PLACE LABEL HERE
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
VENO-VENOUS ORDERS
for Nx Stage System
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Mode: q CVVH (Continuous Veno-venous Hemofiltration)
q CVVHD (Continuous Veno-venous Hemodialysis)
q SCUF (Slow Continuous Ultrafiltration): q Continuous q 8 hrs
2. Filter: Nx Stage Cartridge Express with pre-filter
3. Blood Flow Rate: q 250-300 ml/min q 300-350 ml/min q Other: ______ml/min
4. Therapy Fluid
q B Braun Bicarbonate 35 Dialysate (2 K/3 Ca) 5 Liter:
K+ 2 mEq/L, Ca++ 3 mEq/L, Na+ 140 mEq/L, Mg++ 1 mEq/L, Chloride 111 mEq/L, Bicarbonate 35 mEq/L, Glucose 1 gm/L
q B Braun Bicarbonate 35 Dialysate (4 K/3 Ca) 5 Liter:
K+ 4 mEq/L, Ca++ 3 mEq/L, Na+ 140 mEq/L, Mg++ 1 mEq/L, Chloride 113 mEq/L, Bicarbonate 35 mEq/L, Glucose 1 gm/L
q 3K solution: hang equal amounts of bags of 2 K/3 Ca and 4 K/3 Ca (listed above).
Example: hang 2 bags of 2 K and 2 bags of 4 K therapy fluid at the same time.
Therapy fluid rate: q 2 L/hr q 3 L/hr q Other: ______L/hr
5. q Set Ultrafiltration rate: ______ml/hr
OR
q Hourly net fluid balance: total input – (total output + ultrafiltration)
q Even
q Positive balance ______ml/hr
q Negative balance ______ml/hr
6. Anticoagulation:
NS 100 ml q 2 hr line rinse PRN, (increase UF an additional 50 ml/hr to remove rinse volume)
q Heparin Infusion Protocol: LOW Intensity, NO initial or prn bolus (form # 39815)
q Other: ______
7. Labs: (DO NOT DRAW LABS FROM CRRT LINES)
Pretreatment Renal Panel and Magnesium, PTT, and PT/INR, hepatitis profile, and hepatitis B antigen if not already
preformed today
After treatment initiated: Renal Panel, Magnesium, and ionized calcium 4 hrs after initiation then q 6 hrs x 24 hrs, then q 12 hrs while on CRRT
Other: ______
8. EFFLUENT: Visually inspect for blood. If pink or red, replace hemofilter immediately. Send specimen to lab for hemocult testing.
9. Intake and Output, including hourly fluid removed (ultrafiltration) q 1 hr
10. Record hourly net fluid removal on CRRT documentation flowsheet (seq # 40036)
11. NOTIFY NEPHROLOGIST for any of the following:
Copy to pharmacy Order writer’s initials ______
*3-40035* FORM 3-40035 REV. 08/2017 Page 1 of 2
PLACE LABEL HERE
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
VENO-VENOUS ORDERS
for Nx Stage System
· Filter clotting
· MAP < 65 mmHg
· HCO3 > 30 mEq/L or pH > 7.45
· Sustained BP < 90/60 mmHg
Copy to pharmacy Order writer’s initials ______
*3-40035* FORM 3-40035 REV. 08/2017 Page 1 of 2
PLACE LABEL HERE
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
VENO-VENOUS ORDERS
for Nx Stage System
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
12. MAP (mean arterial pressure): maintain > 65 mmHg. If MAP < 65 mmHg, use the following order of treatment
Decrease Ultrafiltration to keep hourly fluid balance positive
Albumin 25%, 25 gm (100 ml) IV bolus, may repeat X 1 dose after 2 hrs
Norepinephrine 4 mg/250 ml NS, titrate to MAP > 65 if no response to first dose of Albumin, and call physician
If MAP remains < 65 despite above interventions or unable to maintain ordered hourly net fluid balance, notify Nephrologist
If unable to achieve blood flow rate of 100 ml/hr, notify Nephrologist
13. Dialysis Catheter Flush/Lock:
Flush catheter at end of treatment with 0.9% Sodium Chloride 10 ml per port then instill with one of the following:
q Heparin 5,000 units/1 ml intracatheter to each lumen
Fill catheter lumen (QS with saline) to volume stated on catheter PRN to prevent catheter occlusion due to clotting Aspirate before use
q Sodium Citrate 4% intracatheter to each lumen
Fill catheter lumen to volume stated on catheter PRN to prevent catheter occlusion due to clotting
Aspirate before use.
q Cathflo (alteplase) 2 mg intracatheter to each lumen
Fill catheter lumen (QS with saline) to volume stated on catheter PRN to prevent catheter occlusion due to clotting Aspirate before use. (Pharmacy: send 2 vials)
14. If filter is clotting, if treatment is held or if new cartridge set-up is necessary (prior to cartridge expirations):
Return blood if possible and flush dialysis catheter as ordered in #13 above.
If system fails restart ASAP.
If restarted twice in one shift call nephrologist.
15. Electrolyte Replacement (via central access, not dialysis circuit) DELETE ALL PREVIOUS REPLACEMENT ORDERS
Potassium Replacement:
Serum Potassium (mEq/L) / Action< 3.5 / KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour X 3 (total 60 mEq)
3.5 - 3.9 / KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour X 2 (total 40 mEq)
4.0 - 4.2 / KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour
Magnesium Replacement:
Serum Magnesium (mEq/L) / Action< 1.5 / Magnesium sulfate 4 gm pre-mix IVPB over 2 hours
1.5 – 1.9 / Magnesium sulfate 2 gm pre-mix IVPB over 1 hour
Calcium Replacement:
Serum Ionized Calcium / Action< 0.7 / Calcium Gluconate 3 gm IVPB over 30 minutes
0.7-0.85 / Calcium Gluconate 2 gm IVPB over 30 minutes
0.86-1.10 / Calcium Gluconate 1 gm IVPB over 30 minutes
1.1-1.33 / Target range. Notify Nephrologist for ionized calcium > 1.4
Phosphorus Replacement: Call nephrologist for patient specific replacement orders.
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-40035 REV. 08/2017 Page 2 of 2