Continuous Renal Replacement Therapy Liverpool SSWAHS

Liverpool Health Service 

Intensive Care Unit 

Self Directed Learning Package: 

Continuous Renal Replacement Therapy 

Written by: Nicholas Mifflin & Sharon-Ann Shunker

How to use this package 

This package is designed to be used in the clinical area as a self directed 

learning tool. 

The package is divided into sections. At the end of each section is a self test 

to determine how well you have understood the information contained in 

that section. You will need to complete the self tests at the end of each 

section and ensure that you have mastered the content before moving on to 

the next section. 

If you have any trouble with the self test, go back over the section and revise 

the content. If you are still unsure then you will need to speak with one of 

the educators in your area. 

The answers to each of the self test questions are contained at the end of the 

package. To gain the most benefit from this package attempt the questions 

first before seeking this reference. 

GOOD LUCK!!!

Learning package objectives 

By the completion of this package, the registered nurse will be able to: 

1. Define and classify acute renal failure according to its aetiology 

2. Identify the signs and symptoms of acute renal failure 

3. Discuss the various modalities of renal replacement therapy including 

advantages and disadvantages 

4. Identify the indications for continuous renal replacement therapy 

5. Describe the basic principles of fluid and waste removal involved in 

CRRT 

6. Describe the various modes of CRRT 

7. Recognise the importance of access in CRRT 

8. Explain the process for troubleshooting a vascath 

9. Differentiate solutions used for CRRT 

10. Discuss the safety precautions required for commencing CRRT 

11. Differentiate pre dilution from post dilution 

12. State the complications of CRRT 

13. Describe methods that optimise clearance of fluid and waste 

14. Describe methods of prolonging filter life 

15. Discuss the indications for ceasing therapy 

16. Recognise common reasons for CRRT machine alarms 

17. Discuss the nursing management of the patient on CRRT

A Brief Look at Renal Anatomy & Physiology 

Structures of the Renal System: 

Adrenal Gland 

Kidney 

Ureter 

Bladder 

Urethra 

Cross Section of the Kidney: 

The renal system is comprised of the 

Kidneys and those structures including 

the ureters, bladder and urethra that 

form the urinary system. 

The primary role of the kidneys is to 

remove metabolic wastes and maintain 

fluid and electrolyte balance. The 

kidneys also have a role in: 

• Blood Pressure Control 

• Red Blood Cell Synthesis 

• Bone Metabolism 

• Acid- Base Balance 

Renal dysfunction can negatively impact 

on all of these roles. 11 

The kidneys are situated in the 

retroperitoneum located between T12 

and L3 on each side of the vertebral 

column. 12 

Two layers form them internally. The 

outer layer is the Cortex that contains: 

• Glomeruli 

• Proximal Tubules 

• Cortical Portions of Loops of 

Henle 

• Distal Tubules 

• Cortical Collecting Ducts 11,12 

The inner layer or Medulla is comprised 

of Renal Pyramids. The pyramids 

contain: 

• Medullary portions of Loops of 

Henle 

• Medullary Portions of Collecting 

Ducts 12 

Multiple pyramids taper and join 

forming a minor calyx. Several 

combined make a major calyx. The 

major calyces join and enter a funnel 

shaped renal pelvis that directs urine 

into the ureter. 11

Components of the Nephron: 

Urine Formation: 

Three processes required for urine formation include: 

• Glomerular Filtration 

• Tubular Reabsorption 

• Tubular Secretion 11,12 

Approximately one million nephrons 

comprise each kidney. The nephron 

consists of: 

• Glomerulus 

• Bowman Capsule 

• Proximal Convoluted Tubule 

• Loop of Henle 

• Distal Convoluted Tubule 

• Collecting Duct 11,12 

There are two types of nephron: 

• Cortical Nephrons 

• Juxtamedullary Nephrons 11 

Cortical Nephrons: 

• Approximately 85 % 

• Perform excretory and regulatory 

functions 11 

Juxtamedullary Nephrons: 

• Approximately 15 % 

• Responsible for concentration and 

dilution of urine 11 

Glomerulus 

• Filters fluid and solutes from blood 

Proximal Convoluted Tubule 

• Reabsorbs Na +, K +, Cl -, HCO3 -, urea, glucose & amino 

acids 

• Filtrate Continues 

Loop of Henle 

• Reabsorbs Na +, K + & Cl - 

• Blocks reabsorption of H2O 

• Dilutes/Concentrates Urine 


Distal Tubule 

• Na +, K +, Ca ++, PO4 selectively reabsorbed 

• H2O reabsorbed in presence of Antidiuretic Hormone 

(ADH) 


Collecting Duct 

• Reabsorption similar to distal tubule 

• HCO3 - & H - reabsorbed/secreted to acidify urine 

• Filtrate leaves hyperosmotic/hypoosmotic depending on 

the body’s requirements 11,12

Composition of Urine: 

H2O 

Electrolytes- Na +, K +, Cl -, HCO3 - 

End products of protein metabolism- urea, creatinine, PO4, SO4 

End products of nucleic acid metabolism- uric acid 

Breakdown products of phosphoric and sulphuric acid 

H + ions excreted bound to buffers such as PO4 and NH3 11 

Renal Anatomy & Physiology in Summary: 

• Kidneys filter blood of waste products 

• Functional units of the kidneys are called nephrons 

• Nephrons consist of a glomerulus, tubule and collecting duct 

• Urine is formed through glomerular filtration, tubular reabsorption 

and tubular secretion 

• Urine moves from the collecting duct via the renal pelvis and ureters 

into the bladder, where it is excreted from the body through the 

urethra 

• Some substances are reabsorbed into the blood and others excreted 

into the filtrate

Self Test 1 

Q1. State the primary and secondary functions of the kidneys. 

Q2. Name the functional units of the Kidneys and list their components. 

Q3. Discuss the processes involved in urine formation

Summary of Acute Renal Failure 

Definition: 

Acute renal failure (ARF) is a clinical syndrome, characterised by an 

abrupt decline in glomerular filtration rate (GFR). There is a subsequent 

retention of metabolic waste products and an inability to maintain 

electrolyte and acid-base homeostasis. Regulation of fluid volume is 

also affected. 1,7,8,16,18,23 

ARF occurs rapidly resulting in fifty percent or more nephrons to lose 

function, and as this occurs quickly the body is unable to compensate. 

