CRRT and ECLS
Video creator: Daniel Moreno BSN, RN, CCRN, CES-A
Content creator: Nicole Reagan BSN, RN, CCRN-CSC, CES-A
Prismaflex by Gambro is a commonly used device for continuous renal replacement therapy. It is user friendly, easy to use, will notify appropriately when there is clogging, clotting, and air in the system. These are safety measures in place that are helpful for managing CRRT while connected to the ECLS circuit.
Numerous medical centers that allow connecting to the ECLS device for the following reasons:
1) Decreased risk for infection while eliminating additional central line access
2) Adequately trained staff to trouble shoot CRRT/ECLS related problems and intervene appropriately
3) Competent staff who know how to safely connect and disconnect with sterile wet connect technique to and from the ECLS circuit
4) Ease of having all of your machines positioned together for easier management and visualization
5) Decreased risk of line and access related problems while on CRRT (kinking, high venous pressure related to volume status and other line access issues that are commonly experienced)
Connecting to the circuit is institution and unit specific. Many medical centers do not allow this in practice because:
1) Risk for error with inadequately trained or inexperienced technicians
2) Accessing the lines and circuit introduces the risk of air with improper technique
3) Centers want to keep the circuit a completely closed system
Connecting CRRT to the ECLS circuit requires appropriately trained staff who perform competency validation through wet lab, simulations, and bedside patient care. It is important that the ECMO Specialist is trained appropriately and able to intervene if air is introduced into the ECLS system via CRRT, ECLS pump failure occurs and other potential complications that can arise in emergent situations.
Technique:
1) CRRT access (red) line is usually connected post oxygenator on the Cardiohelp, Centrimag and Soren devices. The rationale is so that positive pressure is being delivered to the CRRT device to help eliminate too negative of a pull on the device. Some centers will connect the access line pre oxygenator post pump on the Centrimag/Soren so that if in the event air is introduced into the system, it could be trapped in the oxygenator and removed more easily. Review the video above for a step by step process.
2) CRRT return (blue) line is usually connected pre oxygenator on the Cardiohelp, Centrimag and Soren devices. Review the video above for a step by step process.
It is important to note that with this set up, you will no longer have a negative access pressure on the Prismaflex device and it may alarm due to this change. This is to be expected due to how the access line is connected to the ECLS circuit.
Common concerns:
What about recirculation? The ECLS device is generally maintaining much higher flows than the CRRT machine, thus recirculation through the CRRT system is minimal.
What is my lines start chattering/chugging? Stop fluid removal and assess your patient's volume status.
