CRRT in your ICU - nephro or Icu drives?

[europeman]

If you have cont renal replacement therapy options in your Icu a does nephrology drive it or does ICU?

Anyone here have a collaborative relationship? If so.... How? Who puts orders? Who decides to start/stop?

Anyone have a pref which way works better at their shop?

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[jdh71]

There is this large group of people who went to special training to learn how to specifically take care of the kidneys. They are called "nephrologist". If you think you know better than thru do you are either 1) an idiot or 2) a surgeon.

Where I work it's a collaboration. I defer to nephrology opinion but if I think I need it bad enough they are nice enough to help me out.

 

[Hernandez]

In my experience Nephrologists as a whole tend to be reasonable, my approach will be are they sick enough that I think we need it now, and I'll indicate to nephrology if I think so, and I will have generalized requests for fluid balance goals if possible. The rest I leave to them. I've had so few push back on sick pts that I can remember the 2 times I told them to make it happen or I'll call the other group anyways, and that was always with a nephro fellow

 

[europeman]

There is this large group of people who went to special training to learn how to specifically take care of the kidneys. They are called "nephrologist". If you think you know better than thru do you are either 1) an idiot or 2) a surgeon.

Where I work it's a collaboration. I defer to nephrology opinion but if I think I need it bad enough they are nice enough to help me out.

Hello. Thanks for the response. No need for the remarks about idiot/surgeon. Many institutions have crrt run without Nephrology at all (university of Maryland ICU's, Mount Sinai in NYC) with intensivists who are neither surgeons or nephrologists, while others totally use nephrology. Depends on institutional skills/comfort/politics/etc. Many nephrologists (and of course most intensivists) have no experience with CRRT. So I disagree with that comment that somehow nephrologists are the only ones who can use crrt. The new CRRT machines are nothing like a traditional hemo-dialysis machine. It's analogous to saying only pulmonology should wean a ventilator and do bronchs, only ID should treat VAP, only surgery should be placing chest tubes, only CT surgery should be initiating ecmo, and only neurosurgery/neurology can medically manage increased icp. Again it's all training/experience/comfort of the doctor involved. All those skills above obviously aren't sub-specialty procedure at every hospital - just depends.

That said, I'm looking to get ideas from others who have a truly collaborative relationship with nephrology and crrt within the ICU. And when I say collaborative, I mean who has shared tasks/responsibility/minute-to-minute decision making capacity - especially in the setting of a closed ICU. Anywhere have ICU initiate it but nephrology follows? Or vice versa perhaps? Who puts the actual order?

 

[jdh71]

Hello. Thanks for the response. No need for the remarks about idiot/surgeon. Many institutions have crrt run without Nephrology at all (university of Maryland ICU's, Mount Sinai in NYC) with intensivists who are neither surgeons or nephrologists, while others totally use nephrology. Depends on institutional skills/comfort/politics/etc. Many nephrologists (and of course most intensivists) have no experience with CRRT. So I disagree with that comment that somehow nephrologists are the only ones who can use crrt. The new CRRT machines are nothing like a traditional hemo-dialysis machine. It's analogous to saying only pulmonology should wean a ventilator and do bronchs, only ID should treat VAP, only surgery should be placing chest tubes, only CT surgery should be initiating ecmo, and only neurosurgery/neurology can medically manage increased icp. Again it's all training/experience/comfort of the doctor involved. All those skills above obviously aren't sub-specialty procedure at every hospital - just depends.

That said, I'm looking to get ideas from others who have a truly collaborative relationship with nephrology and crrt within the ICU. And when I say collaborative, I mean who has shared tasks/responsibility/minute-to-minute decision making capacity - especially in the setting of a closed ICU. Anywhere have ICU initiate it but nephrology follows? Or vice versa perhaps? Who puts the actual order?

I've always thought it was cute when nonexperts think they are as good as the experts.

I think it shows a lack of real self-awareness.

But that's just my opinion. I'm sure I could do a half way decent job of running crrt if I wanted to. But why would I?

I work closely with my nephrology colleagues. If I ask for a more dry run, want to push the sodium higher, or would like to buffer acid in unique situations. They come in whenever. It's great. Maybe if my nephrology friends were jerks and unhelpful I might consider learning how to half ass the whole thing. I'm sure it's not rocket science. But with anything in medicine the devil is in the nuance.

 

[europeman]

I've always thought it was cute when nonexperts think they are as good as the experts.

I think it shows a lack of real self-awareness.

But that's just my opinion. I'm sure I could do a half way decent job of running crrt if I wanted to. But why would I?