There are three classifications of ARF based on the location of the cause. 23 

Prerenal 

Renal dysfunction is largely related to systemic factors that limit blood flow 

and reduce glomerular filtration rate. Examples include: 

• Hypotension 

• Hypovolaemic shock- dehydration, blood loss 

• Cardiogenic shock – post MI 

• Septic Shock 

• Bilateral renal vascular obstruction- thrombosis 1,8,9,16,18,23 

Intrarenal 

Renal impairment occurs secondary to damage that is sustained at the site 

of the nephrons. This may be the result of a number of conditions or 

nephrotoxins: 

• Acute Tubular Necrosis (ATN) 

• Acute Glomerulonephritis 

• Acute Pyelonephritis 

• Acute Cortical Necrosis 

• Malignant Hypertension 

• Acute Vasculitis 

• Rhabdomyolysis - drugs, trauma 

• Nephrotoxins - IV contrast, aminoglycosides 1,8,9,16,18,23 

Postrenal 

Renal failure secondary to obstruction that prevents excretion of urine 

• Prostatic Hypertrophy 

• Renal Calculi 

• Tumour 

• Blocked Urinary Catheter 1,8,9,16,18,23

Signs & Symptoms 

• Fluid and electrolyte abnormalities 

• Metabolic acidosis 

• Anaemia 

• Pruritis secondary to uremic frost 

• Nausea & vomiting 

• Confusion 

• ↓LOC 

• Congestive heart failure resulting in acute pulmonary oedema 1,8,16,18,23

Self Test 2 

Q1. Define Acute Renal Failure 

Q2. Describe 3 forms of acute renal failure and the associated causes 

Q3. List the signs and symptoms of acute renal failure

Renal Replacement Therapy 

Renal replacement therapy (RRT) is an extracorporeal technique of blood 

purification. Blood passes over a semipermeable membrane (filter) allowing 

solutes and water to cross over to a collection side. There are various 

modalities included under the umbrella of RRT. 19 

Continuous Modalities (CRRT) 

• Haemofiltration 

• Haemodialysis 

• Haemodiafiltration 

• Ultrafiltration 

Advantages: 

• Better for haemodynamic instability 

• Readily accessible 

• Effective fluid removal and clearance of solutes 

• Can be performed by ICU staff rather than specialised renal nurses 

2,4,5,9,17,20 

Disadvantages: 

• Patient mobilisation is limited 

• Access complications 

• Anticoagulation 

• Reduced blood flow rates secondary to small filters when compared to 

IHD 2,4,5,9,17,20 

Intermittent Haemodialysis (IHD) 

Advantages: 

• Quick and effective 

• Large amounts of fluid and solutes can be removed over a short 

period 5,9 


• Access Complications- formal access such as A.V. Fistula is 

eventually required 

• Requires specialised staff and is therefore not readily accessible 

• May not be well tolerated by haemodynamically unstable patients 

• Intermittent fluid removal with IHD can be associated with fluid 

overload and increased electrolytes between treatments 5,9 

Peritoneal Dialysis 

This form of dialysis utilises the peritoneum as the semipermeable 

membrane. 

Advantages: 

• Comparatively Cheaper 

• No anticoagulation required

• No haemodynamic instability 5,9,24 


• High incidence of peritonitis 

• Slow clearance 

• Access – Formal access required (Tenkhoff catheter) 

• Limitations on patient as it is required frequently 5,9,24

Continuous Renal Replacement Therapy (CRRT) 

Indications 

• Fluid Overload, pulmonary oedema 

• Worsening Metabolic Acidosis 

• Hyperkalaemia 

• Worsening Azotaemia 

• Drug overdoses 

• Removal of toxins 9 

Basic Principles 

The basic principles incorporated in the function of CRRT involve: 

• Convection 

• Diffusion 

• Ultrafiltration 

• Hydrostatic Pressure 2,4,9,17,20 

Terminology 

Diffusion 

The movement of small and middle molecule solutes from an area of high 

concentration to low concentration across a semipermeable-membrane. 5,9 

Osmosis 

The movement of water from an area of high water concentration to an area 

of lower water concentration across a semi-permeable membrane. 5,9 

22 

22

Ultrafiltration 

The movement of water and solutes across a semipermeable membrane by 

solvent drag created by convection and hydrostatic pressure. 5,9 

Convection 

Water flow across a semi-permeable membrane by hydrostatic pressure that 

drags solutes with it (the way a waterfall moves pebbles and sand) 9 

Hydrostatic Pressure 

The force that pushes fluid and solutes across the membrane. The 

mechanical blood pump on the dialysis machine creates this. 5,9 

Oncotic Pressure 

Plasma proteins including albumin, globulin and fibrinogen create the 

pulling pressure that favours fluid retention and opposes hydrostatic 

pressure. 5,9 

Counter Current 

The flow of two fluids in opposing directions. The direction of dialysis flows 

opposite to that of blood flow maximising the concentration difference 

between blood and dialysate. 5 

Dialysate 

A synthetic solute free solution used to achieve diffusive solute clearance 5 

Effluent 

Erroneous term used to indicate the solute and solvent discarded form the 

patient. 9 

Replacement 

Pre or post dilution fluid 

Pre-dilution 

Administration of the replacement fluid into the circuit prior to the filter 5,9 

Post-dilution 

Administration of replacement fluid into the circuit after the filter 5,9 

22

Modalities 

• Slow Continuous Ultrafiltration (SCUF) 

• Continuous Arterio/Venovenous Haemofiltration (CAVH/CVVH) 

• Continuous Arterio/Venovenous Haemodialysis (CAVHD/CVVHD) 

• Continuous Arterio/Venovenous Haemodiafiltration 

(CAVHDF/CVVHDF) 

SCUF 

Slow Continuous Ultrafiltration is the method used when fluid removal is 

the only objective. Dialysate and replacement fluids are not utilised. 

Maximum fluid removal is 2000ml/hr. 2,17,20 

SCUF System Setup 13 

= pump 

CAVH/CVVH 

Continuous Venovenous Haemofiltration uses convective clearance to 

remove water and solutes. Replacement is used to replace ultrafiltrate. 


CVVH System Setup 13 

= pump

CAVHD/CVVHD 

Continuous Venovenous Haemodialysis uses diffusion to remove fluid and 

solutes. Dialysate is pumped in a counter current to blood flow. Maximum 

fluid removal is 1000ml/hr. 2,17,20 

CVVHD System Setup 13 

= pump 

CAVHDF/CVVHDF 

Continuous Venovenous Haemodiafiltration utilises both convection and 

diffusion to remove fluid and solutes. Dialysate and replacement is used. 


