CRRT technology and logistics: is there a role for a medical emergency team in CRRT?

Implementing continuous renal replacement therapy (CRRT) in a intensive care unit (ICU) is a somewhat difficult issue and quiet different from starting a new ventilation mode or a new hemodynamic device. It may indeed require an on-call medical emergency CRRT team as expertise in this field is really a key issue to success. Education for the nursing team is another key point, especially as ongoing or continuous education is changing very quickly. Uniformity of the type of device used is another crucial part in the organization process with regard to CRRT implementation in the ICU. Involvement of both the ICU and nephrology teams is another key to success especially when different modes and higher exchange rates are used. Also, a nursing group devoted to the ongoing implementation and education of the ICU team is very useful in order to attain the goals that have been set. Already in 1984 acute renal failure was described as one of the remaining and challenging problems in the ICU. Hemodialysis was not always feasible then because of the hemodynamic instability of critically ill patients. Under those circumstances continuous arteriovenous hemofiltration (CAVH) was advocated as an efficient alternative method with less detrimental hemodynamic effects. At the time it was thought that CAVH would be found to be an effective 'artificial kidney' (control of body fluid, electrolyte and acid-base homeostasis and uremia) and this without serious side effects. But already nearly 25 years ago, it was found that continuous anticoagulation was a major problem that could cause life-threatening complications in posttraumatic and surgical patients. At the time, it was thought that running a protamine infusion on the venous line would help to diminish these complications. CRRT has been carried out in our ICU since 1985, first with CAVH and since 1989 with some early forms of continuous veno-venous hemofiltration (CVVH). The unit has used BSM 22, BM 25 and Prisma for nearly 10 years, and Aquarius since the end of 2001. The educational process started at the beginning of 1990 with the implementation of CVVH using BSM 22 and BM 25. Very soon it was realized that a new strategy implementing pulse high-volume hemofiltration (pulse-HVHF) was really needed. Therefore, a nursing group composed of 5-8 nurses who would be taught beforehand was started, and this dedicated group would then teach the rest CRRT Technology and Logistics 355 of the staff nurses. This group exists today and has at least 6-8 meetings/year in which all the problems that must be faced in the implementation of CRRT are dealt with. Here all the steps made by our and other units in this field will be discussed, including an overview of the various protocols implemented and a description of our dedicated nursing group with regard to CRRT.