Citrate Practicall Issues - CRRT Online

1 Citrate AnticoagulationNEXT Return to Main MenuOverviewPractical IssuesSample OrdersHELPSEARCHPRINTCRRTThe Sixth InternationalContinuous Renal replacement TherapiesConferenceSan Diego, California PRACTICAL Issues IN Citrate ANTICOAGULATIONS liding scales for adjusting Citrate Flow ratesGeneral principles:-Initial Citrate flow rate (4% trisodium Citrate ) 2-3% of blood flow rate for BFR 100 ml/min Citrate flowis 180 ml/hr or 3 patients with hepatic insufficiency or coagulopathies start with Citrate flow rates of 130-160 ml/min forBFR of 100 Set a ceiling and a floor for Citrate flow rates do not increase Citrate flow rates above 210 ml/hr orbelow 100 ml/hr for BFR of 100 ml/min. In most situations this is Make sure sliding scales are reviewed periodically and are changed based on changes in dialysisprescription BFR or that unless bicarb is added to dialysate or replacement fluid Citrate is the only base being addedto system hence if Citrate flow rates are reduced acidemia may ensue and similarly if flow rates areincreased alkalemia can ) Sliding Scale for Citrate adjustment using Post-filter ACT (Replaced by post-filter ionized calcium scale)

2 Check ACT values every 4 hours x 24 then every 6-8 hrs x 24 then every 8- 12 hrs unless change inBFR or operational value 180-220 secsACT < 140 Increase Citrate flow by 15 ml/ hr and call nephrologist on callACT 140-159 Increase Citrate flow rate by 10 ml/hrACT 160-179 Increase Citrate flow rate by 5 ml/hrACT 180-220No change ( Initial Citrate flow rate 180 ml/hr assuming BFR 100 ml/min)ACT 221-240 Decrease Citrate flow rate by 5 ml/hrACT 241-260 Decrease Citrate flow rate by 10 ml/hrACT > 260 Decrease Citrate flow by 15 ml/ hr and check access and call NephrologistCitrate AnticoagulationNEXT PREVIOUSR eturn to Main MenuOverviewPractical IssuesSample OrdersHELPSEARCHPRINTCRRTThe Sixth InternationalContinuous Renal replacement TherapiesConferenceSan Diego, California Do not exceed Citrate flow > 210 ml/hrDo not decrease Citrate flow < 100 ml/hrb)

3 Sliding Scales for Citrate adjustment using Post-Filter ionized post filter ionized calcium every 4 hours x 24 then every 8 hours x 24 then every 12 hoursunless change in BFR or operational value mmol/LPost-filter ionized calcium > mmol/LIncrease Citrate flow by 15 ml/ hr and callnephrologist on callPost-filter ionized calcium mmol/LIncrease Citrate flow rate by 10 ml/hrPost-filter ionized calcium mmol/LIncrease Citrate flow rate by 5 ml/hrPost-filter ionized calcium mmol/LNo change (Initial Citrate flow rate 180 ml/hrassuming BFR 100 ml/min)Post-filter ionized calcium mmol/LDecrease Citrate flow rate by 5 ml/hrPost-filter ionized calcium < mmol/LDecrease Citrate flow rate by 10 ml/hrand check access and call NephrologistDo not exceed Citrate flow > 200 ml/hrDo not decrease Citrate flow < 120 ml/hrc) Sliding Scale for calcium chloride flow rates based on peripheral Ionized calcium ( normal values )Check peripheral ionized calcium every 4 hours x 24 then every 8 hours x 24 then every 12 hoursunless change in BFR or operational value mmol/LPeripheral Ionized Ca < calcium flow by 15 ml/ hr and give 20ml of Ca Gluconate(2 amps IV bolus) and call nephrologist on callPeripheral Ionized Ca calcium flow by 10 ml/ hr and give 20ml of Ca Gluconate(2 amps IV bolus)