CVVHDF System Setup 13 

= pump

CRRT Modality Summary 2,17,20 

Mode Filtering Process Removes Indication 

Slow Continuous 

Ultra Filtration 

(SCUF) 

Continuous 

Arterio/Venovenous 

Haemofiltration 

(CAVH/CVVH) 



Haemodialysis 

(CAVHD, CVVHD) 



Haemodiafiltration 

(CAVHDF/CVVHDF 

Convection- 


Convection- 


Diffusion 

Convection & 

Diffusion 

Fluid, Minimal 

solutes 

Fluid removal. 

Moderate solute 

removal. Urea 

clearance 

approximately 15- 

17ml/min 

Fluid removal. More 

aggressive solute 

removal. Urea 

clearance 


21ml/min. 

Maximum fluid and 

solute removal. Urea 

clearance 


26ml/min. 

NB: There are other forms of CRRT however the above are most 

applicable to LHS 

Fluid Overload 

Heart failure 

Moderate electrolyte 

imbalances 

Oliguria with 

parenteral nutrition 

or blood 

requirements 

Septic Shock 

Fluid overload with 

haemodynamic 

instability 

Azotaemia 

Electrolyte 

disturbance and 

acidosis 

Parenteral nutrition 

accompanying fluid 

overload 

Fluid Overload, 

pulmonary oedema 

Worsening Metabolic 

Acidosis 

Hyperkalaemia 

Worsening Azotaemia 

Drug overdoses 

Removal of toxins

Self Test 3 

Q1. What is renal replacement therapy? 

Q2. List advantages and disadvantages of continuous modalities compared 

to other forms of RRT 

Q3. List Indications for CRRT 

Q4. Describe the basic principles of fluid and solute removal involved in 

CRRT. 

Q5. Describe the different modes of CRRT.

Vascular Access 

Good access that allows high flow rates through the circuit is one of the key 

aspects in CRRT that effects blood flow, clearance and filter life. 

Catheters 

Blood Flow is proportional to the diameter of the catheter- i.e. the wider the 

tube the better the blood flow. 3,4 Therefore the largest diameter catheter 

should be utilised. Vascaths available in Liverpool ICU include. 

• Gambro- 13fr ( 15cm &20cm) 

• Niagra- 13.5Fr (15cm & 24cm) 

• Gambro- 12Fr (15cm & 20cm) 

• Arrow Triple Lumen- 12 Fr (20cm) 

Lumens are colour coded being red and blue. The red lumen is the arterial 

port also known as the access port. This lumen supplies blood from the 

patient to the filter. The blue lumen is the venous port also known as the 

return port. Blood is returned via this lumen from the filter to the patient. 

Differentiating these lumens is necessary when troubleshooting access or 

return pressure alarms on the CRRT machines. 5 

Catheter Location 

Typically the vessels utilised for vascaths are the Internal Jugular, Femoral 

and Subclavian veins. The choice of catheter site is dependant on many 

factors including: 

• Skill of the accessing clinician 

• Size of the patient 

• Mobility of the patient 

• Anticipated Duration of therapy 

• Presence of other intravenous lines 

• Coagulopathy 3,4 

Internal Jugular Vein 

Advantages: 

• Allows for patient mobility 

• Easy to visualise insertion site 


• Requires Chest Xray prior to use 

• Kinking can occur when the patient moves their head 

• Sometimes attains insubstantial blood flows secondary to variations 

in central filling and intrathoracic pressures. Positive pressure 

ventilation can make this more apparent. 3,4,5

Femoral Vein 

Advantages: 

• Easily accessible by most clinicians 

• May allow greater blood flows 


• Prone to kinking, more so in the obese patient 

• Does not allow for patient mobility 

• Difficult to visualise and dress insertion site 

• Higher incidence of infection secondary to the proximity to intestinal 

flora. 3,4,5 

Subclavian Vein 

Advantages: 


• Easy to visualise and dress insertion site 



• Risk of pneumothorax on insertion 

• Risk of subclavian stenosis, which can impair suitability for an A-V 

fistula on the affected side, if renal failure becomes chronic. 



ventilation can make this more noticeable. 3,4,5 

Nursing Care for the Access Device 

• Regularly inspect insertion site for signs of infection, haematoma and 

bleeding 

• Apply standard precautions and aseptic technique whenever 

connecting or disconnecting lines to and from the catheter 

• Clean catheter and site with 0.5% chlorhexidine once weekly and prn 

using an aseptic technique and cover with an occlusive dressing (IV 

3000) 

• When catheter is not in use lumens should be “Heparin-Locked” to 

prevent clotting within the catheter 5 

NB: Form more information on care of a vas cath see policy- 

management of central venous access devices in appendix 

Heparin-Lock for a Vas-Cath 

• Apply standard precautions and utilise aseptic technique 

• Using 3 ampoules of 5000 units heparin in 1ml (15000 units/3ml) 

inject the stated amount (located on each port) of this solution into 

the Vas Cath port. Label lumens as Heparin Locked 9,10

Troubleshooting Access Device 

Where the CRRT machine exhibits high-pressure alarms the problem may 

stem from a malfunctioning catheter. Assess catheter patency as follows: 


• Aspirate and flush 10ml of blood on the effected lumen to test 

resistance to blood flow. Further, flush 10ml 0.9% sterile normal 

saline. 22 

Where resistance is present, a clot may be obstructing the catheter, but 

more likely it is positioned against the vessel wall. Slightly withdrawing or 

rotating the catheter may overcome this problem. Where this fails to resolve 

the problem the catheter must be changed. 5,9,21 

NB: Swapping the lumens- i.e. attaching the access line to the return port 

and visa versa may also overcome this problem, however this can result in a 

significant reduction in clearance and is therefore not recommended. It can 

be used as a temporary measure to overcome access problems. 9

Self Test 4 

Q1. What is the importance of adequate access? 

Q2. Sate the appropriate name and functions of the red and blue lumens on 

a vascath 

Q3. What are the three possible sites for vascath insertion? State the 

advantages and disadvantages of each. 

Q4. How would you troubleshoot a vascath? 

Q5. How would you heparin lock a vascath?

Preparation for Therapy 

Orders & Equipment 

• Obtain a complete and correctly filled order for CRRT using the ICU 

CRRT prescription form. NB: Pre dilution or Post dilution set 

• Obtain equipment according to ICU protocol Continuous Renal 

Replacement Therapy (CRRT) using the PRISMA MACHINE. NB: 

equipment for the PRISMA FLEX is identical except for the required 

set, compatible warming line and one extra bag of GAMBRO or 

HEMOSOL solution as ordered. 

Please read and become familiar with this protocol in conjunction 

with this package. (See appendix) 

Preparation of Fluids 

Losses in ultrafiltrate through CVVH and CVVHDF require replacing. 

