Utility of failure mode and effect analysis to improve safety in patients with continuous renal replacement therapies / 中国实用护理杂志

Objective To identify the potential risks in patients receiving continuous renal replacement therapies (CRRT). Methods The concept of failure mode and effect analysis (FMEA) was used to analyze the management of CRRT, to find out the potential failure risks in all of the steps, risk priority numbers (RPNs) of each failure mode were calculated and countermeasures were implemented. Results Twenty-eight failure modes were analyzed, of which 8 modes RPN>125. After improvement of the nursing process in patients with CRRT, the RPN was lowered. The incidence of unplanned end of the CRRT was decreased from 10.86％ (24/221) to 5.81％ (14/241) (χ2=3.896, P<0.05). Conclusions Application of FMEA in risk management for CRRT can help to standardize the workflow and guarantee the safety of patients during CRRT, and is beneficial to continuous improvement of nursing.

Questões bioéticas envolvidas na comunicação dos enfermeiros com os usuários portadores de insuficiência renal crônica

Na relação entre o enfermeiro e o usuário, o processo de comunicação precisa ser eficiente, com objetivo de tornar a assistência humanizada e personalizada, em sintonia com as necessidades de cada indivíduo, levando em conta suas particularidades e respeitando sua autonomia. No setor de nefrologia, onde esta pesquisa está circunscrita, a atuação do enfermeiro em sua relação com usuários hospitalizados, portadores de insuficiência renal crônica, revela, no universo da comunicação clínica, situações importantes para a reflexão ética. Busca-se compreender os vieses éticos e morais impressos na comunicação entre os enfermeiros e os usuários portadores de insuficiência renal crônica diante da escolha da terapia renal substitutiva, no que tange ao reconhecimento do usuário como autônomo neste processo comunicativo. A partir da questão norteadora - Em que nível as questões bioéticas presentes na comunicação resultam do reconhecimento ou não dos usuários como sujeitos autônomos pelos enfermeiros do setor de nefrologia? – construiu-se o objeto: a comunicação acerca da terapia renal substitutiva como indicador do reconhecimento da autonomia do usuário. São os objetivos: descrever a comunicação dos enfermeiros com os usuários portadores de insuficiência renal crônica acerca de sua terapia renal substitutiva; analisar as esferas de reconhecimento da autonomia dos usuários portadores de insuficiência renal crônica pelos enfermeiros, à luz de Axel Honneth e discutir as consequências da comunicação dos enfermeiros com os usuários sobre sua terapia renal substitutiva....

In the relationship between nurses and users, the communication process needs tobe efficient, with the objective to make humanized and custom assistance in tunewith the needs of each person, considering their particularities and respecting theirautonomy. In the nephrology department, where this research is limited, the nurse'sperformance in the relationship with hospitalized users, with chronic kidney disease,reveals, in the universe of clinical communication, important situations for ethicalreflection. The idea of this research is seek to understand the ethical and moralbiases printed at the communication between nurses and users with chronic kidneydisease against the choice of renal replacement therapy, relative to the recognition ofthe user as self-governing in this communication process. Starting from the guidingquestion – In what level bioethical questions present in communication result fromrecognition or not of the users as self-governing subjects by nurses of nephrologydepartment? - Built up the object: the communication about renal replacementtherapy as an indicator of recognition of the user’s autonomy. Objectives: describethe communication of nurses concerning users with chronic kidney disease, abouttheir renal replacement therapy; analyze the spheres of recognition of the autonomyof users with chronic kidney disease by nurses, in the perspective of Axel Honnethand discuss the consequences of the communication of nurses with users about theirrenal replacement therapy...

Evaluación nutricional de niños con insuficiencia renal aguda que reciben diálisis / Nutritional assessment of children presenting with acute renal insufficiency and underwent to dialysis

INTRODUCCIÓN. La insuficiencia renal aguda se produce en horas o en algunos días, y durante su evolución se produce un deterioro del estado nutricional del paciente. El objetivo de este estudio fue caracterizar el estado nutricional de niños con esta enfermedad que requirieron terapias de reemplazo renal. MÉTODOS. Se realizó un estudio retrospectivo y transversal que incluyó a los pacientes ingresados por insuficiencia renal aguda en dos hospitales pediátricos de Santiago de Cuba entre diciembre de 2006 y diciembre de 2008. Se analizó edad, sexo, etiología, terapia de reemplazo renal, causa del uso de nutrición parenteral, evaluación nutricional según tablas cubanas de percentiles y parámetros antropométricos (edad, peso, talla) y aporte de nutrientes parenterales. RESULTADOS. Eventos prerrenales fueron la causa de la insuficiencia renal aguda en el 44,4 por ciento de los casos, y renales y posrenales, en el 33,4 y 22,2 por ciento, respectivamente. Como método de depuración renal se utilizó la diálisis peritoneal en el 66,6 por ciento de los casos y la hemodiálisis en los restantes pacientes. Las principales causas que motivaron la nutrición parenteral fueron las afecciones quirúrgicas, los estados hipercatabólicos, la hemorragia digestiva y la pancreatitis, en orden decreciente. Cuatro pacientes fueron evaluados como de bajo peso. CONCLUSIONES. El aporte promedio de proteínas y lípidos estuvo por debajo de los aportes nutricionales establecidos, y el aporte de kilocalorías fue superior a lo recomendado. Se deben mejorar estos parámetros en el tratamiento de estos pacientes