I work closely with my nephrology colleagues. If I ask for a more dry run, want to push the sodium higher, or would like to buffer acid in unique situations. They come in whenever. It's great. Maybe if my nephrology friends were jerks and unhelpful I might consider learning how to half ass the whole thing. I'm sure it's not rocket science. But with anything in medicine the devil is in the nuance.

Sounds like u have a great set up - coupled with lack of incentive to do it yourself so I don't blame you. One of my good friends is a nephrology trained intensivist who is a big proponent of ICU run (non nephro run) crrt actually because it ends up being a more efficient use of resources at many places. Again depends on the setup of the individual place. I assure you with proper training you wouldn't half ass it! Why are you so bitter? U must be a Micu attending? 😉 j/k

For me I was trained in the mode in units with and without nephro. Frankly the care was identical, but it was just a bit more complicated with nephro from a time perspective - having to call them and wait etc. Where I'm at now though I have limited resources and I'm at a place with no ICU fellow BUT with nephro fellows (and no nephro attending with experience using it) so I'm being asked to essentially run it, AND also incorporate the nephro fellows (which I am a big proponent for them to learn!) and (hopefully) nephro attendings (some of which are not enthused about it, but some of which really want us to start).

Hence my questions.....

 

[jdh71]

Sounds like u have a great set up - coupled with lack of incentive to do it yourself so I don't blame you. One of my good friends is a nephrology trained intensivist who is a big proponent of ICU run (non nephro run) crrt actually because it ends up being a more efficient use of resources at many places. Again depends on the setup of the individual place. I assure you with proper training you wouldn't half ass it! Why are you so bitter? U must be a Micu attending? 😉 j/k

For me I was trained in the mode in units with and without nephro. Frankly the care was identical, but it was just a bit more complicated with nephro from a time perspective - having to call them and wait etc. Where I'm at now though I have limited resources and I'm at a place with no ICU fellow BUT with nephro fellows (and no nephro attending with experience using it) so I'm being asked to essentially run it, AND also incorporate the nephro fellows (which I am a big proponent for them to learn!) and (hopefully) nephro attendings (some of which are not enthused about it, but some of which really want us to start).

Hence my questions.....

Hm. How well does it bill?? What's the wrvu on running the thing?

 

[Doctor Bob]

That said, I'm looking to get ideas from others who have a truly collaborative relationship with nephrology and crrt within the ICU. And when I say collaborative, I mean who has shared tasks/responsibility/minute-to-minute decision making capacity - especially in the setting of a closed ICU. Anywhere have ICU initiate it but nephrology follows? Or vice versa perhaps? Who puts the actual order?

For us, we determine the type of dialysis needed (HD/SLED or CRRT); then renal comes in and puts in the starting orders. We then put in the hour to hour changes (removal rate, etc). Renal comes by once a day and tweaks the diasylate. It's a team effort. In theory either of us could do it entirely alone, but what ends up happening is that we have the 30,000 ft view of what's needed, and we also have real-time control; and renal makes it work in the way we want.

 

[Nash]

For us, we determine the type of dialysis needed (HD/SLED or CRRT); then renal comes in and puts in the starting orders. We then put in the hour to hour changes (removal rate, etc). Renal comes by once a day and tweaks the diasylate. It's a team effort. In theory either of us could do it entirely alone, but what ends up happening is that we have the 30,000 ft view of what's needed, and we also have real-time control; and renal makes it work in the way we want.

My experience has been similar to Doctor Bob's, although I'm a pulmonologist by trade. I've had experience in both closed and open ICUs. The closed units have typically been academic MICU and SICUs, and the open units have typically been large community-based mixed med-surgical ICUs. In the closed MICU, Nephro has generally taken ownership of all of the CRRT-related orders. We still placed the lines and made hourly overnight adjustments, if necessary. In the open med-surgical ICUs, we placed the lines and initiated CRRT. Nephro would get consulted on all of those patients and would make recommendations regarding changes to dialysate, flow rates, etc. However, we wrote and adjusted all of the orders, so we really had "ownership" of CRRT. In general, I've always had a collegial relationship with the nephrologists and rarely disagreed about overall management of CRRT. Overall, the nephrologists I've worked with have preferred the open setup, because they don't have to come in overnight, and they don't get paged over and over again for minor adjustments. Plus, they get involved up front and can help navigate through any potential issues, instead of getting asked to fix things a week or two into CRRT (which is not all that infrequent in some of our ICUs).

 

[europeman]

Thanks for the responses.

