Inpatient RRT and COVID-19

Last update: April 17, 2020

Patient management protocol

• Regardless of COVID 19 status, evaluate if dialysis will impact patient outcomes before initiating therapy. Consider palliative care consultation where appropriate.

• COVID 19 suspected and test results pending:
  • When possible, avoid RRT if COVID-19 results are pending to conserve PPE.
    • If necessary, CRRT or PIRRT is preferred for ICU patients (see below).
    • Floor patients will need HD in their room to prevent traveling.
  • Hyperkalemia: See hyperkalemia protocol. Note sodium zirconium cylcosilicate (Lokelma) is now available.
    • Dose: 5-10 gm TID for 48 hours or 5-10 gm daily dosing
  • Maximize use of diuretics (torsemide, up to 200 mg once daily).
• COVID-19 positive
  
  • Use prolonged intermittent renal replacement therapy (PIRRT) via continuous venovenous hemodiafiltration (CVVDHF) for all ICU patients to limit staff interactions.
    • Evaluate all patients for change to very other day vs daily PIRRT-CVVHDF using PrismaFlex (or PrisMax).
      • Duration: 10 hours per treatment (range 7-14 hours)
      • Dose: 15-45 ml/hour (CVVHDF)
      • Anticoagulation: Unfractionated heparin, citrate, note
      • CRRT (continuous): Requires approval. Call Catherine Wells if someone is unstable and requires CRRT.
      • See below for stepwise progression from the use of CRRT to PIRRT-CVVHDF to maximize the use of available equipment.
  • Symptomatic Floor patients will dialyze at the bedside with NxStage IHD or Fresenius HD machines.
    • Patients with hyperkalemia, acute intoxications, or other need for high efficiency HD in all areas may use Fresenius machines.
  • Once fever/symptoms resolve – patients may travel to AKU wearing a mask and dialyze in a negative pressure isolation room using staff/PPE sparing protocols as below.
• Patients with suspected COVID-19 or symptoms similar to COVID, but no testing recommended and on the floor
  • If allowed, travel to the AKU wearing a mask and dialyze in a negative pressure isolation room using staff/PPE-sparing protocols as below,
• Consent and communication
  • oFor patients who cannot consent for themselves, ensure a team member has contacted the family by phone to obtain consent for CRRT/HD.
  • Coordinate daily family updates with the primary team.
• Conserve HD/RRT resources among non-COVID-19 patients
  • When AKU at 80% of capacity (available RNs and machines for required treatments), nurses will request to reduce treatment time for patients.
    • Monitor labs for safety.
    • Consider HD 2X/week + Lokelma/Kayexalate and diuretics as possible per evaluation of Nephrology.

Machine allocation plan

• Change all or most CRRT patients to PIRRT-CVVHDF as part of hospital crisis management plan to conserve PPE and extend the use of existing CRRT machines.
• Primary machines in use will PrismaFlex and PrisMax. NxStage machines can be used for PIRRT or IHD. NxStage will be the last machines pulled to use for PIRRT.
• Step 1: Convert COVID19 positive patients to PIRRT-CVVHDF using PrismaFlex or PrisMax machines
  • Initiate daily PIRRT-CVVHDF (2 patients treated per CRRT machine) effective April 9, 2020.
  • 7-14 hours of PIRRT-CVVHDF per day, Dose 15-45 mL/kg/hour, appropriate Ultrafiltration
  • Anticoagulation options:
    • Regional citrate anticoagulation by fixed ratio 1.5 times the blood flow rate
    • Systemic anticoagulation during PIRRT. Use unfractionated heparin via syringe pump:
      • Bolus with 80 units per kg (admission weight) IV before treatment, then
      • Infusion 1000 units per hour via syringe pump.
    • Target aPTT is 60-80. Check aPTT 6 hours after starting treatment and titrate.
      • Repeated clotting: Evaluate for all factors contributing to clotting, including dialysis access, patient position, mechanical obstruction, etc.

• Step 2: When all PrismaFlex/PrisMax machines are used for daily PIRRT-CVVHDF
  • Initiate every other day PIRRT-CVVHDF starting with 1 machine at a time (4 patients treated with 1 machine).
  • Use the same prescription and anticoagulation parameters described in Step 1.
• Step 3: When all PrismaFlex/PrisMax machines are used for every other day PIRRT-CVVHDF
  • Initiate 3 day/week PIRRT-CVVHDF (≥ 6 patients treated with 1 machine).
  • Use the same prescription and anticoagulation parameters described in Step 1.
• CRRT
  • Must be approved. Contact Catherine Wells.
  • Only allowed for patients who are hemodynamically unstable and require extended time for UF
  • Continuation requires daily approval. Contact Catherine Wells.

