AQUARIUS Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation (RCA) Competency

Transcription

1 Demonstrates an understanding of why RCA has been prescribed Explain the anticoagulation protocol Demonstrate an understanding of potential complications associated with CRRT. Explain potential indications and complications related to Infection Fluid imbalances Electrolyte imbalances Metabolic imbalances Bleeding Circuit clotting Filter clogging Fractured filter fibers Accidental disconnection / removal / dislodging of vascular catheter Spontaneous hypotension Bradycardia Cardiac Arrest 1

2 Preparation Explain the procedure to the patient and significant others Prepare the patient. Ensure a safe environment for the patient and staff Prepare the Hospital Guidelines and protocols followed environment. Infection control measures are met Gather equipment required to Setup and prime the Aquarius Haemofiltration Identify vascular access sites, and explain the benefits and the limitations of each. Femoral, subclavian and internal jugular veins. Types and lengths of vascular catheters available machine with RCA Collect equipment required for set up and priming the Aquarius machine Capability. Aquarius machine with RCA capability Aqualine RCA circuit Aquamax filter Manifold if using multiple bags Replacement fluid; Accusol 35 as per prescription Potassium Chloride (KCl) as per prescription 1L normal Saline (consider priming with Heparin) Anticoagulant; Acid Citrate Dextrose Solution A (ACD-A) Anticoagulation Solution as per prescription Calcium Chloride or Calcium Gluconate as per prescription 1 x 10 luer lock syringe 2

3 DefInitions: Preparation (Continued) Gathers appropriate equipment for accessing vascular access according to unit protocol. Can identify Doctor s written orders; Mode Blood Pump rate Post dilution rate Fluid loss Replacement solution; Accusol 35 +/- potassium ACD-A Anticoagulation rate Calcium Rate Signed and dated by doctor 3

4 Set Up Can identify and discuss the renal replacement mode used with RCA. Set up the Aquarius Aqualine RCA circuit Can perform Self-test ensuring pump doors are closed and no bags are on the scales according to the manufacturer's recommendations, the Before commencing lining Aquarius wait for a static orange light Commence lining following zoom graphic instructions on screen ICU policy and procedure manual. 4

5 DefInitions: Set Up (Continued) 5

6 DefInitions: Priming Commence priming following zoom graphic instructions on screen. Prime the Aquarius RCA circuit successfully according to company recommendations and unit policy. How long does priming of the Aquarius RCA circuit take? What do you do if part of the circuit fails to prime? How much fluid is used to prime and adult circuit? Clamp and Pressure Test Navigate to the Clamp and pressure test post priming following zoom graphic instructions on screen. Ensure there is enough fluid in the bag connected to the Y-connector. Perform Clamp and pressure test accurately and successfully. What is the clamp and pressure test trying to achieve? Why would the machine fail the clamp and pressure test? Successful completion of clamp and pressure test. 6

7 Recirculation Put the Aquarius machine into Recirculation mode Navigate to Recirculation mode. Commence recirculation successfully What is the purpose of recirculation? How long should you / could you re-circulate for. At what other times could you use recirculation? Explain how you would change bed spaces with the Aquarius. Programming Navigate to the programming screen. Program Aquarius as per medical orders and commence therapy. Program Aquarius according to prescription; Blood pump rate Citrate flow Calcium flow Time Fluid Loss Rate Total Fluid Loss Post dilution rate Number of bags Temperature Validate and exit after programming. If Calcium is set to zero a confirmation box will appear after exiting the programming screen. 7

8 Connection Connect patient to the Aquarius using hospital procedure and protocol. Connect patient to the Aquarius Haemofiltration machine. Have all equipment required to connect to patient Enter Patient Weight in order for Renal Dose calculation Assess vascular catheter no Identify problems with vascular catheter and suggest solutions Choose double or single connection. Connect vascular catheter to access and return line Commence filling circuit with blood. Remain with the patient after pressing the blood pump key to start. What is the default speed for the blood pump during connection? Why do we not increase the blood pump speed during the blood prime? When does the clamp come on? Commence therapy Monitor the patient s haemodynamic response to commencement of therapy. Observe access site and all connections Chart initial pressures Chart vital signs Identify when blood samples are taken to check anticoagulation results. Identify where the blood sampling ports are in RCA circuit. 8

