Procedure: CRRT Accessing and Initiating Treatment

Ensure that patient and health care provider safety standards are met during this procedure including:

• Risk assessment and appropriate PPE
• 4 Moments of Hand Hygiene
• Procedural Safety Pause is performed
• Two patient identification
• Safe patient handling practices
• Biomedical waste disposal policies
• Sharps handling

INDEX

1. Eye Protection
2. Prime Circuit
3. Prepare Catheter
4. Prepare Sterile Tray
5. Perform Hand Hygiene and PPE
6. Cleanse Catheter
7. Apply Sterile Towel
8. Discard Gauze
9. Prepare Access Limb
10. Withdraw Blood
11. Check for Clots
12. Confirm Adequacy of Flow Rate and Flushes with Saline
13. Repeat with Return Limb
14. Connect CRRT Circuit
15. Prepare Saline Flush
16. Administer Heparin Bolus

Accessing Dialysis Line Checklist

Deaccessing Dialysis Line Checklist

Equipment Required:

1. PPE with eye protection
2. Sterile dressing tray (the dressing tray includes the sterile drapes and a place to inject blood for clot inspection).
3. 2 pairs non-sterile gloves
4. 2 large (1.5 mL) chlorhexidine 2% swabs (without alcohol) (use 4 wipes if catheter or clamps are visibly soiled.
5. 2 empty 10 mL syringes
6. 2 - 4 10 mL NS syringes (extra syringes may be required to rinse blood or debris from limbs or clamps)
7. 1 Sterile 4X4 gauze
8. Non-sterile gauze (for clot assessment)
9. Primed CRRT circuit
10. Saline rescue line with Y connector with red and blue clamps

 1.

Select PPE with Eye Protection

Select PPE including mask with face shield.

 2.

Prime the CRRT Machine
Prime the CRRT machine using on-screen instruction. 

Set the flow rate as per orders. Set initial blood flow rate to 250 ml/min and fluid removal to 0 ml/hour.  The PrisMax will ramp up to this speed as tolerated.  Fluid removal can be started once patient has stabilize.

Follow the on-screen prompts to complete priming. 

You can prime outside the patient room. The CRRT machine and heater must be connected to a wall outlet during priming. Set-up and prime the machine until the second bag of priming solution has been administered.  Note the displayed message "no further priming past this screen".  If you are not hooking the patient up right away, hang a new 1 L bag of saline on the priming hook. The new bag of saline will prevent accidental priming with an empty bag.  If you are setting the machine up for another nurse, place a note on the bag to confirm that the machine was already primed with 2 bags of saline - to avoid confusion over the new 1 L bag.

The machine can be unplugged and moved once you reach this screen.  If the machine is not connected within 1 hour, you will need to manually prime with at least 250 mL of saline to clear any ETO sterilization gas that has reaccumulated.  

Complete the priming process following on-screen instructions. Check for any air in the filter; tap gently to eliminate any visible air with manual priming. 

Prepare Saline Rescue Line

Prepare and add a rescue line to the end of the Access Line of the CRRT tubing. If the lines will be reversed (using the blue catheter limb as access and red limb as return), the rescue line stays with the CRRT Access line tubing.  

A rescue line should never be added to the return tubing.  If the stopcock became disconnected, this could result in blood being pulled from the patient and returned into the bed at up to 250 ml/min. The stopcock could create enough resistance to prevent a "return disconnect alarm".  A return disconnect alarm will be activated if the return pressure falls below a pressure of +10 mmHg.

Prepare and Connect Rescue Line

1. Prime a 1 L bag of 0.9% normal saline with regular IV tubing.
2. Connect the saline line to the limb on the Y Connector with the blue clamp
3. Prime all limbs of the Y Connector with saline
4. Connect the red limb of the Y connector to the red Access Line on the CRRT circuit
5. When ready to connect patient to CRRT machine, Connect the single male end of the Y Connector to the access limb of the dialysis catheter
6. During treatment, blood will be drawn from the access limb to the "red" limb of the Y Connector, then into the red access tubing of the CRRT circuit.

The rescue line can be used to deliver a rapid fluid bolus, to flush the filter and inspect for clotting, or to quickly retransfuse blood at the end of a treatment. Refer to the Procedure: CRRT Saline Flush, Ending Treatment or Deaccessing Dialysis Treatment. 

3.

Prepare Catheter

Remove gauze and tape that is surrounding the catheter limbs and discard.