Replacement fluid should be a balanced electrolyte solution that will offset 

the convective loss of electrolytes and plasma water during haemofiltration. 

As stated earlier, replacement fluid is a pre or post dilution fluid. The fluids 

available for such purpose in Liverpool ICU include HEMOSOL and 

GAMBRO. These fluids are also used as dialysate in modalities where 

diffusive clearance is also involved (CVVHDF, CVVHD). 3 To maintain acidbase 

balance, it is necessary for these fluids to contain base that will provide 

a buffer. Typically lactate serves this purpose as it is converted to 

bicarbonate in the liver. 4, GAMBRO is the fluid that contains lactate as 

its buffer. 

Lactate free solutions also exist where bicarbonate must be added 

immediately prior to use. 4, HEMOSOL is considered lactate free and thus 

requires the addition of bicarbonate prior to use. This is accomplished by 

breaking the seal within the bag to mix the solutions together. 

HEMOSOL is the fluid of choice where the patient is severely acidotic or 

suffering liver dysfunction that would prevent the metabolism of lactate to 

bicarbonate. Utilising GAMBRO in this circumstance may contribute to a 

worsening acidosis. 

Specific to Dialysate 

Both GAMBRO and HEMOSOL solutions require addition of KCL when used 

as dialysate. KCL is added to these fluids to reduce loss K + of through 

diffusion. 

NB: KCL is only added to these fluids when patient’s K + level is 

Procedure 

• GAMBRO- Add 15mmol K + to 5L (already contains 5mmol K +/ 5L) 

• HEMOSOL- Add 20mmol K + to 5L (Contains no K + ) 

Addition of K + in these quantities will make a final concentration of 4mmol 

K + /L. 9 

Priming The Circuit 

Both PRISMA and PRISMA FLEX machines contain on screen step by step 

instructions for setting up and priming the circuit. For further information 

on priming the PRISMA machine consult ICU protocol, Continuous Renal 

Replacement Therapy (CRRT) using the PRISMA MACHINE. Further 

information regarding the same processes for the PRISMA FLEX can be 

found in the operator’s manual located on the back of the machine. Failing 

this, please consult a senior staff member or educator that may assist you. 

Access 

Once the circuit is primed and ready to connect, 5ml of blood should be 

aspirated and discarded to remove heparin from the line. The vascath 

should then be checked for patency as described earlier in troubleshooting 

access device. It is important that therapy with a good circuit not be 

commenced on inadequate access. Circuits are expensive and poor access 

will significantly reduce its functional duration. Always apply aseptic 

technique when accessing catheter. 9

Commencing Therapy 

Providing access is adequate, access and return lines can be connected to 

the corresponding lumens of the vascath using standard precautions and 

aseptic technique. A full breakdown of this procedure is located in ICU 

protocol Continuous Renal Replacement Therapy (CRRT) using the PRISMA 

MACHINE. 

Connecting Patient to CRRT (Running pt on) 

• Once patient is connected select desired flow rates for Dialysate, 

Replacement, Blood Pump Speed, Ultrafiltrate/Fluid removal 

according to order (Commence blood pump at 80-100ml/hr and 

increase as tolerated by patient) 

• Assess patient’s haemodynamic status 

• Commence therapy 

• Administer 2500 units heparin bolus via the red port on the access 

line. Omit heparin bolus if patient is coagulopathic or has been on 

CRRT in the last 4 hours. 

• Monitor patient for haemodynamic instability for 15-30 minutes post 

commencing therapy. Patient may experience a transient drop in 

blood pressure, that will therefore require adjustment of pump speed 

to compensate, depending on the sensitivity of the patient. 9,21 

Safety 

• CRRT Machine should be plugged into an isolated power socket 

• When commencing therapy, colloid on a pump giving set should be 

connected to patient’s intravenous access 

• 10mg Metaraminol (Aramine) should be drawn up and readily 

available. 10mg of Aramine is prepared in 20ml of 0.9% sodium 

chloride. This in conjunction with colloid is precautionary, should the 

patient become hypotensive. If the patient is on inotropes, Aramine 

may not be necessary as blood pressure can be controlled with the 

existing inotropic drugs. 9,21 

Pre-dilution or Post-dilution 

Pre-dilution involves administering replacement fluid prior to the filter. This 

thereby reduces the viscosity of blood and hematocrit and in effect may aid 

in preventing filter clotting. Unfortunately this method also dilutes the 

concentration of solute in plasma, which can negatively impact on clearance. 

In order to optimise clearance of solutes, replacement rate must be 

increased in order to increase the rate of ultrafiltration. 3,9 

Post-dilution therefore involves administering replacement fluid after the 

filter. This does not dilute solutes in plasma, however the ability for optimal 

clearance is lost when blood viscosity is not reduced and high flow rates are 

then difficult to achieve. With reduced blood flow comes reduced 

ultrafiltration. Utilising filters with larger surface areas in conjunction with 

this method may improve clearance. 9

Complications 

• Hypotension that may result from aggressive fluid removal 

• Electrolyte imbalances 

• Cardiac Arrhythmias 

• Anaemia secondary to haemolysis of red blood cells 

• Thrombocytopaenia secondary to platelet aggregation in filter 

• Hypothermia secondary to extracorporeal blood circulation 

• Coagulopathy secondary to over heparinisation 

• Infection (line sepsis) 

• Heparin induced thrombocytopaenia 2,9,17,21

Self Test 5 

Q1. What is the purpose of dialysate and replacement fluids? 

Q2. State the two fluids available at Liverpool ICU for CRRT, including the 

major difference and the preparations required. 

Q3. How do you prepare the vascath prior to commencing CRRT with a new 

circuit? 

Q4. List the safety aspects of connecting and commencing therapy. 

Q5. Differentiate pre dilution from post dilution including benefits and 

disadvantages. 

Q6. List the complications of CRRT.

Optimising Clearance 

Regardless of which CRRT machine is being used, optimising clearance is 

dependant on two factors. These include improving diffusion and 

convection/ultrafiltration. 

Improving Diffusion 

Using filters with larger surface areas is one means of improving diffusion. 6 

Currently Liverpool ICU stock consists of M100 and ST 100 filter sets. The 

M100 circuits incorporate an AN69 hollow fiber filter. These filters are 

comprised of Acrylonitrile and sodium methallyl sulfonate copolymer and 

have a surface area of 0.9m 2. The ST 100 sets are similar but have a surface 

area of 1.0 m 2. The filter is comprised of identical materials, however also 

includes the surface treatment agent polyethylene imine. 14 This surface 

treatment aims to encourage heparin binding during priming that can 

ultimately reduce heparin requirements for anticoagulation of the circuit. 