4 Peripheral Ionized Ca calcium flow by 5 ml/ hr and give 10ml of Ca Gluconate (1amp IV bolus) Citrate AnticoagulationNEXT PREVIOUSR eturn to Main MenuOverviewPractical IssuesSample OrdersHELPSEARCHPRINTCRRTThe Sixth InternationalContinuous Renal replacement TherapiesConferenceSan Diego, California Peripheral Ionized Ca calcium flow rate by 5 ml/hrPeripheral Ionized chloride (1meq/10cc saline) flow rate (initial) 40 ml/hr(assuming BFR 100 ml/min and Citrate flow rate of 180 ml/hr))Peripheral Ionized Ca calcium flow rate by 5 ml/hrPeripheral Ionized Ca calcium flow rate by 10 ml/hrPeripheral Ionized Ca > calcium flow by 15 ml/ hr and call NephrologistDo not exceed Calcium Chloride flow rate > 85 not decrease Calcium Chloride flow rate < 30 ml/hrSpecial considerations for Citrate anticoagulation The following Issues deserve special site of delivery of Citrate should be as close to the catheter as possible.

5 We use a threeway stop-cock at the catheter exit site and start the Citrate infusion at this point. The calcium dripshould not be in the circuit and should be preferably in a central pump speed on the roller pump may not necessarily reflect the delivered flow rate and inthis situation, you will find that the post filter ACT s or ionized calcium tend to go up as theproportion of Citrate delivered to more than needed. If this happens, I would look diligently foraccess problems, particularly for poor flow from the arterial the setting of hepatic failure, the total amount of Citrate needed is generally less. Also thecitrate load is not from the Citrate anticoagulation for dialysis, but from the vast amounts of wholeblood or FFP, and cryo precipitate given to these patients.

6 In this instance, we watch for thedevelopment of a Citrate gap characterized by an increased anion gap, lower ionized calciums andhigh total calciums. The latter occurs as the low ionized calciums trigger an increase in thecalcium chloride given back to the patient. Once the Citrate is metabolized or Citrate flow rates arereduced, the anion gap corrects and the ionized calciums return to normal rates. Setting a floor andceiling for Citrate and calcium flow rates limits these check our ionized calciums initially every 4-6 hours and subsequently once every 12hours. We utilize a sliding scale on the calcium flow rates similar to that of the Citrate . This tendsto automate the should anticipate filter life anywhere from 4-6 days using this protocol.

7 We routinelyCitrate anticoagulation PREVIOUSR eturn to Main MenuOverviewPractical IssuesSample OrdersHELPSEARCHPRINTCRRTThe Sixth InternationalContinuous Renal replacement TherapiesConferenceSan Diego, California measure sieving coefficients (ultrafiltrate to pre-filter urea nitrogen ratio) every 12 hours and usethese to guide our filter changes. We will change a filter if the sieving coefficients for UreaNitrogen is or less. We have found that this method allows us to assess for clotting before We utilize standard Citrate orders to allow our pharmacy to make the appropriate dialysissolution. Our standard formulation uses 1 liter of saline to which is added 40 ml of 23%saline, meq of Magnesium and 0-5 meq of potassium. We use a dextrose concentration whichis variable in a dialysis solution from to depending upon the caloric need for the general, most of our patients are now utilizing a dextrose and dialysate solution.

8 In somecircumstances we add bicarbonate to the dialysate substituting the 23% Na Cl with Na HCO3 sothat final concentration of Na is 117 meq/L. The final concentration of dialysate has Na 117 meq/L, Mg meq/L, K 0-5 meq/L and dextrose Usually 4L bags areprepared by the pharmacy. The prepared solutions can easily be stored for several days as they dialysate flow rates are 1L/hr. If you do increase the dialysate flow rates to 2L/hr, youshould anticipate a greater removal of bicarbonate and Citrate and therefore your Citrate flow ratesmay need to be changed. If you use higher blood flow rates, you may want to increase your citrateflow rates. From our studies, we know that to a large extent there is a still a greater excess ofcitrate in the circulation, so you should not have to increase your Citrate flow rate much beyond 250mls even if your blood flow rates are in the 200-250 mls/min will be glad to assist you with any L.

9 Mehta MD CRRT Program,UCSD Medical Center,200 W. Arbor Street,San Diego CA 92103 Tel 619-294-6083 Fax 619-291-3353 Page 619-543-6737 bpr 290-5598e-mail: Or