Glossary
Arteriovenous: referring to vascular access, when blood is removed from an artery and returned to a vein.

Cardiac output: the amount of blood pumped by the heart in one minute.

Convection: solute transport across a membrane together with a solvent (usually water) in response to a pressure gradient across the membrane.

CRRT: continuous renal replacement therapy.

Crystalloid: fluid composed of water and one or more dissolved salts (e.g. saline, lactated Ringers).

CVVH: continuous venovenous hemofiltration.

CVVHD: continuous venovenous hemodialysis.

CVVHDF: continuous venovenous hemodiafiltration.

Dialysate: solution administered into the compartment of the hemofilter opposite the blood to achieve diffusive solute clearance.

Diffusion: solute transport from a compartment with high concentration to a compartment with low concentration.

Effluent: the fluid that drains out of the hemofilter; a combination of plasma water, removed solutes, spent dialysate and replacement fluid volume. Effluent volume is only equal to fluid removal volume in SCUF.

Fluid balance: net amount of fluid gained or lost by the patient in a given period of time. Negative fluid balance occurs when losses are greater than gains and positive fluid balance results when gains are greater than losses.

IHD: intermittent hemodialysis.

Preload: the amount of blood in the ventricle just prior to systolic ejection.

Replacement fluids: fluids administered into the blood compartment to drive convective solute losses. All replacement fluid volume is removed during CRRT.

SCUF: slow continuous ultrafiltration.

Semipermeable membrane: a barrier, either cellulose or synthetic, that allows water, electrolytes and other molecules to pass through while cellular components and larger molecules are held on one side.

Solute: a substance dissolved in water or plasma (e.g. sodium chloride).

Ultrafiltrate: plasma water and solutes that pass through the semipermeable membrane.

Ultrafiltration: transport of water across a membrane by a pressure gradient. In hemofiltration, the process by which plasma water and filterable solutes are separated from whole blood.

Venovenous: taken from a vein and returned to a vein

Test

1. The multidisciplinary team that manages CRRT is usually composed of a nephrologist or
intensivist, a critical care nurse, dialysis nurse and
A. Pharmacist, consulting MD, dietician and clinical laboratory
B. Pharmacist and physical therapist
C. Consulting MD, clinical laboratory and social worker
D. No other members

2. CRRT is a preferred blood purification therapy for emodynamically unstable patients because it:
A. Achieves blood purification faster
B. Causes less hypotension
C. Removes larger volumes of fluid
D. Is a non-invasive therapy

3. One advantage of CRRT vs. traditional intermittent dialysis therapy is that CRRT:
A. Requires strictly limited protein intake
B. Allows complete nutritional support
C. Removes toxins intermittently
D. Eliminates the need for large-volume infusions

4. Central venous access for venovenous CRRT must be placed away from other central venous access devices because:
A. The two devices could become tangled with one another
B. Two access devices in close proximity increase infection risk
C. Medications administered through the other device would be rapidly filtered out
D. Two access devices in close proximity increase bleeding risk
CRRT

Match the following four terms to their definitions (labeled A, B, C and D below):

5. _____ Ultrafiltration

6. _____ Diffusion

7. _____ Convection

8. _____ Adsorption
A. Movement of solutes by the force of water flow. Also called solvent drag.
B. Removal of solutes by the adherence of the solute to the membrane
C. Movement of water by a positive pressure such as gravity or via a negative pressure
applied to the opposite side of the membrane
D. Movement of solutes from an area of high concentration to an area of lower concentration

Match the therapy to the types of fluids it uses (labeled A, B, C and D below):

9. _____ SCUF

10. _____ CVVH

11. _____ CVVHD

12. _____ CVVHDF
A. Uses dialysate only
B. Uses replacement fluid only
C. Uses both dialysate and replacement fluid
D. No dialysate or replacement fluid are used

13. Select the best candidate for CRRT
A. Chronic renal failure patient; unable to establish vascular access
B. Trauma patient with acute renal failure and septic shock
C. Chronic dialysis patient with stable hemodynamics
D. Acute renal failure patient with advance directive stating no dialysis

14. The patient receiving CRRT is at risk for hypothermia related to:
A. Metabolic suppression
B. Extracorporeal circulation of blood
C. Large volumes of room temperature fluids
D. B and C

