937 Nurse Responsibilities and Clinical Decision-Making When Caring for Critically Ill Pediatric Patients Requiring Continuous Renal Replacement Therapy

Abstract

Continuous renal replacement therapy (CRRT) is a valuable treatment tool for critically ill pediatric patients suffering from acute renal failure. CRRT can be easily initiated with less intravascular fluid shifts in critical patients who may be prone to hemodynamic instability. PICU nurses are responsible for set-up, initiation, maintenance and troubleshooting of CRRT. They are intricately involved in clinical decision-making and adjustments based on laboratory results and fluid balance. CRRT is utilized on approximately 20 patients annually in the 20-bed pediatric intensive care unit (PICU). Standardized orders allow nurses to adjust citrate and calcium chloride based on laboratory values. Nurses calculate total fluids (including intermittent medications, nutrition, flushes and continuous drips) in a 24-hour period and adjust fluid removal rate based upon a determined net fluid goal. Nurses are also responsible for the CRRT machine intra-operatively during orthotopic liver transplantation. Patients with severe hepatic disease requiring liver transplantation are at risk for acute kidney injury. These patients receive large amounts of volume during the operative period and aggressive management of fluid status appears to improve outcomes. Maintaining even or negative fluid balance may be beneficial in a recent 2009 adult study. Care of the patient in the PICU and management of the CRRT machine is the responsibility of the bedside nurse. All charge nurses and ECMO certified nurses are also expected to remain competent in CRRT management. Conclusion: Protocol- driven CRRT program in a high-volume critical care setting can be successfully run by nurse professionals in an efficient and safe manner.