefore, potassium must be added to all bags
• Prism0CAL also has zero calcium
• Flow rates – Dialysate 1,000 mL/hr
– Predilultion hemofiltration (PBP) is the citrate solution
– Postdilution hemofiltration (POST replacement pump) 1000 mL/hr
• Prime with heparin 5,000 (if no HITT) and reprime with saline; or saline without heparin if HITT
• Potassium replacement protocol enabled
• Electrolyte replacement orders activated
• Citrate titration orders enabled
• Calcium chloride titration protocol enabled
Additional Reminders
• CRRT orders should be made collaboratively between
Nephrology and CCTC medical teams
• It is important that CCTC physicians know the treatments (e.g.,
heparin or citrate use) as this has implications for care
• If a patient has persistent hyperkalemia, CCTC physicians
must be made aware to evaluate possible reasons for the
hyperkalemia (e.g., rhabdo, bowel infarction)
• Critical Care Electrolyte orders should also be ordered for
patients on CRRT
• We use the same Prisma solutions on all pumps for safety
Additional Reminders
• Any situation that causes a red alarm will cause blood
flow through the filter to stop. Each time blood flow stops
(even if only for a few seconds) the likelihood of filter
clotting increases
• Filter clotting will occur regardless of anticoagulation if
there are frequent high pressure alarms. Line issues
should always be addressed as a priority
– High pressure alarms can occur if there is catheter
thrombosis, kinks or flow problems
– Frequent coughing with frequent high pressure backup to IJ
or SC lines can also lead to increased filter clotting
Additional Reminders
• High flow PBP of at least 2,000 – 2,500 mL/hr is
recommended when no anticoagulation is being used
• When high flow PBP is being used, dialysate is not
required (clearance will be provided by the predilution
hemofiltration)
• CCTC nurses continue to have an automatic order to
switch back and forth between PrismaSoL 4 and 0 to
achieve desired potassium (or if you run out of stock at
night)
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