1. Types of Renal Replacement Therapy (RRT)
|
Intermittent hemodialysis (IHD). |
|
Continuous renal replacement therapies (CRRT). |
|
Hybrid therapies e.g., Sustained low-efficiency dialysis (SLED)/ Prolonged Intermittent Renal Replacement Therapy (PIRRT). |
2. Common Indications of RRT in ICU
|
Acute kidney injury (AKI) ● Fluid overload (refractory to diuretics). ● Hyperkalemia (K + > 6.5). ● Severe metabolic acidosis (pH < 7.1). ● Rapidly climbing urea/creatinine (or urea > 30mmol/l). ● Symptomatic uremia: encephalopathy, pericarditis, bleeding, nausea, pruritus. ● Oliguria/anuria. |
|
Overdose with a dialyzable drug or toxin: The examples of removable drugs include Lithium, Methanol, Ethylene glycol, Salicylates, Barbiturates, Metformin, Aminoglycosides, metronidazole carbapenems, cephalosporins and most penicillins. |
|
Preexisting ESRD |
3. General Principles
|
Assessment: Proper medical history and condition assessment including physical examination, vital signs, laboratory tests, and imaging studies is required to determine the treatment strategy. |
|
Fluid management: Due to risk for fluid overload leading to pulmonary edema, meticulous intake and output charting is required to maintain the balance. |
|
Electrolyte balance: Electrolyte imbalances commonly of sodium, potassium, magnesium and calcium can lead to arrhythmias and muscle weakness. Closely monitoring and appropriate management of electrolytes is important. |
|
Blood pressure management: Consider BP optimization as hypertension is a common problem in renal patients during dialysis which can further damage the kidneys. |
|
Nutrition support: Specialized nutritional support including a low-protein diet to reduce the workload on the kidneys may be required. Consider supplementations to address specific nutritional deficiencies. |
|
Medication management: Nephrotoxic medications should be used with caution or avoided completely. Consider dose adjustments while using any drugs metabolized by the kidneys. |
|
Monitoring and follow-up: Close monitoring and follow-up using laboratory tests and imaging studies is needed assess the condition and detect any complications and adjust treatment as required. |
|
Individualization of the treatment protocol is needed and depends on patients’ condition. Consider working closely with nephrologist and other specialists to provide the best possible care. |
4.Care of Dialysis Catheter
|
Perform hand hygiene using soap and water or an alcohol-based hand sanitizer before touching the dialysis catheter or the surrounding area. |
|
Clean the catheter site with an antiseptic solution, such as chlorhexidine or povidone-iodine, using a sterile technique before and after every dialysis session, and whenever it becomes visibly soiled or contaminated. |
|
Place a sterile dressing over the catheter site after cleaning to prevent infection and secure the catheter in place and change at least once a week, or more frequently if it becomes soiled or loose. |
|
Consider flushing the dialysis catheter using a sterile technique before and after every use with heparin or saline solution to maintain patency and prevent blood clots. |
|
Consider using a sterile technique during dialysis catheter removal to minimize the risk of infection. The catheter site then needs to be cleaned and covered with a sterile dressing. |
|
Monitoring the patient and documentation of any signs of infection, such as fever, redness, or swelling at the catheter site is important. Any changes should be documented in the patient's medical record. |
|
Dialysis catheter with 3 ports (one port for IV access/ sampling) MUST NOT be used as it increases the risk of bleeding, thrombosis and sepsis. |
5. Steps of Priming of the circuit
Proper priming of a dialysis circuit is critical to ensure its functionality and reduce the risk of complications during dialysis.
|
Before priming the dialysis circuit, gather all necessary equipment including the dialysis machine, dialysis tubing, saline solution, and heparin solution. |
|
Verify the patient's prescription for dialysis with the healthcare provider and confirm the correct type and dose of anticoagulant (heparin) to be used in the circuit. Some patient may need Heparin free dialysis. |
|
Attach the dialysis tubing to the machine, ensuring that all connections are secure and airtight. Prime the tubing with saline solution to remove any air bubbles. |
|
Add the appropriate amount of heparin solution to the dialysis tubing, as prescribed. Mix the heparin solution with the saline solution already in the tubing by gently agitating the tubing. |
|
Slowly infuse the saline and heparin solution through the dialysis tubing, filling the entire circuit from the dialysis machine to the patient's access point ensuring that the circuit is fully primed and any remaining air in the tubing is removed. |
|
Closely monitoring the patient's vital signs for any signs of adverse reactions or complications, such as hypotension or hypovolemia is important while the circuit is being primed. |
|
Record the details of the priming procedure, including the date, time, solution type and volume used, and any observations or interventions made during the process. |
|
If the patient’s is hypotensive and receiving >0.1 mcg/kg/min of Noradrenaline or requiring two vasopressors, priming may be done with 200 ml Albumin to avoid hypotension. |
Further Readings:
1. Gemmell, L., Docking, R., & Black, E. (2017). Renal replacement therapy in critical care. Bja Education, 17(3), 88-93.
2. Ahmed, A. R., Obilana, A., & Lappin, D. (2019). Renal replacement therapy in the critical care setting. Critical care research and practice, 2019.
3. Richardson, A., & Whatmore, J. (2015). Nursing essential principles: continuous renal replacement therapy. Nursing in critical care, 20(1), 8-15.
