PLACE LABEL HERE
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
VENO-VENOUS ORDERS
FOR NX STAGE SYSTEM
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1.
Mode:
 CVVH (Continuous Veno-venous Hemofiltration)
 CVVHD (Continuous Veno-venous Hemodialysis)
 SCUF (Slow Continuous Ultrafiltration):  Continuous
2.
Filter:
3.
Blood Flow Rate:
4.
 Replacement fluid (for CVVH)
 8 hours
Nx Stage Cartridge Express with pre-filter
 250-300 ml/min
 300-350 ml/min
 Other: __________________ml/min
 Dialysate (for CVVHD)
 B Braun Bicarbonate 35 Dialysate (2 K/3 Ca) 5 Liter:
K+ 2 mEq/L, Ca++ 3 mEq/L, Na+ 140 mEq/L, Mg++ 1 mEq/L, Chloride 111 mEq/L, Bicarbonate 35 mEq/L, Glucose 1 gm/L
 B Braun Bicarbonate 35 Dialysate (4 K/3 Ca) 5 Liter:
K+ 4 mEq/L, Ca++ 3 mEq/L, Na+ 140 mEq/L, Mg++ 1 mEq/L, Chloride 113 mEq/L, Bicarbonate 35 mEq/L, Glucose 1 gm/L
Dialysate flow or Replacement fluid rate:  2,000 ml/hr 3,000 ml/hr
 Other: ___________ml/hr
5.
Hourly net fluid balance: total input – (total output + ultrafiltration)
 Even
 Positive balance __________ ml/hr
 Negative balance __________ ml/hr
6.
Anticoagulation:
 None
 Heparin continuous infusion: Follow weight-based heparin orders for CRRT (form # 28554), No bolus
 NS 100 ml q 2 hr line rinse, (increase UF an additional 50 ml/hr to remove rinse volume)
 Other: _________________________________________________________________________________

7.
Labs: (DO NOT DRAW LABS FROM CRRT LINES)
Pretreatment Renal Panel and Magnesium, PTT, and PT/INR if not already preformed today
After treatment initiated: Renal Panel, Magnesium, and ionized calcium q 4 hrs after initiation then q 6 hrs x 24
hrs, then q 12 hrs while on CRRT
Other: ___________________________________________________________________________
8.
EFFLUENT: Visually inspect for blood. If pink or red, replace hemofilter immediately. Send specimen to lab for
hemocult testing.
9.
Intake and Output q hr
10.
Record hourly fluid removed on CRRT documentation flowsheet (form # 40036), Record net fluid loss q 12 hrs
11.
NOTIFY NEPHROLOGIST for any of the following:
 Filter clotting
MAP < 65 mmHg
 Sustained BP < 90/60 mmHg
pH > 7.45
Send copy to pharmacy
*3-40035*
HCO3 > 30 mEq/L
Order writer’s Initials___________
FORM 3-40035 INITIATED 01/2012
Page 1 of 2
PLACE LABEL HERE
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
VENO-VENOUS ORDERS
FOR NX STAGE SYSTEM
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
12. MAP (mean arterial pressure): maintain > 65 mmHg. If MAP < 65 mmHg, use the following order of treatment
Decrease Ultrafiltration to keep hourly fluid balance positive
Albumin 25%, 25 gm (100 ml) IV bolus, may repeat X 1 after 2 hrs
If no response to first dose of Albumin 25%, initiate and/or titrate Levophed (norepinephrine) 4 mg/250 ml NS to MAP > 65
If MAP remains < 65 despite above interventions or unable to maintain ordered hourly net fluid balance, notify Nephrologist
If unable to achieve blood flow rate of 100 ml/hr, notify Nephrologist
13. Dialysis Catheter Flush/Lock:
Flush catheter at end of treatment with 0.9% Sodium Chloride 10 ml per port then instill with one of the following:
 Heparin 5,000 units/1 ml intracatheter to each lumen
Fill catheter lumen (QS with saline) to volume stated on catheter PRN to prevent catheter occlusion due to clotting
Aspirate before use. (Pharmacy: send 1 x Heparin 5,000 unit/ml, 10ml vial)
 Cathflo (alteplase) 2 mg intracatheter to each lumen
Fill catheter lumen (QS with saline) to volume stated on catheter PRN to prevent catheter occlusion due to clotting
Aspirate before use. (Pharmacy: send 2 vials)
 Sodium Citrate 4% intracatheter to each lumen
Fill catheter lumen to volume stated on catheter PRN to prevent catheter occlusion due to clotting
Aspirate before use. (Pharmacy: send 1 x 250 ml bag daily for RN to draw up flush)
14.
If filter is clotting, if treatment is held or if new cartridge set-up is necessary (prior to cartridge expirations):
Return blood if possible and flush dialysis catheter as ordered in #13 above.
If system fails between 2400-0600 then restart  ASAP  0700
15. Electrolyte Replacement (via central access, not dialysis circuit) DELETE ALL PREVIOUS REPLACEMENT ORDERS
 Potassium Replacement:
Serum Potassium (mEq/L)
Action
KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour X 3 (total 60 mEq)
< 3.5
KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour X 2 (total 40 mEq)
3.5 - 3.9
4.0 - 4.2
KCl 20 mEq in 100 ml pre-mix IVPB over 1 hour

 Magnesium Replacement:
Serum Magnesium (mEq/L)
< 1.5
1.5 – 1.9
Action
Magnesium sulfate 4 gm pre-mix IVPB over 2 hours
Magnesium sulfate 2 gm pre-mix IVPB over 1 hour

 Phosphorus Replacement:
Serum Phosphorus (mmol/L)
<2.0
2.0-2.5
Action
Sodium Phosphate 30 mM IVPB in 250 ml NS over 6 hours
Sodium Phosphate 15 mM IVPB in 250 ml NS over 4 hours
 Calcium Replacement:
Serum Ionized Calcium
< 0.7
0.7-0.85
0.86-1.10
1.1-1.33
_____________
Date
Action
Calcium Gluconate 3 gm IVPB over 30 minutes
Calcium Gluconate 2 gm IVPB over 30 minutes
Calcium Gluconate 1 gm IVPB over 30 minutes
Target range. Notify Nephrologist for ionized calcium > 1.4
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy
FORM 3-40035 INITIATED 01/2012
Page 2 of 2