ส่วนที่ 1 ข้อมูลเอกสาร
| ชื่อ CNPG | การพยาบาลผู้ป่วย CRRT (Continuous Renal Replacement Therapy) |
|---|
| วัตถุประสงค์ | ให้การดูแลผู้ป่วยที่ได้รับ CRRT อย่างปลอดภัย ลดภาวะแทรกซ้อน |
|---|
| มาตรฐานอ้างอิง | KDIGO AKI 2012, ADQI Consensus, ELSO Guidelines |
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ส่วนที่ 2 CRRT Modalities
| Modality | Mechanism | Used for |
|---|
| CVVH | Convection (ultrafiltration + replacement) | Volume + moderate solute |
| CVVHD | Diffusion (dialysate countercurrent) | Small solute removal (urea, Cr) |
| CVVHDF | Both convection + diffusion | Combined (most common) |
| SCUF | Ultrafiltration only | Volume removal in CHF |
ส่วนที่ 3 Prescription
3.1 Typical Prescription
| Parameter | Value |
|---|
| Effluent dose | 20-25 ml/kg/hr (delivered) |
| Blood flow rate (Qb) | 150-250 ml/min |
| Ultrafiltration rate | Depends on fluid balance goal |
| Replacement fluid | Bicarbonate-based (Hemosol B0) |
| Dialysate | Bicarbonate-based |
| Anticoagulation | Regional citrate preferred |
3.2 Regional Citrate Anticoagulation (RCA)
- Citrate infusion at pre-filter → binds ionized Ca²⁺ → no clotting
- Calcium infusion at post-filter (return to patient)
- Monitor post-filter ionized Ca (0.25-0.35 mmol/L) — check q 6h
- Monitor systemic ionized Ca (1.0-1.2 mmol/L) — check q 6h
- Risk: Citrate accumulation (liver failure), metabolic alkalosis/acidosis
ส่วนที่ 4 Nursing Care
4.1 Circuit Setup
- Prime circuit with NSS 2L (per manufacturer)
- Connect vascular access (dialysis catheter — non-tunneled/tunneled)
- Verify flow direction, no air in circuit
- Double-check fluid bags (replacement, dialysate, effluent)
4.2 Hourly Monitoring
- V/S: BP, HR, SpO₂, temp
- Circuit pressures: Access, return, pre-filter, TMP
- Fluid balance: Effluent out, replacement in, net UF
- Access/return lines: No kinks, secure
- Alarms: Troubleshoot immediately
4.3 Laboratory Monitoring
| Lab | Frequency |
|---|
| Electrolytes, BUN/Cr | q 6-12h |
| ABG + Lactate | q 6-12h |
| Systemic + Post-filter iCa | q 6h (citrate) |
| Mg, Phos | q 12-24h |
| CBC, Coag | Daily |
| Filter life / clotting | Continuous |
ส่วนที่ 5 Complications
5.1 Filter Clotting
- TMP rise, low effluent flow
- Causes: inadequate anticoagulation, access problem, high Hct
- Action: Troubleshoot, change circuit if needed
5.2 Hypothermia
- Common due to cold fluids
- Use blood warmer, warm patient (Bair Hugger)
- Monitor core temp
5.3 Electrolyte Imbalance
- Hypophosphatemia common — add PO₄ to replacement
- Hypomagnesemia — supplement
- Hypokalemia — adjust K+ in fluids
5.4 Catheter-Related Issues
- Poor flow: repositioning, flush (no force)
- Infection: CLABSI prevention bundle
- Thrombosis: may need tPA flush
ส่วนที่ 6 Drug Dosing
- Adjust doses for dialytic clearance
- Consult pharmacist for antibiotics (Vancomycin trough, aminoglycoside levels)
- Water-soluble vitamins replaced
KPIs
| KPI | Target |
|---|
| CRRT prescribed dose vs delivered | > 85% |
| Filter life (citrate) | > 48 ชั่วโมง (mean) |
| CLABSI rate | < 1 per 1,000 catheter-days |
| Hypothermia incidence | < 10% |
References
- KDIGO. (2012). Clinical Practice Guideline for Acute Kidney Injury.
- Bagshaw, S.M., et al. (2020). Timing of initiation of renal-replacement therapy in AKI (STARRT-AKI). NEJM.
- Ronco, C., et al. (2019). Continuous renal replacement therapy. Lancet, 394(10193).
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