CONTINUOUS RENAL REPLACEMENT THERAPY INSERVICE JENNIFER A WOOLEY MS

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Continuous Renal Replacement Therapy Inservice

Continuous Renal Replacement Therapy Inservice

Jennifer A. Wooley, MS, RD, CNSD

November 14, 2001


WHAT: Continuous Renal Replacement Therapy (CRRT) – always involves dextrose. Net absorption/assimilation of dextrose from dialysate is 270 grams per day, which contributes 918 calories/day.

1L [2.5%] dextrose (25 g /L) dialysate / hr x 24 hr / day = 600 gm dextrose x 45% uptake = 270 gm dextroxe x 3.4 kilocalories /gram = net absorption of 918 dextrose calories/day


Slow Continuous Ultrafiltration (SCUF) – does not involve dextrose


WHY: Primarily used for the removal of fluid and azotemic waste products in critically ill patients that are hemodynamically unstable.


WHO: Acute Renal Failure

Multi-system organ failure

Fluid overload

Hypotensive/hemodynamically unstable patients


HOW: CRRT uses a dextrose-based osmotic gradient to pull fluid and azotemic waste products from the blood at a continuous rate over 24 hours per day. Net fluid loss per hour is programmed into the process.

NUTRITION ASSESSMENT:


Calories: 25 – 30 calories/kg reference weight


- Hypothermia induced by CRRT may decrease REE by as much as 7%.


- Indirect calorimetry during CRRT may not be a reliable indicator of energy expenditure.


Protein: CRRT is a catabolic process. Patients may require 1.5 – 2.0 gm/kg protein per day. Re-evaluation of protein requirements may become necessary based on acute visceral protein trends.




Fat: goal: < 1 gm/kg reference weight


Fluid: LIBERAL


Micronutrients: depends on the nutrition mode


DESIGNING THE NUTRITIONAL REGIMEN:


  1. Complete a thorough review of the medical record.

  2. Review all medications.

  3. Review all laboratory data.

  4. Assess the patient’s nutritional status.

  5. Determine the patient’s predicted caloric and protein requirements.

  6. Evaluate the most appropriate route for nutrient delivery.


PARENTERAL NUTRITION:


  1. Determine whether the patient has central access and a clean port for parenteral nutrition.


  1. Determine the contribution of obligatory dextrose and lipid calories from all I.V.’s, medications and CRRT.


  1. The base solution:







  1. The Nephrology Service generally, manages serum ionized calcium levels and treats acid –base abnormalities via the dialysis bath. Therefore, daily manipulation of these substrates via the nutrition regimen is not necessary.


  1. Anticipate an increased need for phosphorus, magnesium and potassium as TPN additives during CRRT therapy. Err on the moderate side with these additives as they can always be supplemented outside the TPN.


  1. Standard MVI and trace element packages are appropriate.


  1. Daily provision of additional water soluble vitamins (Nephrovite®) crushed and administered via the nasogastric tube may be beneficial to replace losses during ultrafilitration.


  1. Physicians and pharmacists routinely use renal dose Pepcid (20 mg/day) unless the patient is coagulopathic in which carafate per tube would be used for GI stress prophylaxis.


  1. Use an insulin drip (dose: 100 units / 100ml volume) as the sole agent for glucose control during CRRT. Insulin must not be incorporated into the parenteral solution as an additive as the risk of hypoglycemia is great should CRRT be interrupted for any reason.








ENTERAL NUTRITION:


  1. This critically ill population must have small bowel access.


  1. Determine the contribution of obligatory dextrose and lipid calories from all I.V.’s, medications and CRRT.


  1. In general, use of Standard or Fat Malabsorption formulas are appropriate.


- Fat Malabsorption formula is appropriate for use when patients are on propofol therapy because it is low in fat (39 gm/liter 70% MCToil).


  1. Renal formula (Nepro) is not indicated for the following reasons:


- This formula is high in calories at 2.0 cals/ml. In particular, the lipid content is very high, at 95.6 gm/liter, and may contribute to overfeeding especially when patients are on propofol therapy.


- The electrolyte and fluid restrictions in this formula are not necessary with this form of dialysis.


  1. It may be necessary to dilute enteral formulas in order to avoid overfeeding CRRT patients.


  1. When adding modular protein powder to diluted enteral formula, limit MPRO to 10 gm/240 ml in order to protect the solubility of the solution as well as prevent clogging of the feeding tube.


  1. A multi-vitamin may be needed to meet 100% RDI’s with diluted enteral formulas.


  1. Daily provision of additional water soluble vitamin (Nephrovite®) delivery may be beneficial during

  1. CRRT to replace losses during ultrafiltration.

  1. An insulin drip is the preferred method for achieving glucose control in this population. Recommend

using 100 units insulin / 100ml volume.


  1. Anticipate that serum phosphorus, magnesium and potassium levels will fall dramatically with CRRT resulting in the need to monitor levels closely and supplement via I.V. route accordingly.


  1. The Nephrology Service generally, manages serum ionized calcium levels and treats acid –base abnormalities via the dialysis bath. Therefore, daily manipulation of these substrates via the nutrition regimen is not necessary.



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AFFIDAVIT CONTINUOUS MARRIAGE HUSBAND AND WIFE BEFORE
ALTERNATIVE ASSESSMENTS – SCR 7 CONTINUOUS PAIN ASSESSMENT NAME


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