The impact of "early" versus "late" initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis.

BACKGROUND: The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of "early" versus "late" RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic. METHODS: A literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to "early" versus "late"/"standard" criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Thirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with "early" RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384-1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of "early" (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies. CONCLUSIONS: Our conclusion based on this evidence synthesis is that "early" initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.

Development of Online Learning Modules as an Adjunct to Skills Fairs and Lectures to Maintain Nurses' Competency and Comfort Level When Caring for Pediatric Patients Requiring Continuous Renal Replacement Therapy (CRRT).

Continuous renal replacement therapy (CRRT) for pediatric patients is an extremely specialized therapy requiring knowledge of the patient's diagnosis, understanding of the principles of the therapy, astute patient assessment, and proficiency with complicated equipment. The complexity of CRRT is compounded by its relatively rare occurrence, in the pediatric population. Maintaining staff competency with this high-risk/low-volume therapy is extremely difficult. This article discusses the development and implementation of a structured system and set of resources to support routine education, and the development of two online, interactive learning modules to provide additional exposure to GRRT throughout the year. The modules are an efficient, effective, and inexpensive way to provide additional education and information to large groups of staff.

Using High-Fidelity Simulation to Assess Knowledge, Skills, and Attitudes in Nurses Performing CRRT.

Continuous renal replacement therapy (CRRT) is an acute therapy for critically ill patients. There are many life-threatening complications that can occur; therefore, it is imperative that nurses are highly trained in the use and troubleshooting of CRRT. A structured simulation exercise was added to an existing CRRT education program by developing and implementing an annual assessment of knowledge, skills, and attitudes (KSAs) using high-fidelity simulation. The use of high-fidelity simulation as an intervention during annual evaluation of KSAs was shown to be effective in increasing nurse satisfaction, understanding of CRRT principles, and critical thinking skills with the operation of CRRT.

[Psychological experiences and coping strategies of children and adolescents with chronic kidney disease on renal replacement therapy]. / Psychische Belastungen und Coping- Strategien von niereninsuffizienten Kindern und Jugendlichen unter Nierenersatztherapie.

Children, adolescents and young adults with end-stage renal disease need a renal replacement therapy (dialysis) or a renal transplant to survive. The dialysis is related to a very complex care, which includes invasive and painful procedures. Chronic diseases have a strong influence not only on the physical but also on the psychological development of children and adolescents. The most important psychological consequences include social isolation, differences in body image, limited lifestyle, as well as the changed personal relationships with family and friends. Therefore, caregivers should also have knowledge about the psychological consequences, being able to provide adequate help and support to children, adolescents and young adults.

[Update in continuous renal replacement techniques]. / Actualización en técnicas continuas de reemplazo renal.

Acute renal failure affects 25% of patients hospitalized in intensive care units. Despite technological advances, the mortality of these patients is still high due to its associated complications. Continuous renal replacement techniques are one of the treatments for acute renal failure because they make it possible to treat the complications and decrease mortality. The nurse's knowledge and skills regarding these techniques will be decisive for the success of the therapy. Consequently, the nurse's experience and training are key components. The objective of this article is to update the knowledge on continuous renal replacement techniques. Keeping this in mind, a review has been made of the physical and chemical principles such as diffusion and convection, among others. A description of the different continuous renal replacement techniques, a presentation of the main vascular access, and a description of the nursing cares and complications related to techniques used have also been provided.

Nursing issues in renal replacement therapy: organization, manpower assessment, competency evaluation and quality improvement processes.

For the patient with acute kidney injury, continuous renal replacement therapy (CRRT) is a treatment option that has application for the hemodynamically unstable critically ill patient. The decision to initiate a continuous renal replacement modality depends not only on the physician, either the nephrologist or intensivist, but also on the availability of specially trained nursing resources. This article will explore the nursing collaborative model of care at a large university-based research and teaching Medical Center in Southern California. The focus will be on nursing issues in CRRT including organization of educational programs, manpower assessment, competency evaluation, and quality improvement processes.

[Critical care nurse learning of continuous renal replacement therapy: the efficacy of a self-learning manual].