Machines/equipment use and decontamination

• COVID 19 suspected or positive - ICU
  • PrismaFlex/PrisMax      CRRT or PIRRT-CVVHDF
    • Label machine as COVID-19 Suspected or COVID-19 Positive.
    • After each treatment clean all exterior surfaces while in room with Sani Cloths (purple top) if no visible blood present. Contact time for Sani Wipes must be >2 minutes. If visible blood present, use bleach wipes for cleaning. Contact time for bleach wipes must be > 4 minutes.
    • Machine can remain in the room or leave the room. To remove the machine, it must be cleaned a 2nd time after exiting room and before returning to storage or AKU (gloves only, not full PPE, required for 2nd cleaning).
    • After the 2nd cleaning, remove the COVID-19 label and machine can be used for general use.
  • If Urgent IHD is required (i.e. symptomatic hyperkalemia, acute intoxications)
    • Use the Fresenius series machine and portable RO for IHD (prefer 2 hours/minimize time).
    • Place the portable RO as far from the patient as possible (prefer 6 feet).
    • After treatment clean all exterior surfaces of both machines while in room with Sani Cloths (purple top) if no visible blood present. Contact time for Sani Wipes must be >2 minutes. If visible blood present, use bleach wipes for cleaning. Contact time for bleach wipes must be > 4 minutes.
    • Repeat exterior cleaning outside of room before returning to AKU (gloves only, not full PPE, required for 2nd cleaning).
    • Replace the bicarbonate and acid jugs between patients.
    • HD machine - Chemical disinfect per manufacturers recommendations
    • RO – Disinfection per manufacturer’s instructions
• COVID-19 suspected or positive - non-ICU
  • Symptomatic, ongoing testing, positive result
    • Bedside HD with NxStage machine is preferred (limit equipment exposure).
    • Label machine as COVID-19 Suspected or COVID-19 Positive.
    • After each treatment, clean all exterior surfaces while in room with Sani Cloths (purple top) if no visible blood present. Contact time for Sani Wipes must be >2 minutes. If visible blood present, use bleach wipes for cleaning. Contact time for bleach wipes must be > 4 minutes.
    • Machine can remain in the room or leave the room. To remove the machine it must be cleaned a 2nd time after exiting room and before returning to storage or AKU (gloves only, not full PPE, required for 2nd cleaning).
    • After the 2nd cleaning, remove the COVID-19 label and machine can be used for general use.
  • Positive with symptoms resolved for > 24 hours
    • Travel to AKU wearing a mask.
    • Dialyze in a negative pressure isolation room using staff/PPE sparing protocols as below.
    • Label machine as COVID-19 Suspected or COVID-19 Positive.
    • After each treatment, clean all exterior surfaces while in room with Sani Cloths (purple top) if no visible blood present. Contact time for Sani Wipes must be >2 minutes. If visible blood present, use bleach wipes for cleaning. Contact time for bleach wipes must be > 4 minutes.
    • Machine can remain in the room or leave the room. To remove the machine, it must be cleaned a 2nd time after exiting room and before returning to storage or AKU (gloves only , not full PPE, required for 2nd cleaning).
    • After the 2nd cleaning, remove the COVID-19 label and machine can be used for general use.
  • If Urgent bedside IHD is required (i.e. symptomatic hyperkalemia, acute intoxications)
    • Use the Fresenius series machine and portable RO for IHD (prefer 2 hours to minimize time).
    • Place portable RO as far from the patient as possible (prefer 6 feet).
    • Label both machines as COVID-19 Suspected or COVID-19 Positive.
    • After treatment, clean all exterior surfaces of both machines while in room with Sani Cloths (purple top) if no visible blood present. Contact time for Sani Wipes must be >2 minutes. If visible blood present, use bleach wipes for cleaning. Contact time for bleach wipes must be > 4 minutes.
    • Machines can remain in the room or leave the room. To remove the machines, they must be cleaned a 2nd time after exiting room and before returning to storage or AKU (gloves only, not full PPE, required for 2nd cleaning).
    • After the 2nd cleaning, remove the COVID-19 label and machine can be used for general use.
    • Replace the bicarbonate and acid jugs between patients.
    • Internal disinfection per manufacturers recommendations for both HD machine and RO.
• Machine management and safety
  • Extension tubing: Do not extend blood lines or add connections, stop cocks, etc. Connect all blood lines directly to the patient access per manufacturer recommendations.
    • Extension tubing decreases the sensitivity of machine alarms and can increase the risk for blood loss from the circuit (up to and including exsanguination).
  • Protocol for moving machines through a closed door outside the patient room
    • Do not add extensions to the blood lines.
    • Ensure there is no tension on the blood lines or at the access at all times. This can dislodge the vascular access, cause kinking, and contribute to circuit clotting.
    • Secure the blood lines to the patient.
    • Do not completely close blood lines or the warmer coil between the doors.
  • Kinking blood lines will contribute to clotting.
    • Crimping the warmer coil can lead to dysfunction and electrical fires.
    • Place Hemoclips on all blood circuit connections to ensure they do not disconnect. Disconnection can cause blood loss up to and including exsanguination.
    • Visually inspect the lines > every hour and PRN. Monitor the machine pressures for changes and problems. This visual inspection can be done via video monitoring or through glass (if the field of view is not obstructed). 

Staffing

• CRRT
  • AKU staff will not enter room for COVID-19 suspected or positive patients
    • Set up outside room.
    • Check prescription with the ICU RN outside room.
    • Stay until the treatment is started and monitor via chart, video through the glass, etc.
• IHD
  • Minimize time in the room.
  • All set up is done outside room.
  • Do not bring outside computers, etc. or any personal items into the isolation room.
  • Monitor from outside the room (rooms with glass doors preferred), via video, collaborating with other nursing staff/providers, and using chart when possible.
  • Visualize the access connection and overall patient condition once every 15 minutes. If necessary enter the room. It is acceptable for another nurse, NP/PA, MD/DO to perform this assessment and report findings to dialysis RN if they enter the room (limit staff entering room and use of PPE).
• Choice of staff, and number of staff dedicated to COVID-19 is per Dialysis Services leadership.

Commodities (Heidi Ferguson, Director of Dialysis)

• We will use more filter sets than usual.
• Review use of Baxter and NxStage filter sets daily (2-day lead time for ordering).
• Review CRRT solution stock routinely.
• Request for additional machines:
  • 10 additional PrisMax/PrismaFlex
  • Rental machines PRN
  • 4 additional portable RO

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.