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      Nursing for Renal Replacement Therapies in the Intensive Care Unit: Historical, Educational, and Protocol Review

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          Abstract

          Nurses have made a significant contribution to the development and application of dialysis in the 1950s and continuous renal replacement therapies (CRRT) in the Intensive Care Unit (ICU) setting from the 1980s. Any treatment requires patient and machine-circuit preparation, connection of the extracorporeal circuit (EC) to the patient vascular access catheter and regular tasks to maintain a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine ‘vital signs’, and then when necessary diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential to a suitable nursing policy or protocol. This paper provides a clinical review for this every day sequence when using CRRT in the ICU setting.

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          Most cited references 16

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          Optimal anticoagulation strategy in haemodialysis with heparin-coated polyacrylonitrile membrane.

          Binding of polycationic unfractionated heparin onto the modified AN69 polyacrylonitrile membrane, whose surface electronegativity has been neutralized by layering polyethyleneimine (AN69ST), produces stable coating. We investigated whether the heparin-coated membrane was suitable for regular haemodialysis with low heparin doses. Sheep were instrumented for extracorporeal circulation perfusing a dialyser equipped with either the AN69ST or the original AN69 membrane. Dialysis sessions were performed after priming the dialyser with heparinized saline. The session was conducted without systemic administration of heparin. In chronic haemodialysis patients, the AN69ST membrane was tested for safety, clotting and thrombin generation according to protocols of 4-h haemodialysis sessions with tapered heparin doses. The goal was to define optimal heparin requirements with the heparin-coated membrane in the setting of continuous or intermittent administration of heparin. Both unfractionated and low molecular weight heparin (LMWH) (enoxaparin) were tested. In sheep, systemic heparin-free haemodialysis was conducted for 6 h without clotting using the heparin-coated dialyser. In the same conditions, massive clotting was observed within 90 min of dialysis with the native AN69 membrane. In man, through kinetic measurements of activated partial thromboplastin time (APTT), heparin anti-Xa concentration and thrombin-anti-thrombin complexes levels (TAT), significant dialyser clotting was avoided when APTT and anti-Xa concentration at 180 min of dialysis, were maintained at >40 s and >0.2 IU/ml, respectively. With the AN69ST heparin-coated membrane, thrombin generation was reduced then suppressed, as compared with the original AN69, primed in the same conditions. Safety of haemodialysis conducted with the AN69ST heparin-coated membrane and low doses of unfractionated heparin (50% reduction of the reference dose) was validated by a survey of 2590 sessions in 32 patients. Doses of LMWH were also safely reduced by 50%. In addition, haemodialysis without systemic administration of heparin was possible with minor risk of clotting. During the rinsing phase, the ionic interactions between the new AN69ST polyacrylonitrile membrane and unfractionated heparin induce stable heparin coating. This allows a significant reduction of systemic anticoagulant requirements without increasing the risk of clotting, both in the experimental setting and in the chronic haemodialysis patients. Further studies are required to assess this advantage in patients with acute renal failure and at risk of bleeding and to reduce the metabolic consequences of long-term treatment with heparin.
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            Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure.

            Although renal replacement therapy is the mainstay of supportive care in patients with severe acute renal failure, its performance can have untoward effects that contribute to the prolongation of renal failure or impede the ultimate recovery of renal function. In this review, we categorize the major complications associated with renal replacement therapy and assess their impact on recovery of renal function.
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              Extracorporeal circuit pressure profiles during continuous venovenous haemofiltration.

              Continuous renal replacement therapy machines are capable of providing continuous pressure measurements at different points of the extracorporeal circuit. This study investigates the pattern of circuit pressure changes during high-volume continuous venovenous haemofiltration (CVVH) with regional anticoagulation with anticoagulant citrate dextrose in formula A. Extracorporeal circuit pressures during 91 treatments of CVVH were analysed. Distinct patterns of extracorporeal circuit pressures were observed: (a) the extracorporeal circuit pressures during a routine uncomplicated CVVH treatment remained close to initial values. The interquartile range (IQR) of pressures during the treatments were as follows: PA (arterial pressure) -3.5 to -10 mmHg, PV (venous pressure) 51 to 41.5 mmHg, PBE (prefilter pressure) 120.5 to 104 mmHg, PD2 (fluid outlet pressure) -23 to -70 mmHg, TMP (transmembrane pressure) 142.75 to 102.75 mmHg and PFD (pressure filter difference) 70 to 62 mmHg. (b) PD2 and TMP showed early separation from baseline values in CVVH treatment compromised by haemofilter clot. Haemofilter clotting problems were associated with median PD2 of -164 mmHg (IQR: -66.2 to -228.7), a fourfold increase from baseline. (c) PA and PV values changed abruptly in catheter-malfunction-related circuit disruption. Poorly functioning catheters tended to have a higher baseline PA (median: -33 versus -25.5) than in those without catheter problems; however, the difference was not statistically significant (p= 0.13). (d) A rise in PBE and PFD followed by changes in PD2 and TMP were noted in a treatment disrupted because of air detection chamber clotting. Distinct patterns of extracorporeal circuit pressures were present in patent and disrupted CVVH circuits. We suggest that the pattern of pressure profiles, not absolute values, may be more relevant in clinical practice.
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                Author and article information

                Journal
                BPU
                Blood Purif
                10.1159/issn.0253-5068
                Blood Purification
                S. Karger AG
                0253-5068
                1421-9735
                2009
                February 2009
                14 January 2009
                : 27
                : 2
                : 174-181
                Affiliations
                Department of Intensive Care, Austin Hospital, Melbourne, Vic., Australia
                Article
                190784 Blood Purif 2009;27:174–181
                10.1159/000190784
                19141996
                © 2009 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 3, References: 38, Pages: 8
                Categories
                Invited Review

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