BACKGROUND: Many nurses have difficulty learning to use the complex, non-traditional, and regularly-updated critical care equipment. Failure to use such equipment properly can seriously compromise treatment and endanger patient health and lives. New self-learning materials for novice nurses are necessary to provide essential and effective guidance as a part of formal nursing training. Such materials can enhance the capabilities of critical care nurses and, thus, improve the general quality of critical care. OBJECTIVES: The purpose of this research was to develop a continuous renal replacement therapy (CRRT)-themed self-learning manual that would provide easily absorbed and understood knowledge in an easy-to-carry format for ICU nursing staff. This study also investigated CCRT skill learning efficacy. METHODS: This study adopted a quasi-experimental design with pretests and posttests. Purposive sampling generated a sample of 66 critical care nurses currently working at one hospital in Taipei City. Participants submitted a completed self-assessment survey that rated their command of continuous renal replacement therapy before and after the self-learning manual intervention. Survey data were analyzed using SPSS Version 17.0 for Windows. FINDINGS: The two major findings derived from the study included: (1) The mean response score from the self-assessment survey filled out after the intervention was 91.06 and 79.75 (SD = 9.49 and 11.65), respectively, for experimental and control groups. Such demonstrated significant difference. (2) The mean posttest score after the intervention for the experimental group was 91.06 ± 9.49. This represents a significant increase of 10.35 ± 10.35 over their mean pretest score (80.71 ± 11.82). The experimental group showed other significant differences in terms of the CRRT self-assessment survey posttest. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Self-learning manuals may be introduced in nursing education as useful aids and catalysts to achieve more effective and satisfying learning experiences.

Considerations in the care of older adult with chronic kidney disease.

The incidence of renal disease is increasing at alarming rates. Older adults with co-morbid conditions are at increased risk for end stage renal disease with the resulting need for renal replacement therapy. Nurses who care for the older adult must know how chronic kidney disease will affect the older adult and must be able to provide compassionate care at the end stage of life.

Clinical nursing for the application of continuous renal replacement therapy in the intensive care unit.

Treatment of critically ill patients with continuous renal replacement therapy (CRRT) requires a set of new skills and knowledge base for the intensive care unit (ICU) nurse. After a decision to treat is made, nurses effectively manage the technique by following a series of steps in sequence. These sequential steps include patient and machine circuit preparation, connection of the extracorporeal circuit (EC) to the patient's vascular access, and nursing management of a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine "vital signs," and, when necessary, diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential for a successful CRRT nursing policy or protocol. This chapter provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Nursing for renal replacement therapies in the Intensive Care Unit: historical, educational, and protocol review.

Nurses have made a significant contribution to the development and application of dialysis in the 1950s and continuous renal replacement therapies (CRRT) in the Intensive Care Unit (ICU) setting from the 1980s. Any treatment requires patient and machine-circuit preparation, connection of the extracorporeal circuit (EC) to the patient vascular access catheter and regular tasks to maintain a treatment in progress. During treatment, nurses prepare fluids, adjust fluid settings to provide fluid balance, prepare electrolyte additives, monitor acid base and electrolyte levels, monitor patient and machine 'vital signs', and then when necessary diagnose circuit clotting and perform a disconnection of the EC from the patient. All of these aspects of CRRT nursing are essential to a suitable nursing policy or protocol. This paper provides a clinical review for this every day sequence when using CRRT in the ICU setting.

Clinical review: Patency of the circuit in continuous renal replacement therapy.

Premature circuit clotting is a major problem in daily practice of continuous renal replacement therapy (CRRT), increasing blood loss, workload, and costs. Early clotting is related to bioincompatibility, critical illness, vascular access, CRRT circuit, and modality. This review discusses non-anticoagulant and anticoagulant measures to prevent circuit failure. These measures include optimization of the catheter (inner diameter, pattern of flow, and position), the settings of CRRT (partial predilution and individualized control of filtration fraction), and the training of nurses. In addition, anticoagulation is generally required. Systemic anticoagulation interferes with plasmatic coagulation, platelet activation, or both and should be kept at a low dose to mitigate bleeding complications. Regional anticoagulation with citrate emerges as the most promising method.

Getting to know you: a national view of acute renal care.