This may also benefit patients who require heparin free dialysis. 15 

A second means of improving diffusion involves utilising an appropriate 

dialysate fluid. Eg. Withholding addition of KCL to dialysate fluid when the 

patient is hyperkalaemic so that serum potassium concentration remains 

higher than that in the dialysate. K + will therefore be filtered off the patient 

from an area of high to low concentration. 

Improving Convection/Ultrafiltration 

Improving convection/ultrafiltration is largely accomplished through high 

flow rates (Dialysate, Replacement, Ultrafiltration & Blood Pump). As 

mentioned earlier pre dilution assists in achieving higher flow rates by 

reducing the viscosity of blood and hematocrit. Location and care of the 

vascath is also shown to influence flow considerably. 6,9

Prolonging Filter Life 

Prolonging filter life simply refers to preventing the filter clotting and 

maintaining its functional ability to remove fluid and waste. Factors that 

prolong filter life include: 

• High blood flow rates 

• Pre dilution and warming of fluid 

• Adequate Access 

• Anticoagulation 3,4,9 

Anticoagulation 

• On priming the circuit 5000 units of heparin should be added to each 

1L bag of warmed normal saline 

• Unless the patient is coagulopathic or has been on CRRT in the past 4 

hours, 2500 units of heparin should be administered as a bolus, via 

the red pre filter port of the access line, as therapy is commenced. 

• A heparin infusion of 15000 units in 50ml 0.9% sodium chloride can 

be administered according to ICU HEPARIN SODIUM protocol for 

anticoagulation of the dialysis circuit via the designated anticoagulant 

line of the circuit. 

• Aim for a pre filter APTT (from pre filter port or arterial line/patient) 

between 30-40 seconds. 10 

NB: If patient is coagulopathic run heparin free CRRT- refer to 

protocol for further precautions. 

NB: Full information for anticoagulation of the dialysis circuit is available in 

ICU HEPARIN SODIUM protocol. Please read and become familiar with this 

protocol in conjunction with this package. (See appendix) 

Discontinuing CRRT (Running Patient Off) 

Refers to ending therapy either temporarily or permanently 

Indications 

• When indications for CRRT are no longer present 

• When return pressures are elevated associated with filter clotting 

• When alarms are indicating poor clearance 

• For procedures in theatre or CT 21

Procedure 

1. Observe standard precautions and aseptic technique. Use sterile gloves 

when disconnecting lines from the Vascath. 

2. Press 'stop' and choose to ‘end treatment’. The PRISMA will then prompt 

you to return blood to the patient after providing the following: 

• Attach a secondary giving set to 500mL bag of normal saline, add 

three-way tap to the end of this line and prime. 

• Connect the red ‘access’ line of the PRISMA circuit to the three-way 

tap, using aseptic technique. 

• Return blood by following on screen prompts 

• Remove circuit as per onscreen prompts. 

3. Flush each lumen of the Vascath with 10mL normal saline. 

4. Heparin Lock as per protocol 

NB: If only a temporary disconnection and filter is still viable then connect 

both lines to a three-way tap. Circuit can then be reconnected to patient as 

normal when recommencing therapy. 21

Self Test 6 

Q1. What factors need to be manipulated in order to optimise clearance? 

Q2. Describe methods of optimising clearance. 

Q3. List four factors that can prolong filter life. 

Q4. When would anticoagulation NOT be used? 

Q5. What are the indications for terminating therapy?

Common Alarms & Troubleshooting 

There are various alarms that occur on both CRRT machines available in 

Liverpool ICU. The most common are discussed. Troubleshooting options are 

available in operator’s manual and instruction cards attached to each 

machine. On screen prompts are also issued when alarms are triggered. 

Access Pressure High 

Possible Triggers include: 

• Red clamps closed 

• Blocked or kinked vascath secondary to clot or position 

• Blocked or kinked access line 

• High blood flow rate 

• High airway pressures 

• Patient coughing 9,13 

Return Pressure High 


• Blue clamps closed 

• Blocked or kinked vascath secondary to clot or position 

• Blocked or kinked return line 

• High airway pressures 

• Filter Clotting/Clotted 9,13 

Treatment obviously involves correcting the above problems. Where 

filter clotting is a possibility blood should be returned ASAP 

Access or Return Disconnect 

Triggered by low pressure in either of the lines. May indicate disconnection 

somewhere in the circuit. Check that all lines are connected securely. 

Air in Blood 


• Fluid level in bubble trap below sensor 

• Air in circuit 

• Incomplete priming 

• Return line not installed in Air detector 

• Dirty sensor 

• Leaking connection 9,13 

NB: This alarm must not be bypassed. It is a protective mechanism 

against the possibility of air embolism. Do not override until 

troubleshooting procedures in operator’s manuals have been fully 

followed. 9,13

There are many alarms that may be triggered during CRRT. If in doubt follow 

the on screen prompts or refer to the operator’s manual for guidance. Most 

alarms that occur will be related to the following: 

• Vascath obstruction due to position of patient 

• Access or return lines kinking or clotting 

• Bag placement on scales is incorrect 

• Clotting of the filter/circuit 

• Poorly placed blood leak detector 

• Air in the circuit 

• Periodic self test failure 9,13 

Diaphragm Reposition Procedure 

Performed if pod is accidentally 

removed or machine alarms 

indicating problem 

-ve Pods (Access & Effluent) 

• Stop Pump 

• Clamp line above & below 

pod 

• Remove pod & clean port 

• Inject maximum of 1cc 

normal saline into pod using 

20 g needle 

• Reinstall pod 

• Resume therapy 

+ve Pods (Filter & Return) 

• Same as above 

• Aspirate maximum of 1cc 

13 

13

Summary of Nursing Care for the Patient on CRRT 

• Continuous monitoring of haemodynamic parameters 

• Pressure area care and hygiene needs 

• Optimise blood pressure prior to commencing therapy 

• Colloid and Metaraminol precautions when running patient on 

• When anticoagulation is running an initial APTT should be checked 4 

hours after commencing therapy. 6 hourly APTT is attended thereafter 

and heparin infusion titrated according to protocol 

• Electrolytes, urea and creatine (EUC) and calcium, magnesium and 

phosphate (CMP) should be checked 2 hours after commencing 

therapy. 6 hourly EUC/CMP thereafter. Where electrolytes need 

replacing, do so in accordance with ICU electrolyte protocols. 

• Strict monitoring of fluid balance to prevent excessive fluid losses 

when removing fluid- this should monitored hourly and documented 

on CRRT observation chart to prevent incorrect fluid removal 

secondary to scale malfunction. 

