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					1-Bunchman PRIMSA M-60 Protocol




                        Pediatric Hemofiltration using the Prisma® M 60

                                         Table of Content

                             Pediatric CVVH Protocol                                     Page 2-7

                            Blood Priming and Membrane Reactions                      Page 7-8

                            Pediatric CVVH(D) Orientation Program                     Page 9-10

                            Orientation Lecture Outline                              Page 10-11

                            Standards of Care for Nursing                            Page 12

                            Trouble Shooting Guide                                   Page 12-14

                            Hemofiltration Orders                                   Page 15-16

                            Hemofiltration References                                Page 17-18




                        Pediatric Hemofiltration with the Prisma® M 60

1. Access

Vascular access will be placed by the ICU staff and should be minimally two single lumen 5 Fr.
Catheters or preferably a dual lumen 7 Fr. Access. Access suggestions are as follows, but err to
the side of larger as opposed to smaller unless the child has a coagulopathy. Although flow and
recirculation data is similar, it is preferable to have the access placed either IJ or subclavian as
opposed to femoral. This is due to the fact as the child "wiggles" there will be less effect of blood
flow rate with a "high" line as opposed to a "low" line. Further the size of the blood vessel in the
cardiac region is larger, allowing for larger access. The final reason that preference is to an IJ or
subclavian is as the child recovers the child can ambulate with out risk of bending a femoral
placed catheter.
2-Bunchman PRIMSA M-60 Protocol

2. Circuit Setup Guidelines:

Follow the manufacture guidelines. Priming of the circuit should be with normal saline. 5%
albumin can be added if indicated. PRBC’s could be used if the child is < 5 - 6 Kg with the
pediatric circuit or < 10 - 11 Kg with the adult circuit or if hemodynamically unstable. If blood
priming is needed the risk of a "Bradykinin Release Syndrome" could occur due to pH and
membrane reaction. If blood priming is needed, see section 9 on blood priming.

3. Blood flow rate (BFR)

A blood flow rate of 5 - 10 mls/Kg/min will allow for adequate flow. The maximum BFR of the
PRISMA® is 180 mls/min. The higher the BFR, the potential for less clotting occurs but the trade
off is more alarms. The use of citrate as an anticoagulant makes clotting less dependent upon
blood flow (i.e. our local experience is that with citrate we have less clotting and therefore can run
the patient at a slower blood flow rate).

4. CVVH vs. CVVHD

Data has shown that if one keeps constant the amount of solution then urea clearance is similar
in CVVH or in CVVHD.



                 Comparison of Urea Clearance:
                      CVVH vs CVVHD
                                      (Maxvold et al, Crit Care Med April 2000)
                                 30
             (mls/min/1.73 m2)




                                 25
              Urea Clearance




                                 20

                                 15
                                                      p = NS
                                 10

                                 5

                                 0
                                           CVVH              CVVHD

      BFR = 4 mls/kg/min
      Replacement Fluid/Dx FR = 2 l/1.73 m2/hr
      SAM = 0.3 m2

In hemofiltration for sepsis, CVVH may have better cytokine clearance. We use a solution rate of
2000 mls/hr/1.73 m² in either CVVH or CVVHD.

Solutions

Dialysis solutions choice can be bicarbonate based (Normocarb, Dialysis Solution Inc ;Hemosol
BO Hospal, [available only in Europe and Canada]), or lactate based (Hemofiltration soln by
Baxter) or a pharmacy made solutions. Presently only pharmacy made solutions are “approved”
3-Bunchman PRIMSA M-60 Protocol

for replacement solutions, but pharmacy made solutions run to the risk of ingredient error due to
lack of standards that are adhered to by Industry.

5. Anticoagulation

Many children who require hemofiltration (eg patients with sepsis, hem/onc patients) will need no
anticoagulation due to their underlying coagulopathy. In patients with “natural ACTs” of > 200,
treating them without anticoagulation is reasonable. In those patients who require anticoagulation
either citrate or heparin can be used. Both protocols are below.

