Troubleshooting/Access/Alarms Simulation. Wendy McCay, MPH, BSN, OCN Brenda Stofan, RN

Transcription

1 Troubleshooting/Access/Alarms Simulation Wendy McCay, MPH, BSN, OCN Brenda Stofan, RN

2 Typical Pressures During Treatment Access Pressure- Negative -50 to -150 mm Hg Filter Pressure- Positive +100 to +250 mm Hg Blood pump Effluent Pressure - Negative or Positive > +50 to -150 mmhg Return Pressure- Positive- +50 to +150mmHg Page 2

3 Scenario Introduction Mr Jones is a 58 year old man well known to the SICU for frequent GI issues. He was admitted to SICU 2 days ago with GI Bleed, frequent bloody stools. His ICU stay has been complicated by Septic shock and Respiratory Failure with Pneumonia. Now he has developed oliguric AKI in the setting of Sepsis, hypotension and increased abdominal pressure. He was started on CRRT yesterday. His premorbid weight is 105 kg. Page 3

4 The First Situation His night shift nurse, Kandi, notices Mr Jones is scheduled for his bath on night shift. She recruits several staff members for help in bathing him. He is turned on his right side away from the CRRT machine, he is bathed, then placed on his back and rolled to his left side to complete bath. The CRRT machine alarms. One of the nurses mutes the alarm button and continues to finish bathing Mr Jones on his side in the bed. CRRT machine continues to alarm: Kandi decides it might be a good idea to check why the machine is alarming, Screen shows ACCESS EXTREMELY NEGATIVE. What could this alarm mean? Page 4

5 RED Red coded line is the Access Line which removes blood from patient. Blood Pump controls this process at 10 ml/min to 180 ml/min Normal pressures: -50 to -150 Pressures are determined by Access Pod which measures pressure as it exits the vascular access Page 5

6 RED- Interventions Reposition patient Trace lines for kinks Flip catheter Flush ports, evaluate patency, and switch ports if necessary Page 6

7 The Second Situation Kandi has corrected the issue with the CRRT alarm but noticed that Mr Jones is still agitated and once again needs pulled up in his bed. Big Alex is recruited to help move Mr Jones and as Alex hoists him toward the top of the bed, the CRRT machine alarms again. Access pressure is now showing positive number on screen. What could this mean? Page 7

8 Return- Blue Blue line is also known as the Return Line which returns blood back to the patient This is also controlled by the Blood Pump Normal pressures are +50 to +150 Pressures are determined by the Return Pods blood re-enters the vascular access Page 8

9 Return Blue-Interventions Reposition patient Trace lines for kinks Flip catheter Flush ports, evaluate patency, and switch ports if necessary Page 9

10 The Issues with Bag Changes Mr Jones is now resting comfortably, Kandi notices her CRRT Bags are getting low, she asks the new nurse (Amy) she is orienting to hang a new Dialysate bag per the orders, Bicarbonate 25, Citrate 0.5%, and empty the full Effluent bag. Amy re hangs new CRRT bags, empties the Effluent bag and resumes therapy. CRRT machine alarms, Amy presses over ride on machine but alarm continues to occur and machine won t run What should Amy do? Page 10

11 Interventions for Changing Bags With the Dialysate bags, once overwrap removed only good for 24 hours Ensure complete opening of seal and mixing of fluids. Remember the scales are weight based so if fluids are caught in a pocket the machine will pull air Make sure to unclamp the bags after hanging on the scale Page 11

12 Scales and Zeroing Kandi and Amy discover the reason they think the CRRT machine won t run and appear to correct the issue. Kandi instructs Amy to clear the alarm and restart machine while she leaves the room to get supplies to draw CRRT labs. Kandi returns to find the CRRT machine still alarming and Amy looking puzzled. CRRT machine alarm reads Scale Open. What should Kandi and Amy look for? Page 12