• Attend CRRT observation chart monitoring pressures in particular 

that may warn of filter clotting or access problems 

• Monitor Vascath site for signs of infection. Clean and dress as 

required as earlier described. 

• Monitor patient’s temperature and actively warm using a bear hugger 

blanket if necessary 

• Maintain standard precautions and aseptic technique when priming, 

connecting, disconnecting the circuit. This also applies when 

changing fluids or disposing of ultrafiltrate 

• As with all intensive care patients the MFASTHUG pneumonic should 

be followed- i.e. Mouth care, Feeding, Analgaesia, Sedation, 

Thromboembolism prophylaxis, Elevated bed head, Stress ulcer 

prophylaxis and Glucose control + Gut- aperients etc 2,5,8,17,20

Self Test 7 

Q1. List the common triggers for alarms on the CRRT machines. 

Q2. How would you reposition the diaphragms on both positive and 

negative pressure pods when required? 

Q3. What nursing care is necessary for the patient undergoing CRRT?

Answers 

Self Test1 

Q1. State the primary and secondary functions of the kidneys. 

The primary role of the kidneys is to remove metabolic wastes and maintain 

fluid and electrolyte balance. The kidneys also have a role in Blood Pressure 

Control, Red Blood Cell Synthesis, Bone Metabolism and Acid- Base 

Balance. 

Q2. Name the functional units of the Kidneys and list their 

components. 

The functional units of the kidneys are known as nephrons. The nephron 

consists of a Glomerulus, Bowman Capsule, Proximal Convoluted Tubule, 

Loop of Henle, Distal Convoluted Tubule and Collecting Duct. 

Or 

Glomerulus, tubule and collecting duct. 

Q3. Discuss the processes involved in urine formation 

Three process involved in urine formation include Glomerular Filtration, 

Tubular Reabsorption and Tubular Secretion. Glomerular filtration occurs 

as blood passes through the glomerulus being filtered of fluid and solutes. 

Tubular reabsorption and secretion occurs progressively through the areas 

of the tubule. Fluid, electrolytes and waste products are excreted as filtrate 

depending on the body’s requirements. 

Self Test2 

Q1. Define Acute Renal Failure 

Acute renal failure (ARF) is a clinical syndrome, characterised by an abrupt 

decline in glomerular filtration rate (GFR). There is a subsequent retention of 

metabolic waste products and an inability to maintain electrolyte and acidbase 

homeostasis. Regulation of fluid volume is also affected. 

Q2. Describe 3 forms of acute renal failure and the associated causes 

Prerenal ARF is largely related to systemic factors that limit blood flow and 

reduce glomerular filtration rate. Related causes may include hypotension, 

hypovolaemic shock, cardiogenic shock, septic shock and thrombosis that 

results in bilateral renal vascular obstruction. 

Intrarenal ARF is the result of damage sustained at the site of the nephrons. 

This could be secondary to a number of conditions or nephrotoxins 

including: Acute tubular necrosis, acute glomerulonephritis, acute cortical 

necrosis, malignant hypertension, acute vasculitis, rhabdomyolysis, IV 

contrast and aminoglycosides.

Post renal ARF occurs secondary to obstruction that prevents excretion of 

urine. This may relate to prostatic hypertrophy, renal calculi, tumour or 

blocked urinary catheter. 

Q3. List the signs and symptoms of acute renal failure 

• Fluid and electrolyte abnormalities 

• Metabolic acidosis 

• Anaemia 

• Pruritis secondary to uremic frost 

• Nausea & vomiting 

• Confusion 

• ↓LOC 

• Congestive heart failure resulting in acute pulmonary oedema 

Self Test 3 

Q1. What is renal replacement therapy? 

Renal replacement therapy (RRT) is an extracorporeal technique of blood 

purification. Blood passes over a semipermeable membrane (filter) allowing 

solutes and water to cross over to a collection side. There are various 

modalities included under the umbrella of RRT. 

Q2. List advantages and disadvantages of continuous modalities 

compared to other forms of RRT 

Advantages: 

• Better for haemodynamic instability 

• Readily accessible 

• Effective fluid removal and clearance of solutes 

• Can be performed by ICU staff rather than specialised renal nurses 


• Patient mobilisation is limited 

• Access complications 


• Reduced blood flow rates secondary to small filters when compared to 

IHD 

Q3. List Indications for CRRT 

• Fluid Overload, pulmonary oedema 

• Worsening Metabolic Acidosis 

• Hyperkalaemia 

• Worsening Azotaemia 

• Drug overdoses 

• Removal of toxins

Q4. Describe the basic principles of fluid and solute removal involved in 

CRRT. 

Diffusion involves the movement of small and middle molecule solutes from 

an area of high concentration to low concentration across a semipermeablemembrane. 

Convection occurs with water flow across a semi-permeable 

membrane by hydrostatic pressure that drags solutes with it (the way a 

waterfall moves pebbles and sand). Ultrafiltration is the movement of fluid 

and solutes across a semipermeable membrane secondary to convection or 

hydrostatic pressure. Positive pressure pushes the fluid across where 

negative pressure pulls the fluid across. The force that pushes fluid and 

solutes across the membrane is known as hydrostatic pressure. The 

mechanical blood pump on the dialysis machine creates this. 

Q5. Describe the different modes of CRRT. 

Slow Continuous Ultrafiltration utilises convection and ultrafiltration to 

remove fluid. It is indicated for fluid overload. SCUF does not require 

dialysate or replacement fluids. 

Continuous Venovenous Haemofiltration incorporates convection and 

ultrafiltration to remove fluid and moderate solutes. Replacement fluid is 

used. This modality is indicated for moderate electrolyte imbalances, oliguria 

whilst receiving TPN or blood and for patients in septic shock. 

Continuous Venovenous Haemodialysis filters via diffusion. Fluid is removed 

together with more aggressive solute removal. Replacement fluid is not used. 

CVVHD is warranted for fluid overload with haemodynamic instability, 

Azotaemia, electrolyte disturbances and acidosis. 

Continuous Venovenous Haemodiafiltration uses both diffusive and 

convective processes. Both replacement and dialysate solutions are used for 

maximum fluid and solute removal. This mode of CRRT is indicated for fluid 

overload, pulmonary oedema, worsening metabolic acidosis, hyperkalaemia 

worsening Azotaemia, drug overdoses and removal of toxins 

Self Test 4 

Q1. What is the importance of adequate access? 

Good access that allows high flow rates through the circuit is one of the key 

aspects in CRRT that effects blood flow, clearance and filter life. 

