I recommend involving your nephrologists. Where I trained we ran all RRT modalities in the M/SICU/Burn units. If someone needed CVVH in the middle of the night we were there. In practice I run all RRT. We have a good collaboration with our ICU physicians and sure there are times we have disagreements about modality of RRT or whether someone even needs RRT (I get a lot of consults telling me a patient needs RRT when in fact they do not) but that's why I have specialty training in dialysis therapy and the vast majority of time my colleagues value this. Just as I defer to their expertise for decisions on when to operate, when/if to bronch, when to tap that pleural effusion, etc.
I guess as long as your hospital credentialing committee gives you CRRT privileges (and your malpractice carrier covers your scope of practice to include CRRT) you can sure go about it , but to do so without a nephrologist actively managing the circuit I think would be a bad idea.
I genuinely appreciate your response! I suspect you have been at your institution for a while, and since you run the pump, your Icu colleagues have overtime never aquiried expertise in it. At many ICUs, intensivists safely and completely run CRRT without nephrology consultation (university of Michigan, university of Maryland, mount Sinai in NYC). What I'm getting at is the notion that running CRRT without a nephrologist actively managing the circuit is a bad idea is something I disagree with. Curious.... What pump do u use at your shop?
There are analogies to everything in critical care which have been debated over time. People used to think u need a pulmonologist to manage a vented patient or do bronchoscopy. Or you need a cardiologist to do bedside goal directed echo. Or you need a surgeon to place a chest tube or do a percutaneous tracheostomy. Or you need a neurologist to manage increased intra-cranial pressure. Or a psychiatrist to manage ICU delirium. Or a CT surgeon to manage ecmo. Or an anesthesiogist for every intubation or moderate sedation. Or a.... The list goes on and on. I'm not saying every Icu or Icu doc should do the aggregate of all the aforementioned skills; rather, I'm saying that Icu docs are fully capable IF properly trained and with proper experience to do a wide range of therapies for their patients..... There is a reason ICUs are all becoming closed.... Outcomes are better.
I think what's more important is understanding the notion that critical care and utilization of experts in different field is dependent on local needs/expertise/resources.
That said, CRRT certainly and by all means falls into that paradigm.
that said.... I trained at a place where CRRT was exclusively run by ICU docs. In fact, some of the Icu attendings were nephrologists, and their political support of keeping it within the paradigm of the Icu and not nephrology was part of the reason it was run that way - these nephrologists felt strongly that CRRT should be run by Icu docs. And thus my training was in large part from nephrology intensivists literally training me how to use the modality and utilize my nephrology consult resources for other purposes (thus maximizing efficiency on both services parts).
Anyway at my current job I'm starting a program and I genuinely want our nephrology fellows not to lose out on this valuable experience and important modality and thus I'm looking for ways to maximize this effort. Indeed I believe in multi-disciplinary training paradigms and such. What I don't need, however, is a nephrologist telling me my patient doesn't "need CRRT" when they don't have a clue as to the critical care indications which are practical "on the ground" (and their being unfamiliar with this doesn't bother me rather it's the sometimes refusal to listen and get experience/perspective from the Icu) which differ drastically from Classic emegency IHD criteria. I'm not trying to frame all nephrologists like this. Not by any means. This phenomenon happens in all fields! Myself included. I'm a surgeon. That doesn't mean I'm god when it comes to the decision to operate. I genuinely try and take my colleagues opinions into consideration. The other day there was a kid in the pediatric Icu who we were called about who met all objective criteria for requiring an emergency laparotomy. The Peds Icu doc stopped me, explained his perspective, and I disagreed with him BUT I respected his knowing the patient better than me and we agreed to disagree AND agreed to watch him together for a little longer before bringing the scalpel. He was right in the end and didn't need an operation.
The decision to initiate CRRT is a complex one which actually is betters suited for an ICU doc in my opinion. A nephrologist certainly can be at this same level (or above!).... But most aren't simply because their involvement in critical care is limited. My goal is to make sure our nephrology fellows get this additional perspective. If a patient is in the grey zone to need RRT from aki..... I may place him on the pump if he's a recent intra-ventricular brain bleeder with borderline icp because I know these patients SIRS response and high fever will be difficult to control (aggressive cooling blanket, increased sedation and sometimes paralysis to tx shivering, having to increase the minute ventilation because spontaneous breathing is now gone, etc) when if I just put him on the pump - boom fevers controlled and aki I don't need to worry about. And better yet.... Icp difficult to manage when your patient has a fever..... Yet another reason to be aggressive early on. Tell me one community nephrologist who does the occasional Icu consult would even think about this kinda stuff? You? Yes. Most nephrologists.... No.
Let me be clear.... It's not the speciality. That's my point. Is the experience and training. in short, it's just frankly wrong to say u *need* a nephrologist. U *need* the proper Doctor. That said in my unit we will hAve a closed system whereby all CRRT orders placed and managed by ICU but with active participation/consultation/oversight by nephrons. Best of both worlds!
This post too long! I mean all the above with the most optimist demeanor and tone... I hope u take it as such. Warm regards.... Europeman