For those of you who consulted nephro for CVVH but functionally controlled the orders and such - may I ask what were some situations where they helped? I mean.... Were you having filter clotting problems and needed help with that? Or was the potassium high and you needed Recs for which replacement fluid to use?

I'm genuinely interested because at my program where we are starting crrt, I WANT nephrology involved for their fellows experience/education. But clinically, these new machines (Prismaflex or Nextstage) are sorta the equivalent to an iPhone.... They are pretty simple. I mean you need to set an initial blood flow rate (fast) and replacement fluid (fast initially then come down to a reasonable dose later) and the patients labs look like the labs of your CRRT fluid. So I'm just curious..... What exactly does nephrology help you with?

I mean when I need an anatomic Echo of a heart I call cards. When I have a complicated infected patient with several resistant organisms I call ID. When I need intermittent hemodialysis I call renal (cuz I have no clue how to order IHD, have no experience/business doing it, etc). But with CRRT, and specifically CVVH I just don't see it? Of course this may be because I trained at a place where we did our own crrt (some of our ICU attendings were actually nephrologists too) so perhaps I'm just more comfortable than the average intensivist who always called renal. I get that.

I guess for those of you who control your CRRT but still val renal..... Besides the political niceties and input of another smart doctor..... How are they helping u clinically with situations?

Comments?

 

[Hernandez]

How do you transition off crrt to ihd as they stabilize?

 

[Nash]

How do you transition off crrt to ihd as they stabilize?

This is actually one of the reasons I like having Nephrology on board, the exit strategy. It's fairly common for my patients to require IHD for a period of time before they have enough renal recovery to stop RRT all together.

 

[europeman]

How do you transition off crrt to ihd as they stabilize?

At our hospital generally we called renal when the patient was anticipated to be downgraded from ICU but still hadn't recovered renal function.

 

[mochief2000]

This is an informative post. In my residency and in my current fellowship, Nephrology pretty much takes ownership of all things renal (CRRT, HD). The intensivists essentially put in lines for them. Mind you, both of these places where large academic places with nephrology fellowships. When i first read your question, I thought it was absurd, why would a intensivists run CRRT. I have seen them make suggestions, which nephrology follows, but not start it up and manage it. I have to say thank you, as I for one did not have plans of truly learning this in fellowship, but seeing how it is not that uncommon as I previously thought it probably worth learning. - Einstein

 

[Hernandez]

At our hospital generally we called renal when the patient was anticipated to be downgraded from ICU but still hadn't recovered renal function.

That sounds like consulting me for respiratory failure after they're trached

 

[europeman]

That sounds like consulting me for respiratory failure after they're trached

I don't understand what you mean? We called renal when IHD was needed. This USUALLY coincided around the time the patient was going to be downgraded from the ICU (ie cuz they were no longer "critical" or "unstable"). Of course there are a subset of patients whom were still in need of critical care but did not have renal recovery yet, but did not necessarily need CRRT (say they had rock stable hemodynamics but on going ventilator weaning or something) and could therefore just get IHD. Those patients got a nephro consult.

Nephro actually was very happy we managed our own crrt and were happy we didn't bother them with it because they were busy as it was. And their fellows still got to manage crrt in the micu (for whatever historic/political reason) of the hospital (whereas crrt was intensivist run in the Neuro ICU, Neurotrauma ICU, trauma ICU, surgical ICU, cardiaC surgery ICU, and lung transplant/ecmo ICU.

Anyway at my current shop, we are in the process of starting CRRT in all the units and we plan to collaborate with nephro for a variety of reasons. Likely CRRT orders/initiation though will be kept within the bounds of the ICU.

 

[europeman]

This is an informative post. In my residency and in my current fellowship, Nephrology pretty much takes ownership of all things renal (CRRT, HD). The intensivists essentially put in lines for them. Mind you, both of these places where large academic places with nephrology fellowships. When i first read your question, I thought it was absurd, why would a intensivists run CRRT. I have seen them make suggestions, which nephrology follows, but not start it up and manage it. I have to say thank you, as I for one did not have plans of truly learning this in fellowship, but seeing how it is not that uncommon as I previously thought it probably worth learning. - Einstein

You 100% should learn this! In my opinion this should be within the domain of critical care and not nephrology since fluid management is such an integral component of ICU care.... That said at my shop for a variety of educational, political, and practical reasons (coverage) I'm planning to make this a collaborative therapy in my ICU.

Here is food for thought.... The physician who is in charge of the 24/7 support service for the Prismaflex CRRT device, one of the popular machines in the country, is a Pulm/critical care physician - not nephrologist.