Place a non-sterile waterproof pad under the dialysis limbs to protect the bed linen.

4.

Prepare Equipment

Open up a dressing tray.

Move the two waterproof (white) and the one non-waterproof towel (blue) out of the way.

Using the blue transfer forceps, place the sterile 4 X 4 gauze in the large cup of the tray (the gauze will be used to hold the catheter during cleaning).

Using transfer forceps, place the large (1.5. mL) chlorhexidine 2% wipes (without alcohol) into a cup in the dressing tray (don't place them on top of the gauze square or they will dry out).

Open up one waterproof towel and place it beside the dressing tray.  Remove the 10 mL empty and saline syringes from the package and place on the towel.   

Place the 2 non-sterile gauze 4X4s onto the waterproof towel, side-by-side (one gauze will be used to assess for clot in each limb)..

Turn back one corner of the blue non-waterproof towel to make it easier to pick up.

Open up the second waterproof towel and place it underneath the catheter limbs (to protect linen during cleaning). 

Maintain sterility while accessing lines. A separate swab stick will be used for each limb.

One waterproof towel will be placed under the limbs before cleansing to protect bed linen. The blue sterile towel will go on top of the waterproof towel AFTER the limbs are cleansed and the prep has dried.

The syringes are placed on the second waterproof sterile towel to maintain aseptic technique.  The non-sterile gauze is placed on the waterproof field to prevent blood exposure during clot assessment.

5.

Prepare Catheter

Apply a clean pair of gloves and pick up the sterile 4X4 gauze square with your non-dominant hand. Using the gauze square, grip the catheter and use the gauze to hold the catheter during cleaning.

Hold the catheter firmly while lifting the limbs off the bed surface. The gauze will minimize any contact between the uncleaned catheter and your clean gloves.

6.

Cleanse Catheter

Using your dominant hand, pick up one of the two chlorhexidine wipes. Vigorously scrub the cap, hub, external lumen and clamp of the Access limb of the dialysis catheter for at least 15 seconds. Repeat with a second swab limb is visibly soiled.

Pick up the second wipe and repeat the procedure with the Return limb.

Continue to hold the limbs with your non-dominant hand until the cleansing solution is completely dry.

Well maintained perm caths can remain in place for many years. The IHD program has identified premature catheter failure due to cracking of hub when alcohol based cleaning preps are used, particularly with perm caths.

7.

Create Sterile Field

With your dominant hand, grab the blue sterile towel by the edge and open it up.  Place it on top of the waterproof (white) towel.

The towel creates a sterile field to minimize contamination of the cleansed catheter limbs and maintain aseptic technique.

 8.

Discard Gauze

Rest the limbs on the sterile towel.

Discard the gauze that was used to hold the catheter.

This will create a wider sterile field and minimize the chance to contaminate your gloves through contact with the uncleansed portion of the catheter.

9.

Prepare Access Limb

Ensure that the clamp on the access limb (red) is closed. Remove the cap from the end and attach an empty 3 mL syringe.

To prevent air entry into the dialysis catheter during opening of the catheter

10.

Withdraw Blood

Open the clamp and vigorously aspirate 5 mL of blood. Note the ease with which the blood can be withdrawn.

Removing this volume will ensure that any clots and/or the citrate anticoagulant are removed from the limb.

11.

Reclamp

Reclamp the limb and remove the syringe after clamping.

Reclamping prevents air entry or blood loss from the limb.

Check for Clots

Slowly inject the aspirated blood onto one non-sterile 4 X 4 gauze (that is on top of the waterproof towel). Disperse the blood over a large area of the gauze using a back and forth motion. Observe for fibrin or clot.

If clots are present, draw off more blood and repeat visible inspection until clear of clots.

The white background and weave of the gauze allows for visualization of any clots.

Confirm Adequacy of Flow Rate and Flushes with Saline

Attach an empty 10 mL syringe to the Access Limb. Vigorously aspirate and immediately return 10 mL of blood (pull-push technique).  Assess for ease of flow and ability to complete the pull-push within 3 seconds. This indicates that the limb is adequate for blood flow rates of at least 200 ml/min.
Note: If flow rates from the access limb are inadequate, do not connect access tubing to access limb. Treatment should either be delayed until correction of any catheter problems or should be initiated with lines reversed (access tubing connected to return limb).

Once flow rate has been evaluated, vigorously flush the access lumen with 10 ml 0.9% normal saline using a stop-start technique. Clamp limb.