15. Select the statement that is true regarding CRRT
A. CRRT can only be used for chronic dialysis patients
B. CRRT should only be used if the potassium is greater than 6.0 mg/dL
C. CRRT is used for hemodynamically unstable patients with renal failure
D. CRRT is a simple, low-risk therapy

16. Within the dialysis filter:
A. Blood and dialysate mix freely
B. The blood is separated from the dialysate by the semipermeable membrane
C. Cellular blood components cross the membrane easily
D. Molecules such as electrolytes and cytokines are not able to cross the membrane

17. The purpose of using replacement fluids is:
A. To eliminate fluid losses
B. To drive convective solute losses
C. To replace electrolytes
D. To restore lost fluids

18. Mrs. T is receiving CRRT for acute renal failure associated with septic shock. The nephrologist has ordered a custom dialysate with a very low concentration of potassium to
help correct her serum potassium of 6.0 mg/dL. Safe administration of this nonphysiologic dialysate requires
A. Monitoring of the serum potassium every hour
B. Calling for a change in the dialysate formula order when the serum potassium approaches normal
C. Use of Citrate anticoagulation rather than Heparin
D. Decreasing the frequency of serum potassium measurement

19. The cardiologist has written an order to add 40 mEq of KCl to the dialysate. Before requesting that the KCl be added to the bag the nurse should:
A. Check the serum potassium
B. Remove any replacement fluids that are hanging
C. Ask the lab to recheck the last serum potassium level
D. Consult with the nephrologist and clinical pharmacist
CRRT

20. Risks associated with Heparin anticoagulation include:
A. Hypocalcemia
B. Deep vein thrombosis
C. HITT
D. Hypotension

21. The effectiveness of Citrate anticoagulation is assessed by:
A. aPTT levels
B. Serum Citrate levels
C. Platelet count
D. Ionized calcium levels

22. Your patient has returned from the operating room after a coronary artery revascularization and aortic valve replacement. In the OR the patient received 5 liters of fluids and blood products. The patient is now exhibiting signs of fluid overload and hemodynamic instability. The patient’s BUN and creatinine are both normal, and the UOP is 45 cc/hour. CRRT is ordered for fluid management. The most appropriate treatment modality for this
patient would be
A. SCUF
B. CVVHD
C. CVVHDF
D. CVVH

23. The CRRT modality that is best able to remove large molecules like cytokines is:
A. CVVHD
B. SCUF
C. CVVH
D. IHD

24. Safety measures to limit the likelihood of blood loss in CRRT include:
A. Continuous cardiac monitoring
B. Turning all alarms on the CRRT machine to the lowest volume
C. Keeping tubing visible and capping all open ports with dead-end connectors
D. Use of Citrate anticoagulation


25. Which type of fluids cannot be warmed?
A. Solutions containing Glucose
B. Solutions containing Citrate
C. Solutions containing Sodium Chloride
D. Solutions containing Bicarbonate

26. Your patient has just been started on CVVHDF therapy. The patient is septic and has been receiving multiple renally cleared antibiotics. You anticipate:
A. Decreasing the doses of all antibiotics by half due to hemoconcentration
B. Increasing the doses of all antibiotics because they will dialyze out
C. Checking antibiotic peak and trough levels to determine appropriate doses
D. Discontinuing all antibiotics because CVVHDF will cure the sepsis

27. Select the statement that is most appropriate regarding input and output (I&O) calculations in patients receiving CRRT
A. All I&O calculations are performed by the CRRT machine
B. The nurse must always manually calculate dialysate and replacement fluid use
C. I&O is not necessary for these patients
D. The nurse must be aware of which calculations are performed by the CRRT equipment

28. Preload measures are used to assess the adequacy of fluid volume in patients receiving CRRT. Which set of measures most accurately
reflects preload?
A. CVP, RVEDVI and PAOP (wedge) pressure
B. PA pressure and systemic vascular resistance
C. Cardiac output and heart rate
D. Mixed venous oxygen and lactate level

29. If the patient is responding well to CRRT, the nurse expects the hemodynamic parameters to:
A. Fluctuate widely from hour to hour
B. Rapidly shift toward normal values
C. Slowly shift toward normal values
D. Get worse before they get better

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