                                         Heparin Anticoagulation

Place a syringe of 100 units/ml of heparin in the heparin syringe holder. Load the child with 20
units/Kg, then begin an infusion at 10 units/Kg/hr. Check ACTs on the "venous" side of the
hemofilter, meaning after the hemofilter. Check an ACT prior to load {pre load ACT should be 90 -
110}. If ACT is > 150 or <180sec., then no load is necessary; just start the drip. If ACT is > 200 no
heparin is necessary and re-checks in 30 min.

Heparin is given on the "arterial" side of the hemofilter, meaning the tubing before the hemofilter.
Adjust the heparin gtt to target ACT between 170 - 210 sec. Check ACTs hourly for 2 - 3 hours,
once as established ACT pattern is identified, then go to q 4 hours ACT checks. If an adjustment
of heparin is needed to a change in ACT follow guidelines below.

              If the ACT is                  make this change

                170 - 220                             none

                  > 220                        HOLD heparin for one hour,

                                               Then restart at 10% less /hr and re-check in an hour

                 < 170                         Bolus with 10 units/Kg,

                                               Then increase the infusion by 10% and re-check in an
                                               hour




                                          Citrate Anticoagulation

                (* see section 9 on Bradykinin release syndrome on use of citrate in small children)


         Citrate requires a separate central access (for calcium infusion) and a calcium free
dialysis solution. Many citrate protocols exist, this one has been used locally and been refined for
ease of use.

        (* In children who receive this form of “blood priming” and who are on citrate
anticoagulation, withhold the citrate for the first 10-15 minutes until hemodynamic stability is
achieved. During this time, if needed, give 20 units per kg of heparin as a one time dose to
4-Bunchman PRIMSA M-60 Protocol

anticoagulate your system until the citrate is begun. Citrate is acidotic and may exacerbate the
Bradykinin release reaction.)




6. Ultrafiltration (U/F)

A suggested net ultrafiltration per hour is 1 - 2 mls/Kg/hr. The system is very efficient; thus, too
much fluid can be removed too quickly. This is the perfect time to maximize the TPN of the
patient. In the face of bicarbonate dialysate and bicarbonate production when using citrate
anticoagulation, a metabolic (hypochloremic) alkalosis often occurs. This can be minimized by
maximizing the Cl ratio and minimizing the acetate ratio in the TPN. Further, in order to get
maximum fluid shift with colloid infusion, the U/F for the colloid previously infused should be over
twice as much time as the colloid rate "in" (e.g. 200 ccs of PRBCs infused over 2 hours should be
ultrafiltrated over four hours).




7. Temperature Regulation

Remember, when blood is outside of the body a tremendous heat loss occurs. The use of the
PRISMA THERM® on the infusion solution, the dialysis solution or the blood line will aid in
keeping euthermic. Additional overhead warmer or external warmer may be needed. Local
experience with the PRISMA THERM® when used as a dialysate warmer, shows that in children
larger then 40 kg the PRISMA THERM® will not mask a fever but in smaller children it appears to
mask a fever. Thus, attention to signs of sepsis is needed, for temperature spikes may not occur.




8. Intravascular blood volume determination and transfusion amount

Unless there is active blood loss {e.g. bleeding, hemolysis}, a good rule of thumb is in a child < 10
Kg, 3.5 cc/Kg will increase the Hct by 3%, while in a child > 10 Kg, 3 cc/Kg of PRBCs will
increase a child’s Hct by 3%.




9. Blood Priming

The AN-69 membrane of the PRISMA™ has been associated with a Bradykinin Release
Syndrome in patients on ACE inhibitors or in acidotic patients. Blood banked blood has a pH
of 6.4 with calcium of essentially zero. This has been shown to cause the Bradykinin Release
Syndrome that clinically appears to be anaphylaxis associated with acute hypotension,
tachycardia and a drop in the CVP. This is immediately reversible by removing the system.
This may be avoided by post hemofiltration blood banked blood transfusion.

