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500 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 18.8 Troubleshooting guide

Nursing area Potential problem Key nursing interventions required
Patient and 1. Machine alarms and 1. Machine test and/or checklist completed
machine/system technical failure on 2. Double-check all line connections around circuit
preparation starting treatment 3. Treatment orders cross-checked with settings
before use 2. Air entrainment 4. Double-check fluids used, e.g. any additives required
3. Fluid setting errors Recommendation: patient in bed, supine position and MAP >70, stable.
4. Fluids/electrolytes
incorrect
Connection to the 1. Access catheter 1. Prep access connections with antiseptic and test flush return (venous) lumen and
system and obstruction/failure aspirate outflow (arterial) lumen
initiation of 2. Hypotension 2. Connect both circuit lines to access catheter administering priming volume to patient
therapy a. Increase vasoactive drugs first to maintain MAP
b. Start blood pump slowly with small increases until blood fills all of the circuit
Recommendation: use two nurses for connection routine. Start fluid replacement and
removal only after blood circuit is full and at prescribed speed.
In-use 1. Low pressure: 1. Maintain access catheter alignment, preventing kinks
troubleshooting ‘arterial alarm’ 2. Do not place extra connections or taps between access catheter and circuit lines
and 2. High pressure: 3. Blood pump speed >150 mL/min
maintenance, ‘venous alarm’ 4. Ensure venous chamber filled well above air sensor, bubbles removed
particularly fluid 3. High TMP alarm 5. Heater set to 37°C
balance 4. Air detected alarm 6. Use fluids chart or similar to account for all fluids used including anticoagulant
5. Hypothermia 7. Potassium additive to CRRT fluid is often required after 24–48 hours of treatment;
6. Fluid balance errors some patients are hypokalaemic despite acute renal failure
7. Electrolyte Recommendation: assess and reset fluid balance settings hourly, particularly in unstable
imbalance patients and for inexperienced staff.
Monitoring and 1. Premature clotting 1. Check and monitor effect of anticoagulant therapy after first 6 hours and then daily
adjustment to in circuit and filter a. Maintain adequate dose to therapeutic range
anticoagulation b. Use predilution fluid administration
c. Use blood flow greater than 150 mL/min
d. Use large-bore access catheter and take care not to obstruct catheter
e. Keep blood pump operating: minimise stops >30 sec
Recommendation: if frequent failure, always check for blood flow obstruction before more
anticoagulation; e.g. request change or replacement access catheter if obstructed.
Access care and 1. Access 1. Ensure catheter sutured in place and well secured with dressing
dressings dislodgement 2. Use asepsis when flushing or connecting to access catheter; monitor site for infection
2. Access catheter 3. Use heparin to fill catheter deadspace when not is use for >4 hours
infection Recommendation: use flexible dressing with application to both sides along catheter
3. Access catheter allowing movement away from skin surface, preventing obstruction during patient
obstruction care/positioning.
Vital sign 1. Arrhythmias, 1. Monitor vital signs hourly, consider any link between changes and use of RRT; e.g. low
monitoring hypotension, fever CVP and inadvertent fluid loss occurring
Recommendation: CVP readings should be performed 2–4-hourly during CRRT; CVP can be
used as a target for daily fluid loss prescription.
Assessment of 1. Filter clotting 1. If transmembrane pressure (TMP) or prefilter pressure (P-IN) >250 mmHg, consider
filter function abruptly with electively returning blood by saline infusion into circuit and ceasing treatment
and patency inability to return a. Observe for venous chamber clot development. If excessive and venous pressure
circuit blood to the >200 mmHg, consider electively returning blood by saline infusion into circuit and
patient ceasing treatment
2. Inadequate solute 2. Assess patient’s urea and creatinine measures; they should be reducing or stable
removal Recommendation: blood flow into venous chamber should be visible, i.e. not full; to
identify clot, reduce level of blood to detect clot and/or perform a small saline flush
(~100 mL) into circuit to check for clot formation.
Cessation of 1. Blockage and/or 1. Use concentrated heparin to fill deadspace of catheter when not in use >4 hours. Use
treatment and clotting in access 1000 IU/mL and follow manufacturer’s specifications for volume required
disconnection catheter 2. Always cease a circuit before it clots, return patient blood
from the 2. Inadvertent blood 3. Use asepsis for disconnection procedure
extracorporeal loss Recommendation: access catheter should not be used for other purposes/infusions when
circuit 3. Infectious risk RRT is not connected.
Temporary 1. Maintenance of 1. Flush out any excess blood residue in circuit, keep blood pump operational with saline
disconnection circuit before in circuit
for procedures reconnection 2. Circuits in use for >24 hours before disconnection or not restarted after 6 hours
2. Infection following temporary disconnection, consider discarding
3. Inadvertent fluid 3. After restarting circuit, increase fluid loss to remove fluid used to re-establish RRT
administration Recommendation: add heparin 5000 IU to circuit when temporarily disconnected, but
flush this out with 200–300 mL saline before reconnection; always use additive label for
this procedure.