A Safety Procedure for Continuous Renal Replacement Therapy
Acute renal failure has been estimated to occur in about 15% of hospitalized patients in the United States. The management of acute renal failure is complex and multimodal. One method frequently used to treat these patients with acute renal failure is continuous renal replacement therapy (CRRT), which manages fluid and electrolyte imbalances in hemodynamically unstable patients who are unable to tolerate standard dialysis treatments. These patients cannot withstand the potential fluid overload or shift that may occur from the toxin removal and electrolyte control of standard dialysis. One key element of CRRT is the use of large-volume dialysate and replacement solutions. Solutions traditionally used were predominantly lactate-based with standardized electrolytes and buffers. Many patients cannot tolerate lactate-based solutions because of lactate intolerance or lactic acidosis. For these patients, CRRT is administered via custom-mix, complex-electrolyte, bicarbonate-based solutions. Published evidence has demonstrated that CRRT solutions contain buffer and electrolytes that can mimic physiological balance and contain bicarbonate. These are preferred in patients with lactic acidosis or liver failure.

One of the National Patient Safety Goals established by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) focused on improving the safety of high-alert medications. Recommendations from JCAHO include standardization and limiting of drug concentrations where possible. The Institute of Safe Medication Practices (ISMP) has designated dialysis solutions, including peritoneal and hemodialysis solutions, as high-alert medications. ISMP supports minimizing unusual concentrations and developing standard concentrations and base solutions, including the use of commercially available pre-mixed solutions whenever possible.

Because CRRT solutions contain potassium chloride and other electrolytes, are considered high-alert medications, and are complex to prepare, these solutions were targeted as a source of potential medication error in our institution. There was no standardized process at our institution to ensure the safe prescribing and preparation of CRRT solutions; therefore, a team was gathered to design a fail-safe process for the provision of CRRT to patients with acute renal failure.