CRRT Updates and Reminders - Aug 2023.pptx

CRRT Updates and Reminders for practice

1. So You are Starting CRRT?

2. Break frangible pin or peel seal CRRT 2024 2

3. No claves on effluent bag CRRT 2024 3

4. Do NOT try to fool the scales CRRT Only the prescribed bag on each scale Do NOT add extra bag/ wt to scale 2024 4

5. Blood flows through the circuit in the same direction CRRT 2024 5 CRRT Circuit

6. CRRT 2024 6 No Calcium in replacement solutions Citrate in use Calcium-free solutions are used to avoid antagonism of the anticoagulation effect (of citrate) ZERO Calcium solutions

7. CRRT 2024 7 CRRT Stopped Calcium Infusion Must STOP calcium gluconate infusion when stopping CRRT or with prolonged access issues

8. So, you are Starting Citrate Do NOT use citrate if (or use extreme caution) any patient with shock liver (transaminase >1,000 units/L) Lactate > 8 mmol/L. Notify nephrologist. Prior to starting citrate protocol, iCa ++ should be greater than 1. If < 1 consult nephrologist for PRN Ca gluconate (plan to give 2 gm calcium gluconate). Repeat labs: check systemic ionized calcium at least q1 hours to ensure iCa >1 prior to initiation. CRRT 2024 8

9. 2024 9 Initiate Citrate Use Caution: Hypocalcemia at initiation Safety check: iCa ++ >1.0 prior to start Pt w/ liver disease Lactate > 8 mmol/L CRRT

10. Blood Flow Rate & Citrate Rate Changes to the blood flow rate will change the rate of citrate elimination at the filter. Maintain a steady blood flow rate whenever possible to minimize changes to the citrate and calcium requirements. There is a corresponding relationship between citrate flow rate and blood flow rate 10

11. Blood Flow Rate & Citrate Citrate rate (mL/ hr ) is typically 0.5 – 1.5 x the blood flow rate (mL/min) Standard citrate dose is 1.3-1.5 x M ost common: citrate starting at 1.5 x the BFR Setting of liver dysfunction, a lower starting dose of 1.0 x BFR can be considered. Example: BFR = 200 mL/min: For 1.0 x BRF = citrate 200 mL/ hr For 1.5 x BFR = citrate 300 mL/ hr BFR = 120 mL/min For 1.0 x BRF = citrate 120 mL/ hr For 1.5 x BFR = citrate 180 mL/ hr ↑ Blood Flow Rate = ↑ citrate use 11

12. Two (2) Different iCa ++ Titrations Monitoring ionized calcium in the circuit AND the patient Titrate Citrate infusion based on Post-Filter iCa ++ result Draw lab: from post-filter Titrate Calcium Gluconate infusion based on Pt’s Systemic iCa ++ result Draw lab: from arterial line (ideal default) or central line (if arterial line not present) Caution with lab result from central venous blood if the CVC and HD catheter tips are close to one another. CRRT 2024 12

13. Two (2) Different iCa ++ Titrations Post-Filter iCa ++ = assess the adequacy of anticoagulation Pt’s Systemic iCa ++ = pt calcium CRRT 2024 13