13 Scales Interventions Look at all scales to determine if any are not fully closed. You will hear a click when the scales closes. When you change a bag you must remove the handle from the scale to properly zero the scale Page 13

14 Green: Dialysate Fluid Green line is also known as the Dialysate Solution Line and carries solution by cross counter flow across filter membrane Controlled by the Dialysate Pump (flow rate ) Dialysate does NOT mix with blood Used dialysate collects in the effluent bag Hang new dialysate bag only when prompted by machine Dialysate bag hangs between PBP and NS replacement bags at bottom of machine Page 14

15 White: PBP (Pre Blood Pump) White line is also known as the PBP (Pre Blood Pump) Solution Line Solution mixes with the blood pre-filter Controlled by the Pre Blood Pump Trisodium Citrate provides pre-filter anticoagulation for circuit Used solution collects in Effluent Bag Hang new bag only when prompted by machine Replacement bag hangs on scale between Effluent and Dialysate bags at bottom of machine Pharmacy delivers dilute citrate bags to carts in units Page 15

16 Purple: Replacement Fluid Purple line is also known as the Replacement Solution Line (1L bag of NS or same HCO3 as dialysate) Normal Saline mixes with the blood post-filter, putting a layer of NS on top of the blood in the deareation chamber Prevents a clot from forming in the deareation chamber; always runs at 200mL/hr Hang new bag only when prompted by machine Replacement NS/Dialysate bag hangs on scale on Right at bottom of machine DO NOT COUNT in I/O!!! Page 16

17 Air leak detector Air Leak Detector Need to remove air before machine will run May aspirate using a 21g or smaller needle May use deareation chamber and adjust the level to bring air into the chamber If fluid is too low, may get false Air in Blood alarm Page 17

18 Yellow line is the Effluent Line Yellow: Effluent Solution Carries fluid removed from patient, used dialysate, and used replacement fluid to effluent bag Based on patient volume removal rate Pressure measured by Effluent Pod as waste exits the filter Normal pressures > Use Universal Precaution when changing the bag Page 18

19 May infuse via a PIV or CVL Calcium Gluconate Replaces Calcium lost when citrate binds to Calcium to cause anticoagulation Whenever you have citrate, you will have a Calcium Gluconate Drip Titrate according to order based on results of ica from the patient Goal patient: Goal machine: <0.25 Page 19

20 Filter clogging vs. Filter clotting Pressure pods measure pressure before and after the filter TMP: Transmembrane pressure wtells you about filter clogging was cytokines/immunoglobulins adhere to sides of filter wtransmembrance pressure tell you how much pressure it takes to push through the walls of the membrane Page 20

21 Filter clogging vs. Filter clotting Pressure pods measure pressure before and after the filter Pressure drop: wtells you about filter clotting was the red blood cells line up to go through the filter, they coagulate and it takes more pressure to get from one end of the filter to the other wpressure drop is the white line Page 21

22 Blood leak detector Blood Leak Detector If effluent bag is pink, stop therapy and do not return blood Notify MD, draw K and CBC from pt to check for hemolysis and draw CBC from effluent. If no blood is visualized, it is recommended that you renormalize, continue therapy, notify renal fellow and recommend a CBC from effluent. Page 22

23 Alarms Page 23

24 Return Blood Indications Going off unit for a trip/procedure Time to change set change set every 72hours done by dialysis RN Contraindications Visible clots Filter is clotted Supplies needed NS Spike Go through process Catheter care post return Needs anticoagulant citrate, heparin, TPA Label Page 24

25 CRRT Labs CRRT labs are scheduled every 6 hours: 0800, 1400, 2000, wdraw labs one hour after CRRT is initiated, then with next scheduled lab time. wif the machine has been alarming for more than a few minutes, make sure to wait at least 20 min after correcting the alarm before you draw any labs from the machine wif the machine is alarming for any reason, the patient is not actually getting therapy. Page 25

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