American journal of kidney diseases : the official journal of the National Kidney Foundation
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Review Comparative Study
CRRT in the area of cost containment: is it justified?
Intensive care accounts for at least 25% of health care costs. One third of this goes to 10% of patients who, in general, have combined respiratory and renal failure. The cost of renal replacement therapy is, therefore, of major importance. ⋯ When comparing randomized patients in a recent prospective trial, aggregate costs for renal replacement therapy were comparable. The advantages of better nutrition, better fluid balance, easier management of hemodynamics, and more complete renal recovery, as suggested by this study, should continue to make it valuable. Physician acceptance of CRRT advantages has been established and suggests clinical benefit despite any potential increased cost.
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It is routine in hemodialysis units to require a chest radiograph after the insertion of an internal jugular line for venous access before dialysis is commenced. There are two principal reasons for this: (1) to ensure that no procedural complications have occurred and (2) to verify correct catheter placement. Knowledge of the time delay involved may prompt nephrologists to opt for femoral access (with increased hemodialysis recirculation and need for repeated line placement). ⋯ There was no case of associated pneumothorax. Of the 370 line insertions in 250 patients in whom it was believed clinically that no complication had occurred, the chest radiograph only showed unsuspected line malposition in four cases (1.08%). Routine chest radiographs rarely contribute to the diagnosis of any procedural complications and are of little value after internal jugular access placement, especially if it is believed clinically that no complication occurred.
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Continuous renal replacement therapy (CRRT) is performed in critical care units around the world with various levels of involvement from critical care and nephrology nurses. In this article, factors affecting the delivery of nursing care and the particular expertise nephrology and critical care nurses have in the area of CRRT are examined. ⋯ Based on related research findings and a comparison of the models, the Collaborative Model is the preferred one, as it brings the highest level of expertise directly to the patient. For the Collaborative Model to work, a framework for collaboration and a high degree of commitment from both specialties must be maintained.
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The arrival of continuous renal replacement therapy (CRRT) has given the intensivist and the intensive care nurse the opportunity to treat acute renal failure (ARF) independently by giving them the necessary technology and taking CRRT away from absolute nephrological control. This structural shift has created a controversy between those countries where control of CRRT has completely shifted to the intensivist and those countries where nephrological input is still dominant. The argument in favor of intensivist-driven CRRT rests upon several observations, including the fact that therapy is continuous, as is the presence of the intensivist in the intensive care unit (ICU). ⋯ Intensivists are successfully performing more and more procedures that were previously seen as part of other specialties and, last but not least, "closed" models of ICU care appear to work best. Australian intensivists have taken up CRRT from the start and now control it. Patient outcomes under such a system, as reported here, are above average, and confirm the effectiveness of such an approach.
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Continuous renal replacement therapy (CRRT) in the intensive care unit (ICU) requires a dedicated training and educational process that includes both theoretical and practical approaches. Important goals for this process include achieving an acceptable circuit life without patient complications and providing a high percentage of staff with bedside expertise. Lectures or didactic sessions must link into bedside instruction and simulations or mock patient/circuit setup. ⋯ Managers require a system of staff review to ensure expertise levels are maintained. Policy development, quality assurance, and complication monitoring systems provide useful information for managers and educators in this field. Credentialing may be useful to confirm the goals of CRRT, but it requires further development of practice standards before adoption.