ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI. CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) HEPARIN ANTICOAGULATION Page 1 of 5

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Winfred Hutchinson
7 years ago
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1 HEPARIN ANTICOAGULATION Page 1 of 5 Pharmacy Mnemonic: CRRTHEP1 PATIENT DATA: DIAGNOSIS: AKI ESRD Other: WEIGHT: Today: kg Admission Weight:: kg Dry Weight: kg Access TYPE: Temporary Dialysis Catheter Tunneled Dialysis Catheter LOCATION: Internal Jugular Right Left Femoral Right Left Other: Catheter Lock Solution: 4% Trisodium Citrate Heparin (1000 IU/mL) Other: MODE OF THERAPY: CVVHDF CVVHD CVVH SCUF RECORD ON SIDE OF FILTER THE DATE AND TIME THE TREATMENT BEGAN Filter Set: HF 1400 Prime options: Heparin Flush followed by Normal Saline Rinse(add 10cc Heparin 1000 units/ml to 1 liter of 0.9% normal saline flushed through circuit followed by another 1 Liter of 0.9% normal saline flushed through circuit) LABS: Normal Saline (2 liters) (NO HEPARIN) Potassium, Sodium, Chloride, Bicarbonate, Creatinine, BUN, Magnesium, Ionized Calcium, Phosphorus PT/PTT CBC Lactic Acid Total Calcium ABG Other: At initiation, then at 3 AM, 11 AM, and 7 PM At 3 AM and then 3 PM Other: HEPARIN ANTICOAGULATION LOW DOSE HEPARIN ANTICOAGULATION (USE SYRINGE PUMP FOR HEPARIN INFUSION) HEPARIN (concentration 1,000 units/ml) ( i.e. 500 units/hour = 0.5 ml/hr, 1,000 units/hour = 1 ml/hr ) BOLUS LOADING DOSE: UNITS IV RATE: UNITS/HOUR. HIGH DOSE HEPARIN ANTICOAGULATION (MEDICATION INFUSION PUMP) HEPARIN LOAD DOSE: UNITS IV, then HEPARIN 25,000 UNITS IN 250 ml 0.45% SODIUM CHLORIDE at ml/hour FOR HEPARIN ANTICOAGULATION ONLY PTT EVERY 6 HOURS If PTT is less than 35, repeat loading dose and increase hourly by 3 ml/hour. If PTT is 35 to 50, repeat 50% of loading dose, and increase hourly by 2 ml/hour. If PTT is 51 70, no change in rate, at goal. If PTT is 71 90, decrease hourly by 2 ml/hour. If PTT is greater than 90, stop infusion x 1 hour, then resume with decrease of 2 ml/hour. *NOTIFY MD IF RATE IS GREATER THAN 2,000 UNITS/HR *MAX RATE IS 5,000 UNITS/HR.

2 HEPARIN ANTICOAGULATION Page 2 of 5 Pharmacy Mnemonic: CRRTHEP2 Blood Flow Rate: ml/minute Recommended minimum flow rate of 200 ml/minute Replacement Solution and Flow Rate: Total Replacement Rate: ml per hour: Standard Rate 25 ml/kg/hr Predilution Replacement Fluid at % Postdilution Replacement Fluid at % MAY USE PRISMASATE OR PRIMASOL AS REPLACEMENT FLUID BUT MAY NEED ADDITIVES!! MAY PLACE ANY PERCENTAGE OF REPLACEMENT FLUID PRE OR POST FILTER!! PRISMASOL PRISMASATE Normal Bicarbonate KCl: 4 meq/l B 22 GK 4/0 Normal Bicarbonate KCl: 4 meq/l B 22 GK 4/0 High Bicarbonate KCl: 4 meq/l BGK 4/0/1.2 High Bicarbonate KCl: 0 meq/l BGK 0/3.5 High Bicarbonate KCl: 2 meq/l BGK 2/0 High Bicarbonate KCl: 2 meq/l BGK 2/0 ADD TO ABOVE INDICATED FLUIDS: Dialysate Fluid: RATE: ml/hour ( CVVHDF or CVVHD) (USE GREEN CALES) Standard = No Dialysate Normal Bicarbonate with 4 meq/l KCL ( B 22 GK 4/0 Prismasate ) High Bicarbonate with 2 meq/l KCL ( BK 2/0 Prismasate ) High Bicarbonate with 0 meq/l KCL and 3.5 meq/l Ca++ ( BK 0/3.5 Prismasate ) ADD TO ABOVE INDICATED Prismasate : NET VOLUME BALANCE: Match input with output Net Volume Negative - ml/hour up to L per 24 hours No Fluid Pull Other: Consult Pharmacy for drug dosing while on CRRT. Consult Pharmacy to concentrate all fluids. **ALWAYS Notify pharmacy when CRRT is initiated, discontinued. or placed on hold for any reason.** HEPARIN ANTICOAGULATION Page 3 of 5