The American Nephrology Nurses' Association's (ANNA's) newest Special Interest Group (SIG) is Acute Care. This SIG recently developed a survey to obtain information about the practice areas from acute care ANNA members as there is a lack of data about this subset of nephrology nurses. The survey was designed to begin to explore the practice of acute care nurses and was distributed via e-mail to 1000 ANNA members who are registered acute care nephrology nurses. There were 246 responses to the survey. While the tool was not developed and confirmed as a reliable and valid tool, it was a first attempt to describe this population of nephrology nurses. Results of this survey of acute care nurses were presented at the Acute Care SIG networking session during the ANNA National Symposium in Dallas, Texas in April, 2007 The presentation, "Getting to Know You: A National View of Acute Renal Care," was presented by Acute Care SIG Members' Mary Rose Kott, MS, RN, CNN; Sue Fallone, MS, RN, CNN; Helen Williams, BSN, RN, CNN; Maureen Craig, MS, RN, CNN, CCNS; Billie Axley, BSN, RN, CNN; and Michelle Krueger, BSN, RN, CNN. The results are highlighted here.

The organisation of paediatric renal care in different European countries: results of the PAC project.

The Paediatric Access Care (PAC) project, organised by the Research Board of EDTNA/ERCA, aimed to study the organisation of paediatric renal care in Europe and to investigate the practice of access care for both haemodialysis (HD) and peritoneal dialysis (PD) paediatric patients. This paper reports on the organisation of paediatric renal care. The majority of paediatric renal care units were located in specific paediatric units of university hospitals. Most of the centres had offered HD, PD and transplantation (Tx) for more than 20 years. Half of nursing staff had qualifications in paediatric and renal nursing. Most of the centres offered an extended multidisciplinary team approach with the family actively involved in the care of the patient. PD and HD were equally used. Automatic Peritoneal Dialysis (APD) was offered as the standard PD treatment in 2 out of 3 centres. The HD schedule mostly utilised was 3 x 4 hours a week. Half of the patients were on the Tx waiting list and one third of registered patients were transplanted in 2004.

Management of pediatric patients with chronic kidney disease.

Chronic kidney disease in children is associated with complications that require nursing interventions in both the inpatient and outpatient settings. Given the progressive nature of the disease and the complexity of the treatment regimen, it is important that nurses be comfortable implementing acute and preventive care strategies and facilitating the coordination of care. In addition, the need for multiple therapies can be distressing for patients and their families, further supporting the role of the nurse in patient and family education and decision making regarding the plan of care. In this review, we discuss the pertinent issues of pediatric chronic kidney disease in the context of a case study to promote better understanding of real-world nursing practice.

Potassium additive algorithm for use in continuous renal replacement therapy.

The performance of continuous renal replacement therapy (CRRT) brings about alterations in the serum potassium levels in patient. Potassium is an electrolyte essential for the regulation of nerve conduction and muscle contraction, particularly important in the case of cardiac muscle. This article describes the physiological mechanisms that affect potassium distribution throughout the body and also describes the effects of hypokalaemia or hyperkalaemia on the heart. This article justifies the need for serum potassium control during CRRT, which recognizes and reconciles the differing areas of responsibility of the medical and nursing staff. This article critically reviews the steps taken to develop and implement into clinical practice and evaluate a potassium additive algorithm. It also discusses the implications of this initiative.

Continuous venovenous renal replacement therapy in critically ill patients: A work load analysis.

OBJECTIVES: To evaluate the nursing workload related to two techniques of continuous renal replacement therapy. RESEARCH METHODOLOGY: We analysed retrospectively the nursing work load caused directly by continuous renal replacement therapy in a cohort of patients admitted consecutively over 10 months. Two types of continuous renal replacement therapy have been compared: dialysis with regional citrate anticoagulation and haemodiafiltration with systemic heparin coagulation. SETTING: Academic Hospital Intensive Care Unit. MAIN OUTCOME MEASURES: The nursing workload was defined by the time spent in the management of continuous renal replacement therapy, including preparation of the circuit and related biological controls. RESULTS: 60 patients underwent a total of 202 sessions of continuous renal replacement therapy. The nursing workload as expressed as % time of nursing care was similar (12.3 [9.4-18.8] vs 13.4 [11.7-17.0] %, for haemodiafiltration and dialysis respectively, P=0.06). However, the distribution of the nursing workload is different: the bigger proportion of care is circuit preparation in haemodiafiltration and biology control in dialysis. CONCLUSIONS: Nursing time dedicated to continuous renal replacement therapy is similar whatever the renal replacement therapy technique. However, a longer duration of the filter and a better circuit predictability with dialysis and citrate anticoagulation are potential benefits for nursing workload.

