PROCEDURE: ACCESSING AND INITIATING CRRT

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. Dons PPE and Hand Hygiene
2. Performs Safety Pause
3. Prepares Catheter
4. Prepares Sterile Tray
5. Performs Hand Hygiene and PPE
6. Cleanses Catheter
7. Applies Sterile Towel
8. Discards Gauze
9. Prepares Access Limb
10. Withdraws Blood
11. Checks for Clots
12. Flushes with Saline
13. Repeats with Return Limb
14. Connects CRRT Circuit
15. Assessment Checklist

Equipment Required:

• Appropriate PPE—always include a mask with a face shield
  Sterile dressing tray (the dressing tray includes the sterile drapes and a place to inject blood for clot inspection).
• 2 pair non sterile gloves
• 2 large (1.5 mL) chlorhexidine 2% swabs (without alcohol) (use 4 wipes if catheter or clamps are visibly soiled.
• 2 empty 3 mL syringes
• 2 - 4 10 mL NS syringes
• 1 Sterile 4X4 gauze
• Non-sterile gauze (for clot assessment)
• Primed CRRT circuit (with one saline infusion attached to a stopcock and connected to the access end of the circuit).

 1.

Dons PPE and Hand Hygiene

Perform hand hygiene, don appropriate PPE including mask with face shield.

 2.

Performs Safety Pause

Review the procedural steps and supply requirements.

Ensure CRRT circuit has been primed and flow rates programmed.

Review online Procedural Safety Pause

3.

Prepares Catheter

Don non-sterile gloves and 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.

Remove non-sterile gloves and perform hand hygiene.
 

4.

Prepares 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  an 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 3 ml and 10 ml 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.

Picks up 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.

Cleanses 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.

Places Sterile Towel

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.

Discards 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.

Prepares 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.

Withdraws Blood

Open the clamp and vigorously aspirate 3 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.

Reclamps

Reclamp the limb and remove the syringe after clamping.

Reclamping prevents air entry or blood loss from the limb.

Checks 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 visualisation of any clots.

Flushes with Saline

Attach one of the sterile NS prefilled syringes; inject 10 mL using a vigorous stop start technique. Repeat with a second 10 mL syringe if flow is sluggish. Re-clamp; leave syringe attached.

This allows you to check flow in the catheter. CRRT success requires adequate flow rates.

Repeats for Return Limb

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

Confirms Blood Flow Rates

Set the flow rate as per orders. Set initial blood flow rate to 150 ml/min.

Adds Saline Flush

Connect the circuit to the catheter as follows:

Heparin Bolus:

If a heparin bolus has been ordered, administer the bolus directly into the access limb (red) just prior to connecting the circuit.

1. Attach the heparin containing syringe to the access limb (red) of the dialysis catheter.
2. Open the access limb clamp.
3. Inject the heparin into the access limb.
4. Reclamp the access limb.

Connects Circuit:

1. Connect the stopcock/saline infusion to the access (red) end of the CRRT circuit.
2. Connect to the access limb (red) of the dialysis catheter to the stopcock (the limb and dialysis circuit should be in straight alignment with saline at 45 degrees..
3. Connect the return (blue) end of the CRRT circuit to the return limb (blue) of the dialysis catheter.

Opens all Clamps:

1. Open the access and return clamps.
2. Close the stopcock to the saline infusion.
3. Open the roller clamp of the saline infusion.
4. Ensure that all clamps in the CRRT circuit are open.

Initiates Treatment:

1. Initiate treatment
2. Monitor circuit closely for leakage or air bubbles
3. Increase blood flow rate quickly to ordered rates.

NOTES:

If treatment is started with lower blood flow rates, the access alarm 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.

If pump pressures permit, increase the blood flow rate as quickly as possible until it is 250 mL/min (or as high as pressures allow). 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.

The heparin bolus has a total volume that is smaller than the volume of the catheter limb, therefore, the heparin bolus will remain in the limb until the treatment is started.

Upon initiation, the first blood that will drawn into the catheter will contain heparin. Thus, the first blood to reach the filter will be anticoagulated.

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.