CRRT CHEAT SHEET
What is CRRT? Indications for CRRT
Continuous Renal Replacement Therapy (CRRT) is used
for critically ill patients with acute kidney injury/severe
kidney dysfunction among other reasons. General Indications for CRRT
It involves the continuous removal of waste products,
excess fluids, and electrolytes from the blood.
CRRT operates continuously, providing gradual and Volume Overload
precise fluid and solute balance adjustments. Drug/Toxin overdose
It is particularly beneficial for hemodynamically unstable
patients as it offers slower fluid removal and more Poor Kidney Function
tolerable renal support in the intensive care setting. Acid-Base Imbalances
More Specific Indications for CRRT
CVVH: Removes fluid and some
solutes. Uses replacement fluid.
CVVHD: Removes waste and Low urine output
corrects solutes. Uses dialysate.
CVVHDF: Removes waste and
Increased BUN/Cr
corrects solutes more Acute Kidney Injury
comprehensibly. Uses dialysate
and replacement fluid.
Increase Potassium: Hyperkalemia
SCUF: Slow removal of fluid Hypo/Hypernatremia
Pulmonary Edema
Third Spacing
Acidemia when pH is less than 7.1
Pericarditis (Uremic especially)
Encephalopathy
Principles of CRRT
1. Diffusion: Diffusion operates based on the principle of concentration gradients. As blood flows through a
semipermeable membrane in the dialysis filter, solutes like urea and creatinine move from areas of higher
concentration in the blood to areas of lower concentration in the dialysate fluid. This movement is driven by the
difference in solute concentrations across the membrane, facilitating the removal of waste products and helping
to restore proper electrolyte balance in patients with acute kidney injury.
2. Ultrafiltration: Ultrafiltration is another key principle alongside diffusion. It involves the removal of fluid from the
bloodstream through the semipermeable membrane of the dialysis filter. Pressure differentials across the
membrane drive the movement of water molecules, allowing excess fluid to pass from the blood into the
dialysate or replacement fluid. Ultrafiltration helps in controlling fluid overload, a common issue in critically ill
patients with kidney dysfunction
3. Convection: Convection involves the movement of solutes across a semipermeable membrane along with fluid
flow, driven by pressure differentials. As blood passes through the dialysis filter, solutes are carried across the
membrane with the ultrafiltrate, aiding in their removal from the bloodstream. Solute drag refers to the dragging
force exerted on solutes as they are carried along with the ultrafiltrate during convection
CRRT MODES
Continuous Veno-Venous Hemofiltration (CVVH)
Description: blood is pumped from a vein, passed Access Return
through a hemofilter to filter waste products and
remove excess fluids, and then the filtrate is
replaced with a balanced solution. CVVH provides Replacement
gentle fluid removal as well as some solute
removal and is suitable for hemodynamically Filter
unstable patients.
Principles Used: Ultrafiltration and convection. No Effluent
dialysate. Requires replacement fluid either pre- or
post filter.
Continuous Veno-Venous Hemodialysis (CVVHD)
Description: blood is pumped from a vein and Access Return
passed through a hemofilter. In CVVHD, the
hemofilter also allows for additional solute removal Dialysate
through diffusion via dialysate, making it effective
for patients with specific electrolyte imbalances
Filter
Principles Used: Diffusion, some ultrafiltration. No
Effluent
replacement fluid necessary.
Continuous Veno-Venous Hemodiafiltration (CVVHDF)
Description: This mode combines both Access Return
hemofiltration and hemodialysis, allowing for a
more comprehensive removal of waste products Dialysate
and solutes. It is suitable for patients with severe Replacement
kidney dysfunction and significant solute
imbalances. Filter
Principles Used: Ultrafiltration, Convection,
Effluent
Diffusion. Both dialysate and replacement fluid are
utilized.
Slow Continuous Ultrafiltration (SCUF)
Description: In SCUF, the emphasis is primarily on Access Return
fluid removal rather than solute clearance. It
involves the slow and continuous removal of
excess fluids without significant solute removal.
