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Managing severe acute kidney injury demands a nuanced understanding of renal replacement therapies. Among the options, including intermittent hemodialysis and prolonged intermittent renal replacement therapy, continuous renal replacement therapy (CRRT) emerges as a preferred modality in various clinical scenarios. A multinational study revealed that CRRT is utilized in 75.2% of intensive care unit visits. CRRT, involving continuous solute removal and fluid balance techniques, employs 3 distinct modalities: continuous venovenous hemofiltration, continuous venovenous hemodialysis, and continuous venovenous hemodiafiltration. CRRT's indications span volume overload, electrolyte disturbances, and uremia complications. This intervention excels in managing hemodynamically unstable patients, allowing controlled fluid management and mitigating risks associated with rapid solute changes. Collaboration in CRRT implementation involves critical nephrology specialists, a proficient CRRT nursing team, and interdisciplinary cooperation. Recognizing associated risks, including intravascular line complications and therapy-related electrolyte disturbances, underscores the importance of a comprehensive approach. CRRT demands an interprofessional healthcare team, incorporating critical care, nephrology, neurology, nursing, pharmacy, and nutrition, each playing a crucial role in patient care, safety, and therapeutic success. This activity for healthcare professionals is designed to enhance learners' proficiency in identifying patients with indications for CRRT and administering the intervention properly. Participants gain a comprehensive understanding of CRRT's underlying principles, optimal dosing, and potential complications. Learners acquire the skills and competencies necessary to deliver high-quality CRRT, equipping them to collaborate effectively within an interprofessional team and optimize outcomes for patients with acute or chronic kidney injury. Objectives: Identify patients with continuous renal replacement therapy indications based on clinical evaluation and diagnostic test results. Determine the most suitable continuous renal replacement therapy modality for a patient with kidney failure. Evaluate continuous renal replacement therapy effectiveness to allow for therapy optimization.

Identify patients with continuous renal replacement therapy indications based on clinical evaluation and diagnostic test results. Determine the most suitable continuous renal replacement therapy modality for a patient with kidney failure. Evaluate continuous renal replacement therapy effectiveness to allow for therapy optimization. Implement effective interprofessional communication practices to optimize outcomes for patients on continuous renal replacement therapy. Access free multiple choice questions on this topic.

Various renal replacement therapies (RRTs) are available for managing severe acute kidney injury (AKI), including intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), and prolonged intermittent RRT. Decisions about technique are dictated by the dialysis indication, clinician preference, outcome data, and, most importantly, hemodynamic status.[1] A 2015 multinational cross-sectional epidemiological study of patients with AKI in intensive care units (ICUs) revealed that CRRT was the preferred treatment modality in 75.2% of sessions, compared to intermittent dialysis in 24.1% of sessions and peritoneal dialysis in 0.7% of sessions.[2] CRRT comprises techniques that manage solute removal and fluid balance over 24 hours. CRRT filters blood through a semipermeable membrane using various solute transport mechanisms. The specific mechanism defines each CRRT type. The 3 CRRT techniques are continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF).

As in every procedure, CRRT has risks that should be communicated to the patient or family during treatment planning. First, the risks associated with intravascular lines include hemorrhage, arteriovenous fistula formation, infection, and thrombosis. The risks of the therapy itself include electrolyte disturbances, clearance of trace elements or antibiotics, hypothermia, and hypotension. Although hypotension occurs less commonly than in IHD, blood pressure changes may occur if the net ultrafiltration rate exceeds the intravascular refilling rate. The electrolyte and acid-base status should be monitored every 6 to 12 hours when starting CRRT. The interval may be increased to 12 to 24 hours if the condition remains stable after the first 24 to 48 hours. As discussed above, the exception is when using citrate as regional anticoagulation, which requires frequent ionized calcium level monitoring. Hypocalcemia, hypokalemia, and hypophosphatemia are the commonly managed electrolyte imbalances with CRRT. The degree of deficiency depends on the CRRT dose delivered. In the Randomized Evaluation of Normal versus Augmented Level Replacement Therapy, hypophosphatemia was a reported electrolyte abnormality in 65% of patients undergoing high-intensity CRRT. This electrolyte deficiency can be managed with intravenous or oral repletion, enteral feed fortification, or the use of a phosphate-containing dialysate or replacement solution.[25] Medication clearance during CRRT is variable. Thus, the doses of required drugs must be checked when administering CRRT. Trough concentrations of these medications determine their bactericidal or bacteriostatic effectiveness. The most clearance-susceptible during CRRT are water-soluble antimicrobials, aminoglycosides, and β-lactam antibiotics.[26] Many patients who meet CRRT indications are septic, meaning that appropriate antibiotic dosage is vital. CRRT also often results in amino acid, micronutrient, and water-soluble vitamin loss. Patients are likewise often in a substantial negative nitrogen balance. Appropriate caloric and protein intake with supplementation of water-soluble vitamins should be ensured. Meanwhile, the risks associated with using an extracorporeal circuit include hypersensitivity to the circuit, air embolization, and blood loss during filter or circuit changes.

CRRT requires an interprofessional healthcare team approach to be provided safely and efficiently. The modality involves the collaboration of specialties, including critical care, nephrology, and neurology, on essential elements such as the timing of initiating a clearance mode, solute and fluid removal targets, and anticoagulation strategies. All clinicians involved in the case, including nurse practitioners and physician assistants, must contribute to care. Nursing is vital during CRRT as nurses have the most exposure to the vascular access site, the CRRT circuit, and the patient. Nursing staff and patient care technicians should be aware of complications to allow timely intervention and communication with the clinician team regarding the event. Additionally, pharmacists and nutritionists are vital to ensure proper medication doses and nutrition while on CRRT. Pharmacists should offer insights on CRRT's impact on the patient's medication regimen and therapeutic outcomes, collaborating with the team to adjust drug therapy as needed. With this team approach and adequate education for each member, CRRT may be delivered as safely and effectively as possible.[30]

The following actions are expected from the interprofessional team: Collaboration between clinician teams Defining CRRT's primary goal Ensuring adequate access, machine, and anticoagulation to maintain high-functioning CRRT with minimal disruptions Ensuring appropriate nutrition support

The following variables must be monitored closely while patients are on CRRT: CRRT prescription and response Aappropriateness of medication dosing Lab results and circuit performance to detect CRRT complications