Honoré Patrick M, Joannes-Boyau Olivier, Gressens Benjamin
St-Pierre Para-University Hospital, Ottignies-Louvain-la-Neuve, Belgium.
Contrib Nephrol. 2007;156:354-64. doi: 10.1159/000102126.
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.
在重症监护病房（ICU）实施连续性肾脏替代治疗（CRRT）是一个颇具难度的问题，与启动一种新的通气模式或新的血流动力学设备截然不同。实际上，这可能需要一个随时待命的医疗紧急CRRT团队，因为该领域的专业知识确实是成功的关键因素。对护理团队的培训是另一个关键点，尤其是考虑到持续教育的发展变化非常迅速。在ICU实施CRRT的组织过程中，所使用设备类型的一致性是另一个关键部分。ICU团队和肾病团队的共同参与是成功的另一个关键，特别是在使用不同模式和更高置换率时。此外，一个专门负责ICU团队持续实施和培训工作的护理小组对于实现既定目标非常有帮助。早在1984年，急性肾衰竭就被描述为ICU中尚存的具有挑战性的问题之一。当时，由于重症患者血流动力学不稳定，血液透析并不总是可行的。在这种情况下，持续动静脉血液滤过（CAVH）被提倡作为一种有效的替代方法，其对血流动力学的不良影响较小。当时人们认为CAVH将被证明是一种有效的“人工肾”（控制体液、电解质和酸碱平衡以及尿毒症），且无严重副作用。但近25年前就发现，持续抗凝是一个主要问题，可能在创伤后和手术患者中引发危及生命的并发症。当时，人们认为在静脉管路中输注鱼精蛋白有助于减少这些并发症。自1985年以来，我们的ICU就开始开展CRRT，最初采用CAVH，自1989年起采用一些早期形式的持续静脉-静脉血液滤过（CVVH）。该科室使用BSM 22、BM 25和Prisma设备已近10年，自2001年底起使用Aquarius设备。教育过程始于1990年初，当时使用BSM 22和BM 25设备实施CVVH。很快就意识到确实需要一种新的策略来实施脉冲高容量血液滤过（pulse-HVHF）。因此，成立了一个由5 - 8名预先接受培训的护士组成的护理小组，这个专门小组随后会向其他护士传授CRRT技术和后勤保障方面的知识。这个小组至今仍然存在，每年至少召开6 - 8次会议，讨论CRRT实施过程中必须面对的所有问题。在此，我们将讨论我们科室以及其他科室在该领域所采取的所有步骤，包括对所实施的各种方案的概述以及我们针对CRRT的专门护理小组的介绍。