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10 Alarms Demonstrate knowledge of the alarms and the ability to troubleshoot the Aquarius accordingly. Explain alarm system signals - the status lights, the audible alarm and screen messages. Demonstrate the use of the help screen Discuss possible causes of the following alarms. Discuss potential action taken to rectify alarm. Balance Alarm Access alarms pressure too high or too low Return pressures too high or too low High pre-filter pressure High Tmp (Trans membrane pressure) High pressure drop High Calcium flow Low Calcium flow Calcium/Citrate scale overload High Citrate flow Low Citrate flow Citrate bag missing Citrate bag change High Filtration Ratio Temperature too high 10

11 Alarms(Continued) Demonstrate knowledge of the alarms and the ability to troubleshoot the Aquarius accordingly. Discuss possible causes of the following alarms. Discuss potential action taken to rectify alarm. Blood leak alarms Blood detected alarms Air detected alarms Blood flow failure alarms ADU alarms 11

12 Management of Therapy Navigate to all information screens and demonstrate an awareness of information displayed and relevance to treatment More Screen Options Screen Performance and Options Demonstrate competent and confident user knowledge of the machine and flexibility. Navigate to the History Screen. Identify where fluid loss can be found. Identify pressure records. Identify alarm history and discuss. Circuit take down and shut down User to demonstrate cessation of therapy, safe and competent removal of the circuit and machine shut down. Identify reasons for electively taking down the circuit. Navigate to where circuit takes down and machine shut down can be located. Can demonstrate safe and effective pressure removal from the circuit Can identify appropriate circumstances when you may or may not return the patient s blood Demonstrate removal of circuit according to the Instructions For Use (IFU)/ User Manual 12

13 Shut down (Continued) Demonstrates end Treatment Correct equipment collected for disconnection 1L bag 0.9% saline 1 x single spike 1 x dressing pack 2 x 10ml 0.9% saline ampoules 2 x 10ml syringes 2 x 2ml syringes Heparin to hep-lock vascath Clamp and disconnect the access line Connect the access line to a bag of normal Saline using a spike Follow the step-by-step on screen instructions to return the blood Unclamp the access line and press the blood pump to start reinfusion of blood back to patient. Disconnect return line and reconnect to return chamber air port. And unclamp. Circuit Removal Identify pressures for safe removal of the Aqualine circuit. What do these pressures mean and how could these pressures influence your decisions? Ensure all the clamps on the access and return lines are off. Flush and lock vascular catheter lumens according to unit protocol. Open the pump doors 13

14 DefInitions: procedure or policy components. Circuit Removal (Continued) Remove the filtration tubing from the filtrate pump in the direction of the arrow then remove the filtrate pressure dome from the filtrate sensor. If return pressure <400mmHg remove the pressure dome from pressure sensor. Is the return pressure >400mmHg? Decrease the pressure by connecting a syringe to the top of the return chamber and fill the syringe with fluid until the pressure on the screen is below 400mmHg. Remove the return pressure dome from the return pressure sensor. Carefully remove the blood pump tubing by rotating in the opposite direction (anti clock wise) Is the access pressure >400mmHg? Decrease the pressure by connecting a syringe to the access infusion port before the access sensor and fill with fluid until the value is below 400mmHg. Remove the access pressure dome from the access sensor. Is the Tmp >200mmHg? Decrease pre-filter pressure by connecting a syringe to the pre dilution port and fill the syringe with fluid until the Tmp is below 200mmHg. Proceed with complete removal of the Aqualine RCA circuit and all the bags from the machine Select Aquarius off on the screen to turn off the machine. All equipment must be removed from the Aquarius and scales before the machine is switched off. Failure to remove circuit and bags from the machine prior to machine shut down will constitute a failure of this section of competency. Dispose of equipment according to unit policy. Ensure patient is comfortable 14

15 DefInitions: Assessment Decision: Competent t yet competent Action/further Training Required/Date Set for next Attempt at : Assessor s Signature: Date: Registered nurse s Signature: Date: References: Aquarius System with RCA Instructions For Use 15