Post hemofiltration transfusion protocol *:

1. Check the child’s pH and give sufficient NaHCO³ (2 meq/kg) to the child to bring the pH > 7.35

2. Normal Saline (NS) prime the PRISMA® circuit
5-Bunchman PRIMSA M-60 Protocol

3. Place 2 stop cocks on the venous return line between the venous line of the PRISMA® and the
venous return line of the vascular access

4. Turn the stop cock closest to the PRISMA® off to the patient and connect a NS dump bag to
the open port of the stop cock

5. Turn the stop cock closest to the child off to the PRISMA® and connect the open stop cock to
an infusion pump that has the blood transfusion needed for the circuit (90 - 100 ccs of blood
banked blood cut 1:1 with NS)

6. Turn on the Prisma® at 10 - 15 mls/min. and turn on the transfusions of the blood to 600 - 900
mls/hr. These identical rates then will allow blood to come from the patient and to push the NS
into the NS dump bag at the same time that the blood will be transfused into the child. In 4 - 5
minutes, this will be complete. Judicious use of NaHCO³ should be given (2 meq/kg each time
into the PRISMA circuit pre hemofilter) through out this "going on" procedure due to some mild
acidosis that will occur for an additional 5 - 10 minutes due to the acid load of the blood banked
blood. This acidosis will cause transient hypotension easily reversible with bicarbonate
supplementation. Hypernatremia as a side effect of the NaHCO³ will not occur due to the Na
clearance by the hemofiltration system.

* In children who receive this form of “blood priming” and who are on citrate anticoagulation,
withhold the citrate for the first 10-15 minutes until hemodynamic stability is achieved. During this
time, if needed, give 20 units per kg of heparin as a one time dose to anticoagulate your system
until the citrate is begun. Citrate is acidotic and may exacerbate the Bradykinin release reaction.
6-Bunchman PRIMSA M-60 Protocol

                             Pediatric CVVH(D) Orientation Program

                                        Program Objectives:

The CVVH(D) orientation program will provide the experienced ICU nurse with knowledge and
skills needed to safely manage the care of patients on CVVH(D).




Program Description:

The orientation program is made up of two sessions. The first session is a lecture presenting the
theory behind CVVH(D), and the nursing care for patients receiving this treatment. The lecture
will be followed by a question and answer period led by one of the CVVH faculty. The second
session is a workshop, in which the orientee will have hands on experience with the pump and
tubing. Also included in this session is practicing hypothetical calculations, and pump
troubleshooting.

After completing the two sessions, the orientee then has a bedside experience of eight hours with
a CVVH preceptor. To maintain ongoing training these sessions are repeated whenever a
sufficient number of nurses meet the requirements. Competencies are completed yearly for all
RNs responsible for the care of these patients.




Program Requirements:

Participants accepted into the CVVH(D) orientation program must be an RN with a minimum of 9
months of ICU experience.




Participant Behavioral Objectives:

1. Identify process for initiation of CVVH.

2. List indications for CVVH and CVVH(D).

3. Identify components of the CVVH(D) circuit.

4. State acceptable range for BFR and demonstrate adjustment.

5. Demonstrate adjustment of fluid level in venous air trap.

6. Demonstrate changing pressure transducer.

7. Identify components of hourly circuit checks.

8. Demonstrate calculations of UF using worksheet.

9. Identify fluid volumes that should not be included in calculations of UF.
7-Bunchman PRIMSA M-60 Protocol

10. List possible reasons for venous pressure change alarms.

11. List possible reasons for collapse of arterial pillow.

12. Identify indications for disconnecting CVVH.

13. Demonstrate emergent stopping of pump, and the disconnection procedure.

14. Demonstrate correct documentation of CVVH info on flow sheet.




                                  Pediatric CVVH Lecture Outline

                                Patient selection for CVVH modality.

