Nursing Issues and Procedures in Continuous Renal Replacement Therapy

Nursing Knowledge and Acute Kidney Injury

The application of lifesaving and supporting devices in the ICU requires human, technical, and educational resources for safe and efficient use by nurses. Respiratory and cardiac support are foundational curriculum for nurses training in critical care mostly because of their commonality and life-sustaining constant use with immediacy of nursing attention and care requirements (e.g., the artificial airway and mechanical ventilators or the maintenance of vasoactive drugs and cardiac pacemakers). CRRT, however, may be required less frequently and sporadically, making the association between base level training and lectures and patient care experience unreliable. Therefore practice and simulation activities are helpful when long periods of time elapse between patient care experiences. However, with increasing use of CRRT in busier referral centers, this new knowledge and practical skill sets are better linked and mandate an expansion of the core curriculum for nursing in the ICU to include CRRT competency development with equal importance to use of a ventilator or monitoring system.

As for other ICU technologies, learning to use the machine or technology is the end point, but this always must be preceded with background education for the “who, why, and how” approach. Theory or didactic classes should be provided before any practical machine use. This may appear to slow the road towards bedside competency. Furthermore, it may be questioned because ICU nurses are usually eager to start using the CRRT machine (or any new technology) with a desire to “master” this, as with the mechanical ventilator, pacemaker, or hemodynamic monitor. Therefore theory must precede some practical experiences, and learning must be in a skill development ladder.

Group One Lectures

To begin, current understanding and key concepts of acute kidney injury (AKI) and critical illness are necessary first lectures in the knowledge and skills pathway for CRRT competency and nursing mastery of this therapy. Classes should provide an understanding of acute kidney failure: how this illness manifests, relevant physiology and pathologic changes, classification for severity, association with other organs and their failure during illness, likely prognosis, and best treatment strategies for renal replacement therapy (RRT) options and different modes. Figure 162.1 indicates this as a concept map for grouped tutorials or lectures suitable to provide this nursing knowledge and practical competency for care of the critically ill with AKI.

Group Two Tutorials and Practical One

When the key aspects of AKI and treatment are presented and learned, CRRT and the devices used are the next step in the pathway to competency and safe patient care. Before this machine training, dialysis mechanisms for waste and fluid removal must be taught in lecture or tutorial format. These are the concepts of diffusion, convection, ultrafiltration, dose, and the extracorporeal circuit(s) to achieve these. This training begins to reveal and describe important terminology and key language for CRRT vital for later clinical experience, prescription orders, and safe care to patients. These lectures may be linked to machine training at this point. With associated priming, the circuit and setup as theory and practical aspects of machine training fit together well in concept, terminology used, and the psychomotor skills required. This describes group two lecture or tutorials in Fig. 162.1 .

Group Three Tutorials and Practical Two

Group three tutorials are designed to consolidate further the use of a prepared CRRT machine and are associated with the connection to patient procedures, monitoring, and settings for a treatment in progress and those for ceasing and terminating CRRT. This third stage is scheduled optimally concurrent with live patient experience. The relevant lectures and tutorials at this time are focused on fluids used, fluid balance, anticoagulation, and the vascular access device. The links from theory or abstract are more logical, faster, and easier learned if nurses can see this in action and real time with a patient in their care experience. This approach does mandate that the learners are supported during the patient care aspects by an experienced CRRT competent nurse possibly in the adjacent bed-patient or in a location to help, teach, oversee their learning, and decision making. In some ICUs clinical educators provide this support and have this dedicated support role. This is a nursing apprentice context and is well established in the ICU for new learners with other technologies and interventions such as ventilation, monitoring, and major surgical care such as postcardiac or neurosurgery.

Sequence and logical progression is therefore evident from pathophysiology of AKI, dialysis clearance processes, circuits for treatment, language and key terminology, fluids and balance, vascular access catheter, anticoagulation, and then practicum of circuit preparation and machine operation. CRRT circuits for each mode or option have been well described in the literature since at least the early 1990s. They are not presented again here but will be viewed in other chapters describing CRRT modes, circuits and machines used. Theory before practical, simple to complex, abstract to concrete is the best advice.