Continuous Renal Replacement Therapy (CRRT) practices in Canadian hospitals: Where are we now?

BACKGROUND: Acute kidney injury (AKI) is a common complication in critically ill patients. Renal replacement therapy is prescribed for as many as 70% of critically ill patients in AKI and may be provided in the form of intermittent or continuous dialysis including intermittent hemodialysis, sustained low-efficiency dialysis, and continuous renal replacement therapy (CR RT). CRRT is commonly used for unstable critically ill patients, as it involves a slow continuous process. The nursing work involved with CR RT is highly complex and the learning requirements are challenging; therefore, it is important to identify nursing practices. PURPOSE: A national survey was conducted to gain insight into CRRT nursing practices. METHODS: T he design for this study was descriptive using a survey The target population for this survey was ICU nurse educators at Canadian teaching and community hospitals. Topics in the survey included staff education, CRRT ordering and initiation practices, vascular access, filters and filter life, fluids used, anticoagulation methods, adverse events, and greatest concerns. FINDINGS: One hundred and twenty-nine surveys were sent out and 73 were returned for a response rate of 57%. Thirty-six hospitals used CRRT and of these, 73% had used CR RT for more than eight years. The findings revealed that educators identified achieving and maintaining competence as their greatest concern related to CRRT practices. CONCLUSION: The fndings of this research revealed that consistent training programs were not the norm. The complexity of caring for patients on CRRT requires consideration of when to introduce to staff the technology and care of patients on CRRT and how to sustain their competence.

Renal replacement therapy choices for pre-dialysis renal patients.

With the numbers of patients developing end-stage renal failure predicted to increase over the coming years, more patients than ever will be expected to choose their future form of renal replacement treatment. This study explored the decision-making processes of pre-dialysis patients to elucidate how these choices were made. Nine pre-dialysis patients were interviewed, transcripts of which were analysed using interpretative phenomenological analysis. Four main themes relating to the decision-making process emerged: maintaining one's integrity, forced adaptation, utilizing information, and support and experiencing illness. While making a decision was an individualized process, contextualized within participants' illness experiences, these core themes emerged for the whole group, irrespective of the chosen treatment modality. For renal services, there is a need to tailor information provided to pre-dialysis patients and to become cognizant of the contexts in which they live and operate.

[Demands on professional nursing staff in institutions for dialysis from the view of male and female patients--the results of a survey by means of Critical Incident Technique]. / Anforderungen an Pflegende in Dialyseeinrichtungen aus Sicht von Patientinnen und Patienten--Ergebnisse einer Befragung mittels Critical Incident Technique.

Contemporary models of competence in nursing are usually based on the questioning of nursing staff and therefore reflect their professional self-image. Our research focuses on the views of male and female patients on the relevant competencies of professional nursing staff. The "Critical Incident Techniqu" (CIT) (Flanagan, 1954) was applied to reveal relevant demands according to the patients' point of view. This technique has proven to be a suitable method for the reflection of nursing practice in this field of research and has provided realistic descriptions of staff behaviour. Nursing in the field of dialysis was chosen because of the specialized qualifications on staff needed and the high expectations assumed in this care. The CIT-interviews of one female and five male patients were transcribed and the content was analysed. Two main fields of demands were identified: "soft skills" and "hard skills". The patients especially stressed the demands on communicative and empathic competence ("soft skills"). Further research may be useful to validate the results with a larger sample.

[The impact of continuous renal replacement therapy training on nursing competence]. / Impact d'une formation en épuration extrarénale continue sur la compétence infirmière.

Specific training adapted to the needs of caregivers in intensive care enables professional competence and quality of care to be developed in continuous renal replacement therapy. In addition, it contributes to reducing the stress felt by caregivers and the costs of this technique.