What are the orders for Continuous Renal Replacement Therapy (CRRT)?

CRRT Orders: A Comprehensive Guide

For patients requiring Continuous Renal Replacement Therapy (CRRT), prescribe an effluent volume of 20-25 mL/kg/h with a higher prescription (25-30 mL/kg/h) to account for treatment interruptions and filter efficiency decline over time. 1, 2

Access and Setup

• Use an uncuffed nontunneled dialysis catheter for initiating CRRT in AKI patients 1
• Select vein for catheter insertion in this order of preference: right jugular vein (first choice), femoral vein (second), left jugular vein (third), and subclavian vein as last choice 1
• Always use ultrasound guidance for dialysis catheter insertion 1
• Obtain chest radiograph promptly after placement and before first use of internal jugular or subclavian dialysis catheters 1
• Use dialyzers with a biocompatible membrane for CRRT 1

Anticoagulation Protocol

• Assess patient's bleeding risk before selecting anticoagulation strategy 1
• For patients without increased bleeding risk:
  • Use regional citrate anticoagulation as first choice for CRRT 1
  • If citrate is contraindicated, use unfractionated or low-molecular-weight heparin 1
• For patients with increased bleeding risk:
  • Consider regional citrate anticoagulation if no contraindications to citrate exist 1
  • Avoid regional heparinization 1
• For patients with heparin-induced thrombocytopenia (HIT):
  • Stop all heparin products immediately 1
  • Use direct thrombin inhibitors (argatroban) or Factor Xa inhibitors (danaparoid, fondaparinux) 1
  • Argatroban is preferred if patient does not have severe liver failure 1

Fluid Composition

• Use bicarbonate rather than lactate as buffer in dialysate and replacement fluid 1, 3
• Bicarbonate is especially important for patients with:
  • Circulatory shock (strong recommendation) 1
  • Liver failure and/or lactic acidemia 1
• Ensure dialysis and replacement fluids comply with American Association of Medical Instrumentation (AAMI) standards for bacterial and endotoxin contamination 1
• Avoid fluids with supra-physiologic glucose concentrations to prevent hyperglycemia 1
• Consider pre-dilution fluid administration for patients with frequent filter clotting or when extracorporeal clearance is limited by achievable blood flow 1

Dosing and Monitoring

• Prescribe CRRT dose before starting each session 1
• Deliver an effluent volume of 20-25 mL/kg/h for CRRT in AKI 1, 2
• Prescribe 25-30 mL/kg/h to account for treatment interruptions and declining filter efficiency 2
• Frequently assess actual delivered dose to adjust prescription as needed 1
• Monitor for filter performance and adjust prescription to achieve goals of:
  • Electrolyte balance 1
  • Acid-base balance 1
  • Solute clearance 1
  • Fluid balance 1
• Avoid volume overload, especially in patients with acute lung injury 1
• Use integrated fluid balancing systems rather than intravenous infusion pumps adapted for CRRT 1

CRRT Modality Selection

• Use CRRT rather than standard intermittent RRT for:
  • Hemodynamically unstable patients 1
  • Patients with acute brain injury or increased intracranial pressure 1
• Consider CRRT and intermittent RRT as complementary therapies based on patient needs 1
• For transitioning from CRRT to intermittent dialysis, consider accelerated venovenous hemofiltration (AVVH) with higher hemofiltration rates (4-5 L/h) for shorter durations (8-10 h) 4

Catheter Care

• Do not use topical antibiotics over the skin insertion site of nontunneled dialysis catheters 1
• Do not use antibiotic locks for prevention of catheter-related infections 1

Common Pitfalls to Avoid

• Failing to account for treatment interruptions when prescribing CRRT dose 2
• Using subclavian veins for access due to risk of thrombosis and late stenosis 1
• Relying on single BUN and creatinine thresholds alone for initiating RRT instead of considering broader clinical context 1
• Using diuretics to enhance kidney function recovery or reduce duration/frequency of RRT 1
• Using lactate-buffered solutions in patients with liver failure or lactic acidosis 1
• Inadequate monitoring of calcium levels when using regional citrate anticoagulation 5