3 Pharmacy Mnemonic: CRRTHEP3 Notify Nephrologist if and when FILTER clots. Notify Nephrologist if ACCESS PRESSURES continue to trend toward out of range. (See Table Below) Notify Nephrologist if bicarbonate is < 15 mmol/l or > 30 mmol/l after 12 hours of therapy. OPTIONAL: Electrolyte Replacement Infuse Electrolyte Replacements ONLY while CRRT is running. Discontinue all electrolyte replacement infusions when CRRT is disconnected for ANY reason. Calcium Chloride: 25 grams in 250 ml Normal Saline (total volume 500 ml) Infusion rate: grams/24 hours **Always Infuse Calcium Chloride post filter via y-connector between circuit and catheter return lumen Sodium Phosphate: 30 mmol in 250 ml Normal Saline (total volume = 260 ml) Infusion rate: mmol/24 hours Potassium Phosphate: 30 mmol in 250 ml Normal Saline (total volume = 260 ml) Infusion rate: mmol/24 hours Magnesium Sulfate: 4 grams in 100 ml Water for Injection (total volume = 100 ml ) Infusion rate: grams/24 hours **** Hold for Mg++ levels > 2 Daily Weights HEPARIN ANTICOAGULATION Page 4 of 5

4 STANDARD SOLUTIONS USED DURING CRRT: ******************************************************************************************************************************* NORMAL BICARBONATE SOLUTIONS: HIGH BICARBONATE 0 K+ SOLUTIONS: HIGH BICARBONATE 2 K+ SOLUTIONS Prismasate B22GK 4/ ml Prismasate BK 0/ ml Prismasate BK 2/ ml Potassium 4 meq/l meq/l Calcium meq/l 0.0 Magnesium 1.5 meq/l 1.0 meq/l 1.0 meq/l Sodium 140 meq/l 140 meq/l 140 meq/l Chloride meq/l meq/l 108 meq/l Bicarbonate 22 meq/l 32 meq/l 32 meq/l Lactate 3 meq/l 3 meq/l 3 meq/l Dextrose 110 mg/dl Osmolarity 296 mosm/l 287 mosm/l 286 mosm/l NORMAL BICARBONATE SOLUTIONS: HIGH BICARBONATE 4K+ SOLUTIONS: HIGH BICARBONATE 2K+ SOLUTIONS Prismasol B22GK4/ ml Prismasol BGK 4/0/ ml Prismasol BGK 2/ ml Potassium 4 meq/l 4 meq/l 2 meq/l Calcium Magnesium 1.5 meq/l 1.2 meq/l 1.0 meq/l Sodium 140 meq/l 140 meq/l 140 meq/l Chloride meq/l meq/l 108 meq/l Bicarbonate 22 meq/l 32 meq/l 32 meq/l Lactate 3 meq/l 3 meq/l 3 meq/l Dextrose 100 mg/dl 100 mg/dl 100 mg/dl Osmolarity 296 mosm/l 295 mosm/l 291 mosm/l TABLE OF RECOMMENDED PRESSURES FOR CRRT: HEPARIN ANTICOAGULATION Page 5 of 5

5 ARTERIAL --50 mmhg -150 mmhg VENOUS +50 mmhg +150 mmhg PRE/FILTER +100 mmhg +250 mmhg BLOOD PULLED OUT OF THE VEIN POSITIVE BLOOD PUSHED BACK INTO THE VEIN POSITIVE BLOOD PUSHED THROUGH NARROW FILTER FIBERS **WILL BECOME MORE POSITIVE AS FILTER FIBERS CLOT TMP TRANSMEMBRANE PRESSURE < 0 mmhg > mmhg POSITIVE OR PLASMA WATER PUSHEDOUT OF THE WHOLE BLOOD (+VE) OR PLASMA WATER PULLED OUT OF THE WHOLE BLOOD (-VE) THROUGH THE FILTER FIBERS PORES BECOMING THE EFFLUENT **WILL BECOME MORE POSITIVE AS FILTER FIBERS PORES BLOCK EFFLUENT > + 50 mmhg mmhg POSITIVE OR THERAPY DEPENDANT *WILL BECOME MORE AS FILTER FIBERS PORES BLOCK / Date Time Physician Signature

Replacement post-filter (ml/hr) Blood flow (ml/min) Dialysate (ml/hr) Weight (kg)

Replacement post-filter (ml/hr) Blood flow (ml/min) Dialysate (ml/hr) Weight (kg) 404FM.1 CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) USING CITRATE Target Audience: Hospital only ICU (Based on Gambro and Kalmar Hospital protocols) CRRT using regional citrate anticoagulation This is