INTRODUCTION: Acute renal insufficiency appears in hours or in a few days and during its course there is a deterioration of patient nutritional status. The aim of present study was to characterize the nutritional status of children with this disease requiring renal replacement therapies. METHODS: A crossed-sectional and retrospective study was conducted including the patients admitted due to acute renal insufficiency in two children hospitals of Santiago de Cuba from December, 2006 to December, 2008. Authors analyzed the age, sex, etiology, renal replacement therapy, cause of parenteral feeding use, nutritional assessment according to Cuban percentile tables and anthropometry parameters (age, weight, height) and parenteral nutrients support. RESULTS: Prerenal events were the cause of acute renal insufficiency in the 44,4 percent of cases and renal and postrenal ones in the 33,4 percent and 22,2 percent, respectively. As a renal depuration method we used the peritoneal dialysis in the 66,6 percent of cases and the hemodialysis in remainder. The main causes that justified the parenteral feeding were the surgical affections, hypercatabolic states, the digestive hemorrhage and the pancreatitis in a decreasing order. Four patients were assessed as of low weight. CONCLUSIONS: The average support of proteins and lipids was under the established nutritional supports and that of kilocalories was higher than recommended. It is essential to improve these parameters in the treatment of these patients

Anticoagulação em terapias contínuas de substituição renal / Anticoagulation in continuous renal replacement therapies (CRRT)

As terapias contínuas de substituição renal (TSRC) são comumente usadas na maioria de pacientes criticamente enfermos com indicação de diálise. O sucesso das TSRC depende de um protocolo de anticoagulação eficiente para manter permeável o circuito de diálise, minimizando complicações como sangramento por anticoagulação excessiva ou a necessidade da troca do sistema por coagulação do mesmo, por anticoagulação insuficiente. Vários fatores podem contribuir para a trombose do circuito de diálise, como a velocidade do fluxo de sangue através do circuito, o cateter de diálise, o tipo de membrana utilizada no filtro dialisador e, também, o tipo de terapia prescrita. A heparina não fracionada (HNF) é o anticoagulante mais utilizado para as diferentes técnicas de diálise e, mais recentemente, as heparinas de baixo peso molecular (HBPM) têm se mostrado seguras e efetivas para TRSC. Em pacientes criticamente enfermos que freqüentemente têm contra-indicação para anticoagulação sistêmica, existe a alternativa da anticoagulção regional com citrato trissódico, método eficiente e seguro, se aplicado com controle metabólico estrito. A anticoagulação regional com HNF/protamina tem seu uso limitado, atualmente, por apresentar muitas complicações decorrentes de efeitos adversos da protamina. Na impossibilidade do paciente ser anticoagulado, ou se a anticoagulação regional com citrato não for disponível, a lavagem freqüente do circuito de diálise com solução salina é a única alternativa aplicável. Novas drogas ainda não disponíveis no Brasil, como prostaglandinas, hirudina recombinante, argatroban e nafamostat podem ser utilizadas em pacientes com contra-indicação para heparinização.

Continuous renal replacement therapies (CRRT) are commonly used in the majority of critically ill patients who need dialysis. Treatment success depends on an efficient anticoagulation protocol devised to maintain the dialysis circuit unclotted, with minimal complications such as bleeding due to excessive anticoagulation. Several features can contribute to dialysis circuit thrombosis, such as the speed of pump blood flow, dialysis catheter, type of dialyzer membrane and also, the type of technique prescribed. Unfractioned heparin (UFH) is the anticoagulant most used in CRRT. Recently, low-molecular weight heparins (LMWH) have been shown to be safe and effective drugs for this purpose. In critically ill patients, who frequently have contraindications to systemic anticoagulation, regional anticoagulation with trisodium citrate is an increasingly accepted method due to its safety and efficiency if applied under strict metabolic control. Regional anticoagulation with UFH/protamin now has limited use because of side effects related to protamin. If the patient has contraindication to systemic anticoagulation or if regional anticoagulation with citrate is not available, continuous flushing of circuit dialysis with saline is the only applicable alternative. In patients with contraindication to heparinization, new drugs not yet available in Brazil, such as prostaglandins, recombinant hirudin, argatroban and nafamostat can be used.

The prescription and anticoagulation of Continuous renal replacement therapies / 中国实用内科杂志

The development of Continuous renal replacement therapies(CRRT) in saving the critically ill patients is rapidly because of its removing the toxins and inflammatory mediators,maintaining the balance of the internal enviroment and preventing the endothelial cell function.The aim of the present paper is to guide and standardize the clinical usage of CRRT in the primary hospitals,through clarifying some problems of CRRT in clinical practice,such as the selection of CRRT pattern,setting the blood flow rate and the prescription and dosage of replacement fluid in CRRT,the selection of anticoagulant and the anticoagulation strategy and the announcements in CRRT. Abstract:Summ ary:The developm ent of Continuous renal rep lacem ent therap ies(CRRT) in saving the critically ill patients is rap-id ly because of its removing the toxins and inflamm atory m ed iators,m aintain ing the balance of the internal envirom ent and preventing the endothelial cell function.The aim of the present paper is to gu ide and standard ize the c lin ical usage of CRRT in the prim ary hosp itals,through c larifying som e prob lem s of CRRT in c lin ical practice,such as the selection of CRRT pattern,setting the b lood flow rate and the prescription and dosage of rep lacem ent flu id in CRRT,the selection of anticoagu lant and the anticoagu lation strategy and the announcem ents in CRRT.