Q2. State the appropriate name and functions of the red and blue 

lumens on a vascath 

The red lumen is the arterial port also known as the access port. This lumen 

supplies blood from the patient to the filter. The blue lumen is the venous

port also known as the return port. Blood is returned via this lumen from 

the filter to the patient. 

Q3. What are the three possible sites for vascath insertion? State the 

advantages and disadvantages of each. 

Internal Jugular Vein 

Advantages: 


• Easy to visualise insertion site 



• Kinking can occur when the patient moves their head 



ventilation can make this more apparent. 

Femoral Vein 

Advantages: 

• Easily accessible by most clinicians 

• May allow greater blood flows 


• Prone to kinking, more so in the obese patient 

• Does not allow for patient mobility 

• Difficult to visualise and dress insertion site 

• Higher incidence of infection secondary to the proximity to intestinal 

flora. 

Subclavian Vein 

Advantages: 


• Easy to visualise and dress insertion site 



• Risk of pneumothorax on insertion 

• Risk of subclavian stenosis, which can impair suitability for an A-V 

fistula on the affected side, if renal failure becomes chronic. 



ventilation can make this more apparent. 

Q4. How would you troubleshoot a vascath? 

Using aseptic technique, assess catheter patency by aspirating and flushing 

10ml of blood on the effected lumen to test resistance to blood flow. Further, 

flush 10ml 0.9% sterile normal saline. Where resistance is present, a clot

may be obstructing the catheter, but more likely it is positioned against the 

vessel wall. Slightly withdrawing or rotating the catheter may overcome this 

problem. Where this fails to resolve the problem the catheter must be 

changed. The lumens may be swapped, however this is only a temporary 

measure as there is a loss in clearance. 

Q5. How would you heparin lock a vascath? 


• Using 3 ampoules of 5000 units heparin in 1ml (15000 units/3ml) 

inject the stated amount (located on each port) of this solution into 

the Vas Cath port. Label lumens as Heparin Locked 

Self Test 5 

Q1. What is the purpose of dialysate and replacement fluids? 

Dialysate fluid is used as a means to encourage diffusive clearance. 

Replacement fluid is a pre or post dilution fluid used to replace losses in 

ultrafiltrate. 

Q2. State the two fluids available at Liverpool ICU for CRRT, including 

the major difference and the preparations required. 

GAMBRO is the fluid that contains lactate as its buffer. HEMOSOL is 

considered lactate free and thus requires the addition of bicarbonate prior to 

use. This is accomplished by breaking the seal within the bag to mix the 

solutions together. Both GAMBRO and HEMOSOL solutions require addition 

of KCL when used as dialysate. 15mmol K + is added to 5L of GAMBRO. 

20mmol K + is added to 5L of HEMOSOL. Both make a final concentration of 

4mmol K + /L. KCL is added to these fluids to reduce loss K + of through 

diffusion. 

Q3. How do you prepare the vascath prior to commencing CRRT with a 

new circuit? 

Once the circuit is primed and ready to connect, 5ml of blood should be 

aspirated and discarded to remove heparin from the line. Assess catheter 

patency by aspirating and flushing 10ml of blood on the effected lumen to 

test resistance to blood flow. Further, flush 10ml 0.9% sterile normal saline. 

Q4. List the safety aspects of connecting and commencing therapy. 

• CRRT Machine should be plugged into an isolated power socket 

• When commencing therapy, colloid on a pump giving set should be 

connected to patient’s intravenous access 

• 10mg Metaraminol (Aramine) should be drawn up and readily 

available. This in conjunction with colloid is precautionary, should 

the patient become hypotensive. Inotropes can be titrated for control 

of hypotension, if the patient is on them rather than utilising 

Aramine.

Q5. Differentiate pre dilution from post dilution including benefits and 

disadvantages. 

Pre-dilution involves administering replacement fluid prior to the filter. This 

thereby reduces the viscosity of blood and hematocrit and in effect may aid 

in preventing filter clotting. Unfortunately this method also dilutes the 

concentration of solute in plasma, which can negatively impact on clearance 

by reducing the diffusion gradient. In order to optimise clearance of solutes, 

replacement rate must be increased in order to increase the rate of 

ultrafiltration. 

Post-dilution therefore involves administering replacement fluid after the 

filter. This does not dilute solutes in plasma, however the ability for optimal 

clearance is lost when blood viscosity is not reduced and high flow rates are 

then difficult to achieve. With reduced blood flow comes reduced 

ultrafiltration. Utilising filters with larger surface areas in conjunction with 

this method may improve clearance. 

Q6. List the complications of CRRT. 

• Hypotension that may result from aggressive fluid removal 

• Electrolyte imbalances 

• Cardiac Arrhythmias 

• Anaemia secondary to haemolysis of red blood cells 

• Thrombocytopaenia secondary to platelet aggregation in filter 

• Hypothermia secondary to extracorporeal blood circulation 

• Coagulopathy secondary to over heparinisation 

• Infection 

• Heparin induced thrombocytopaenia 

Self Test 6 

Q1. What factors need to be manipulated in order to optimise 

clearance? 

Regardless of which CRRT machine is being used, optimising clearance is 

dependant on two factors. These include improving diffusion and 

convection/ultrafiltration. 

Q2. Describe methods of optimising clearance. 

Using filters with larger surface areas and appropriate dialysate fluid can 

optimise diffusive clearance. Improving clearance via 

convection/ultrafiltration is largely accomplished through high flow rates 

(Dialysate, Replacement, Ultrafiltration & Blood Pump). Pre dilution assists 

in achieving higher flow rates by reducing the viscosity of blood and 

hematocrit. Location and care of the vascath is also shown to influence flow 

considerably.

Q3. List four factors that can prolong filter life. 

• High blood flow rates 

• Pre dilution and warming of fluid 

• Adequate Access 


Q4. When would anticoagulation NOT be used? 

Anticoagulation is not used if the patient is coagulopathic. A heparin bolus 

is not given if the patient has had CRRT within the last 4 hours. 

Q5. What are the indications for terminating therapy? 

• When indications for CRRT are no longer present 

• When return pressures are elevated associated with filter clotting 

• When alarms are indicating poor clearance 

• For procedures in theatre or CT 

Self Test 7 

Q1. List the common triggers for alarms on the CRRT machines. 

• Vascath obstruction due to position of patient 

• Access or return lines kinking or clotting 

• Bag placement on scales is incorrect 

• Clotting of the filter/circuit 

• Poorly placed blood leak detector 

• Air in the circuit 

• Periodic self test failure 

Q2. How would you reposition the diaphragms on both positive and 

negative pressure pods when required? 