SCUF is useful for patients with fluid overload but
stable electrolyte levels. It provides a more gradual Filter
approach to fluid management, which can be
beneficial in certain clinical scenarios.
Effluent
Principles Used: Ultrafiltration, very little convection
CRRT TMP/PRESSURE DROP & ORDERS
Pressure Drop and Transmembrane Pressure(TMP)
1. Pressure Drop: In CRRT, pressure drop refers to the decrease in pressure that occurs as blood moves through the
circuit. This drop in pressure is influenced by various factors such as the diameter and length of the tubing, the
resistance within the filter, the viscosity of the blood, and the flow rate of the blood. A pressure drop is essential to
drive the movement of blood through the circuit and facilitate the filtration or dialysis process. However, excessive
pressure drop can indicate issues such as clotting within the filter, kinks or obstructions in the tubing, or
inadequate blood flow rates. Monitoring pressure drop helps ensure proper blood flow and effective therapy
during CRRT.
2. Transmembrane Pressure (TMP):TMP refers to the pressure gradient across the semipermeable membrane of the
filter used in CRRT. It represents the difference in pressure between the blood side and the filtrate (or dialysate)
side of the filter membrane. TMP is a critical parameter in CRRT because it drives the movement of fluid and
solutes across the membrane during filtration or dialysis. A sufficient TMP is necessary to achieve adequate
ultrafiltration rates and clear toxins and excess fluid from the patient's blood. However, excessively high TMP can
indicate issues such as filter clogging/clotting, membrane fouling, or excessive resistance within the circuit.
Healthcare providers monitor TMP closely during CRRT to ensure it remains within the optimal range for effective
therapy while minimizing the risk of complications such as filter clotting or hemolysis (rupture of red blood cells).
Anatomy of a CRRT Order
1. CRRT Mode: Specify the chosen CRRT mode. CVVH, CVVHD, CVVHDF, SCUF
2. Flow Rates: The prescription should indicate the desired flow rates for blood (QB) and effluent (QF). Blood flow
rate determines the amount of blood passing through the CRRT circuit per unit of time, and effluent flow rate
corresponds to the rate at which waste products and excess fluids are removed from the patient.
3. Replacement Fluid Rate (Qr): If the patient requires additional fluids, the Qr is prescribed to maintain fluid
balance.
4. Anticoagulation Protocol: Specify the anticoagulant agent, dosage, and mode of administration (e.g.,
continuous infusion) to prevent clotting in the CRRT circuit and filter.
5. Filter Type and Size: Specify the type and size of the hemofilter being used for the CRRT treatment.
6. Prescribed Effluent Composition: If using CVVHDF, the prescription may include the desired composition of the
effluent, including the concentration of bicarbonate, calcium, and other electrolytes.
7. Ultrafiltration Rate: Set the desired rate of fluid removal (ultrafiltration) based on the patient's fluid balance
requirements.
8. Monitoring Parameters: Indicate the target ranges for critical lab values (e.g., BUN, creatinine, potassium,
sodium, pH) to guide adjustments in the CRRT prescription.
CRRT COMMON ALARMS
“Access Extremely Negative”
Description: Causes: Actions:
This alarm occurs when the Patient coughing/moving Fix any kinks in the tubing
pressure required to pull blood from Access Line is kinked Flush or reposition
the patient becomes more negative Catheter is clotted catheter per hospital
than set limit. protocol
Lower blood flow rate
Wait for patient to stop
moving/coughing.
“Return Extremely Positive”
Description: Causes: Actions:
This alarm occurs when the Patient coughing/moving Fix any kinks in the tubing
pressure required to return blood to Return Line is Flush or reposition
the patient becomes more positive kinked/clamped catheter per hospital
than set limit. Catheter is clotted protocol
Lower blood flow rate
Wait for patient to stop
moving/coughing.
“TMP excessive”
Description: Causes: Actions:
Transmembrane Pressure exceeds Ultrafiltration rate is too Decrease PBP,
membrane pressure limit. high. replacement fluid and/or
Inadequate UF rate.
anticoagulation in the Increase blood flow rate.
circuit. Adjust anticoagulation
Change circuit if filter
clotted.