A. Decrease or non urine output

B. Increase BUN, Creatinine

C. Hypervolemia

D. Electrolyte abnormalities

E. Metabolic abnormalities

**** Any or all of the above with hemodynamic instability that would not allow intermittent
hemodialysis.

                                            Goals of CVVH

A. Restore fluid and electrolyte balance

B. Remove waste products

C. Improve acid base balance

D. Nutritional support

                                            Hemodynamics

A. Solute transfer across a semi permeable membrane

  1. Convective solute transfer (dilution; CVVH)

  2. Conductive solute transfer (diffusion; CVVHD)

B. Ultrafiltration

C. Transmembrane Pressure (TMP)
8-Bunchman PRIMSA M-60 Protocol

 1. Oncotic pressure

 2. Hydrostatic pressure

                                      Hemofiltration Fluids

A. Replacement fluid

  1. Purpose

  2. Base

  3. Flow rate

B. Dialysate (D)

  1. Purpose

  2. Base

  3. Flow rate

  4. Countercurrent

C. Ultrafiltration

 1. Purpose

 2. Flow rate/pump assisted, minimum rate FRF+D

D. Citrate

    1. Continuous Infusion
    2. Prisma Ionized Ca

E. Calcium Infusion

         1. Patient Ionized Ca

F. Saline Flush

         1. When to use
         2. How much to use
9-Bunchman PRIMSA M-60 Protocol

                                Pediatric Standards of Care for Nursing

                                          Initiation Process

        ICU RN responsibilities

    1. Obtain preprinted orders and UF calculation sheets
    2. Nephrology to complete orders
    3. Send orders to pharmacy for process
    4. Assist with catheter placement
    5. Obtain additional infusion pumps for citrate and calcium

        Dialysis RN responsibilities

1. Set up PRISMA®

2. Connect patient to circuit

3. Remain at patient bedside until patient stable

4. Remain a resource for the ICU RN




Ongoing Management

1. CVVH orders are rewritten QD by Nephrology Service

2. Replacement fluid and citrate are run prefilter only

3. System ionized calciums are obtained from post filter blue port

4. Vital signs and pump check are Q1 hour and PRN

5. Calculate UF Q1 hour based on intake and output

6. FRF tubing changed QD

7. Blue "kelly" clamps must be available at all times




Catheter Care

1. Document catheter size and heparin requirements in the nursing kardex.

2. Dressing changes are Q3 days and PRN




Documentation
10-Bunchman PRIMSA M-60 Protocol

1. FRF and dialysate are included in the intake on the nursing flow sheet

2. UF Q1 hour and UF Q24 hours are included in the output on the nursing flow sheet

3. Nursing progress note are Q24 hours and PRN




Disconnection Procedure

1. Return blood if possible

2. Turn blood pump off

3. Clamp both lines with "kelly" clamps

4. Using aseptic technique:

- Disconnect the red line

- Flush with NS with a 10 cc syringe

- Prime with the appropriate dose of 1:1000 Units heparin

- Place a sterile cap and secure with tape

- Repeat procedure for the blue line




Trouble shooting the PRISMA™ - see guide from manufacturer

Alarms

1. Venous pressure alarm

- This alarms when the blood flow back to the patient is impeded.

- The causes may be:

       * The patient has rolled on to the venous line impeding flow

       * A clot is occurring or growing in the venous drip chamber

       * A clamp is partially occluding the venous flow

2. Arterial pressure alarm

- This alarms when the blood flow to the system is impeded
11-Bunchman PRIMSA M-60 Protocol

- This may be due to:

     * Vasospasm in the "arterial" access of the patient

     * The patient has rolled over on the "arterial" line

     * clotting is occurring in the filter causing inhibition of blood flow out of the filter (yet usually
the UF drops off first)

3. Air leak alarm

- this alarms when air is seen by the "eye" in the blood going back to the child The cause of this is
usually do to a crack in    tubing with a leak of air into the blood tubing.

4. Blood leak detector

- factors that influence this alarm or a blood leak across the hemofilter, free hemoglobin and
myoglobin.

				
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