If the pump has not stopped with an alarm, it should first be stopped. Apply 

clamps above and below the affected pod. Remove the pod and clean the 

port. If the pod is negative (Access & Effluent), inject a maximum of 1cc 

normal saline using a 20g needle into the pod. Conversely, if the pod is 

positive then a maximum of 1cc should be aspirated from the pod. Following 

this step the pod can be reinstalled into the appropriate port and therapy 

resumed. 

Q3. What nursing care is necessary for the patient undergoing CRRT? 

• Continuous monitoring of haemodynamic parameters 

• Pressure area care and hygiene needs 

• Optimise blood pressure prior to commencing therapy

• Colloid and Metaraminol precautions when running patient on 

• When anticoagulation is running an initial APTT should be checked 4 

hours after commencing therapy. 6 hourly APTT is attended thereafter 

and heparin infusion titrated according to protocol 

• Electrolytes, urea and creatine (EUC) and calcium, magnesium and 

phosphate (CMP) should be checked 2 hours after commencing 

therapy. 6 hourly EUC/CMP thereafter. Where electrolytes need 

replacing, do so in accordance with ICU electrolyte protocols. 

• Strict monitoring of fluid balance to prevent excessive fluid losses 

when removing fluid- this should monitored hourly and documented 

on CRRT observation chart to prevent incorrect fluid removal 

secondary to scale malfunction. 

• Attend CRRT observation chart monitoring pressures in particular 

that may warn of filter clotting or access problems 

• Monitor Vascath site for signs of infection. Clean and dress as 

required as earlier described. 

• Monitor patient’s temperature and actively warm using a bear hugger 

blanket if necessary 

• Maintain standard precautions and aseptic technique when priming, 

connecting, disconnecting the circuit. This also applies when 

changing fluids or disposing of ultrafiltrate 

• As with all intensive care patients the MFASTHUG pneumonic should 

be followed- i.e. Mouth care, Feeding, Analgaesia, Sedation, 

Thromboembolism prophylaxis, Elevated bed head, Stress ulcer 

prophylaxis and Glucose control + Gut- aperients etc

References 

1. Agraharkar, M., Gupta, R., Agraharkar, A., & Workeneh, B.T. (2006). 

Acute renal failure, [Online]. Available: 

http://www.emedicine.com/med/topic1595.htm [2006, 

September 13]. 

2. Astle, S. (2001). A new direction for dialysis. RN. 64(7), 56-60, 62 

3. Baldwin, I., Bridge, N., Elderkin, T. (1998). Nursing issues, practices 

and perspectives for the management of continuous renal 

replacement therapy in the intensive care unit. In Bonett, J., 

Hattley, S., & Bastick, M. Continuous renal replacement 

information package. A quick guide to CRRT. (pp1-41) Gosford: 

NSCCH. 

4. Bellomo, R., Baldwin, I., Ronco, C. (2001). Atlas of haemofiltration. In 

Bonett, J., Hattley, S., & Bastick, M. Continuous renal replacement 

information package. A quick guide to CRRT. (pp1-41) Gosford: 

NSCCH. 

5. Bonett, J., Hattley, S., & Bastick, M. (2005). Continuous renal 

replacement information package. A quick guide to CRRT. (pp1- 

41) Gosford: NSCCH. 

6. Brunet, S., Leblanc, M., Geadah, M., Parent, D., Courteau, S., & 

Cardinal, J. (1999). Diffusive and convective solute clearances 

during continuous renal replacement therapy at various 

dialysate and ultrafiltration flow rates. Am J Kidney Dis. 34, 

486-492. 

7. Cannon, J.D. (2004). Recognizing chronic renal failure…the sooner 

the better. Nursing, 2004, 34(1), 50-53. 

8. Campbell, D. (2003). How acute renal failure puts the brakes on 

kidney function. Nursing 2003. 33(1), 59-64. 

9. Castro, P., & Shunker, S. (No date). Continuous renal replacement 

therapy. Workshop handout. Liverpool: LHS. 

10. Crawley, T. Shunker, S. & Edgtton-Winn, M. (2004). Heparin sodium. 

ICU protocol. Liverpool: LHS.

11. Glann, J.K. (2002). Renal disorders and therapeutic management. In 

Urden, L.D., Stacy K.M., Lough, M.E. (Eds). Thelan’s critical 

care nursing- diagnosis and management. (pp745-777). St 

louis: Mosby. 

12. Henke, K. (2003). Renal physiology. Dimensions of Critical Care 

Nursing 22(3), 125-132. 

13. Hospal. (2000). Prisma system operator’s manual, Gambro Dasco 

14. Hospal. (No date) Renal intensive care- PRISMA. Filter instruction 

Guide, Gambro. 

15. Hospal (No date). AN69ST membrane- the bioactive membrane 

[Online]. Available: http://193.15.174.148/index.html. 

16. Kaplan, A.A. (2003). Renal failure. In F.S. Bongard, & D.Y. Sue. 

Current critical care diagnosis & treatment (2 nd Ed.). [Online]. 

Available: 

http://online.statref.com/TOC/TOC.aspx?FxId=5&SessionId=7 

A4937EMGZBYBIEJ 

17. Kaplow, R., & Barry, R. (2002). Continuous renal replacement 

therapies: a more gentle blood filtering technique allows for 

fewer complications. American Journal of Nursing. 102(11), 26- 

33. 

18. Lameire, N., Van Biesen, W., & Vanholder, R. (2005). Acute renal 

failure. The Lancet. 365(9457), 417. 

19. Medtel. (No date). Kimal- Continuous renal replacement therapy 

workbook. In Bonett, J., Hattley, S., & Bastick, M. Continuous 

renal replacement information package. A quick guide to CRRT. 

(pp1-41) Gosford: NSCCH. 

20. Paton, M. (2003). Continuous renal replacement therapy: slow but 

steady. Nursing 2003. 33(6), 48-50 

21. Sommer, N., Edgtton-Winn, M., & Shunker, S. (2004). Continuous 

renal replacement therapy (CRRT) using the prisma machine. 

ICU protocol. Liverpool: LHS

22. Toltec International. (2006). How haemodialysis works. [online] 

Available: http://www.toltec.biz/how_hemodialysis_works.htm 

(December, 2006). 

23. Ward, K. (2005). Kidneys don’t fail me now. Nursing Made Incredibly 

Easy. 3(2), 18-26 

24. Zabat, E. (2003), When your patient needs peritoneal dialysis. Nursing 2003, 

33(8), 52-54.

Appendix

Continuous Renal Replacement Therapy Liverpool SSWAHS

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