Operating an effective CRRT team - PowerPoint Presentation

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Operating an effective CRRT team - PPT Presentation

Jung Tak Park MD PhD Department of Internal Medicine Division of Nephrology Yonsei University College of Medicine CRRT dose and outcome ID: 812745

team crrt time dose crrt team dose time outcome communication cvvhdf 2015 simplification delivered operating prismaflex care task intensive

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Slide1

Operating an effective CRRT team

Jung

Tak

Park MD., PhD.

Department of Internal Medicine, Division of Nephrology Yonsei University College of Medicine

Slide2

Slide3

Slide4

CRRT dose and outcome

Down time

CRRT team set-up experience

Slide5

CRRT dose and outcome

Down time

CRRT team set-up experience

Slide6

CRRT dose in YUHS

800 ml/h

convection

800 ml/h

diffusion

150 ml/h

800+800+150

= 1750

50kg

1750/50=35 ml/kg/h

Slide7

CRRT dose

Semin Dial. 2009 Mar-Apr;22(2):151-4.

“CRRT dose”

Slide8

Intensive hemodialysis reduces mortality

Daily or intermittent dialysis

N=160

CRRT dose

N Engl J Med. 2002 Jan 31;346(5):305-10.

Slide9

Increasing dialysis dose confers a better survival

CVVHDF

CVVH

N=206

CRRT dose

Kidney Int. 2006 Oct;70(7):1312-7.

42 ml/kg/hr

Slide10

Effluent volume should reach at least 35 mL/h/kg

CVVH

N=425

CRRT dose

Lancet. 2000 Jul 1;356(9223):26-30.

Slide11

Practice Patterns

CRRT dose

Nephrol Dial Transplant. 2006 Mar;21(3):690-6.

Slide12

Intensive renal support does not decrease mortality

Acute Renal Failure Trial Network (ATN) Study, N=1124

Intensive vs. less intensive

Mixed medical, surgical AKI

CRRT dose

N Engl J Med. 2008 Jul 3;359(1):7-20.

Slide13

Higher intensity CVVHDF does not reduce mortality

RENAL Replacement Therapy Study Investigators, N=1508

CVVHDF, mixed medical and surgical AKI

CRRT dose

N Engl J Med. 2009 Oct 22;361(17):1627-38.

Slide14

CRRT dose

Am J Kidney Dis. 2016 Oct;68(4):599-608.

Ultra-high intensity CVVHDF does not reduce mortality

40 mL/kg/h vs. 80 mL/kg/h CVVHDF

Septic shock patients

N=212

40 ml/kg/hr

80 ml/kg/hr

Slide15

Relationship between CRRT dose and outcome

CRRT dose

Crit Care. 2011;15(2):207.

Slide16

We recommend delivering an effluent volume of

20–25 ml/kg/h

for CRRT in AKI

35 ml/

/kg is a reasonable target

for prescription to make sure no less than 25 ml/

/kg is effectively delivered

Considerations on CRRT dose prescription

KDIGO Clinical Practice Guideline for Acute Kidney Injury 2012

Slide17

CRRT dose and outcome

Down time

CRRT team set-up experience

Slide18

Continuous

is not continuous

Filter clotting

Catheter malfunction

Outside ICU procedure

Imaging studies

pts

, United states

Mean 7.9

/day down time, 67% of prescribed dose

35 ml/kg/

CRRT prescription

/day down time

→ 23 ml/kg/

CRRT down time

Kidney Int. 2001 Sep;60(3):1154-63.

Slide19

Down time reduces actual delivered dose

CVVHDF, RCT, 200

pts

Delivered dose is less than 80% of prescribed dose

CRRT down time

Crit

Care. 2009;13(2):R57.

Slide20

Down time reduces CRRT dose

pts

, prospective observation

Mean 5.4

/day down time, 78% of prescribed dose

CRRT down time

Intensive Care Med. 2003 Apr;29(4):575-8.

Slide21

Continuous

is not continuous

Filter clotting

Catheter malfunction

Outside ICU procedure

Imaging studies

CRRT down time

“Specialized CRRT management team”

Slide22

CRRT dose and outcome

Down time

CRRT team set-up experience

Slide23

CRRT team structure

Operating CRRT team

신장내과

소아신장과

전담 간호사

CRRT

팀장

Slide24

CRRT team job description

ICU 3

교대

, 24

시간 근무

Day, evening 2, Night 1

Operating CRRT team

Slide25

CRRT team history

2008.08

전담

기 시작

총

명

(

보유기기

대

)

2010.04 HICU

PrismaFlex

대 가동

(

보유기기

대

)

2010.06 새병원

PrismaFlex

대 가동

(

보유기기

대

)

2010.12 CCU

PrismaFlex

대 가동

(

보유기기

대

)

2015.03

인력증원

명으로 총

명

2015.03

암병원

PrismaFlex

대 가동

(

보유기기

대

)

2015.03

Polymyxin

-b filter

hemoperfusion

전담 시행

2016.08

전담

기 시작

2016.08

MARS

전담 간호사 교육 이수

2016.09 PICU

PrismaFlex

대 가동

(

보유기기

대

)

Operating CRRT team

Slide26

CRRT team management obstacles

Work overload

Lack of communication

With nurse colleagues

With physician

Loneliness

Overcoming obstacles

Expertise

Communication

Task simplification

Sense of belonging

Operating CRRT team

Slide27

Education

업체 교육

일

원내 교육

일 시행

매뉴얼 숙지

평가

업무 매뉴얼

기본업무와 특수상황

알람과

해결방법

장비관리

교육

CRRT

team

expertise

CRRT

업무매뉴얼 목차

I. CRRT

전담팀

업무 목적

II. CRRT

전담 기본 업무

시작 및 교환

ii.

기록 및 문서 관리

iii. Duty

별 업무

iv.

라운딩

소모품청구

III.

중환자실외 병동 적용 시

수술실

ii.

응급실

iii.

일반병동

iv.

기타장소

IV.

알람

해결

ⅰ

알람의

종류

ⅱ

문제 파악

ⅲ

혈액 흐름 관련 문제

ⅳ

저울 관련 문제

ⅴ

시스템 관련 문제

연구

VI.

교육

VII.

장비관리

VIII.

기타 대처

ⅰ

. MARS

ⅱ

. PCPS

연결

ⅲ

Hemoperfusion

Slide28

알람

해결 매뉴얼

자주 발생하는

알람

해결 방법에 대한 정리

CRRT

team

expertise

Slide29

CRRT

전담팀

Study

모임

횟수

: 1

회

주

CRRT

Operating an effective CRRT team - PowerPoint Presentation

Operating an effective CRRT team - PPT Presentation

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