If the dialysis circuit is flushed and ready to connect, you can proceed to connect to the circuit (Step 15). If CRRT initiation will not be immediate, instill sodium citrate locking solution into the limb before clamping. Place a dead-end Luer-lock cap on the end of the limb. Each blocked limb should be wrapped with gauze and have a medication sticker added to identify any blocking medication (e.g., sodium citrate).

Repeat for Return Limb

Repeat steps 8-13 for the return limb (blue)

Prepare to Connect Patient to CRRT Machine

Follow on-screen prompts to complete setup. The final steps include connecting the yellow effluent tubing to the effluent bag and the blue return line to the priming Y Connector (where the yellow effluent tubing was connected). 

At this point, do not follow the on-screen process for connecting the patient. Instead:

1. Ensure the rescue line is connected to the Access Line (red circuit line). Close the red clamp on the red limb of the rescue line (this is now the distal end of the Access Line).
2. Move the clamp on the Return Line (blue) close to the distal end of the tubing and close the clamp.
3. Clamp both limbs of the Y Connector that is attached to the priming bag (the Y Connector should have the Access Line connected to one side and the Return Line attached to the other. 
4. Take the priming bag with the Access and Return Lines still attached and position it near the patient's catheter.  
5. If you are administering a heparin bolus, follow the procedure in #18 below and administer the heparin into the Access Limb of the catheter.
6. Connect the Access Line to the red limb of the dialysis catheter. 
7. Connect the Return Line (blue) to the blue limb of the dialysis catheter.
8. Ensure the blue clamp on the rescue line (with the saline infusion) remains clamped.
9. Open the clamps on the Access Limb of the catheter and the Access Line. 
10. Open the clamps on the Return Limb of the catheter and the Return Line.

Administer Heparin Bolus if Ordered

If a heparin bolus has been ordered (for heparin filter anticoagulation prescription), administer the bolus directly into the access limb (red) immediately before connecting the red Access Line as follows (the volume of heparin must be less than the volume of the catheter):

1. Clamp the access limb of the catheter
2. Attach the heparin containing syringe to the access limb (red) of the dialysis catheter (e.g., 5,000 in 0.2 ml)
3. Open the access limb clamp.
4. Inject the heparin into the access limb.
5. Reclamp the access limb.

This technique ensures that the first blood to hit the filter will be heparinized, but prevents the patient from receiving a direct heparin bolus. Subsequent boluses given during treatment can be administered directly into the red sampling port of the circuit.

Initiate Treatment

1. Double check to ensure all clamps are open EXCEPT the clamp to the syringe.
2. Confirm the dearation chamber level and raise it slightly to accommodate any air that may be released at the start of treatment. 
3. Initiate treatment following on-screen prompts
4. Observe catheter connections for blood leak
5. Monitor circuit closely for leakage or air bubbles and be prepared to raise the deaeration chamber level quickly to prevent air in return alarm

NOTES:

If treatment is started with lower blood flow rates, the access pressure will be too low (i.e., less negative). As blood flow increases, the access pressure becomes more negative (more “suck” is required to pull the larger blood flow volume). If the access pressure is less negative than minus 10, the CRRT machine will interpret this as a disconnected access limb and generate an alarm. To avoid access disconnection alarms, escalate the blood flow rate quickly during initiation of treatment. Starting at 250 mL/min will usually prevent this from happening.

If pump pressures permit, increase the blood flow rate as quickly as possible to 300 mL/min (as tolerated). Higher blood flow rates can reduce filter clotting by shortening the duration of time that blood remains in the filter. Blood flow rates must be increased as quickly as possible for maximum clotting reduction benefit. Access and return pressures will increase as blood flow rate increases - once blood flow is stable, these pressures should also stabilize.

Once the circuit is connected, all clamps should remain open. Any time that a high priority alarm is activated, the blood pump automatically stops and the blood flow circuit closes (safe mode).

If therapy is initiated with any clamps closed, the CRRT machine will immediately alarm and shut down. Repeated alarms during initiation may lead to treatment failure/shut down.

DOCUMENTATION

Activate the Continuous Renal Replacement Therapy Band in the Electronic Patient Record as follows:

1.  Select IView (you must be in IView to open Navigation Bands)

2.  Go to View from Windows menu bar.

3.  Choose Layout - Navigation Bar - Continuous Renal Replacement Therapy as shown below.

4.  When done, Exit Through the Door.  This will add the Continuous Renal Replacement Therapy Band permanently.