1. CONTINUOUS RENAL REPLACEMENT THERAPY PRESCRIPTION
ORDER
Please complete this form and attach to the drug chart.
Patient Name________________________ Hospital Number______________________
DOB_______________________________ Weight______________________________kg
RENAL REPLACEMENT MODALITY
Please select the renal replacement modality -
 Continuous venovenous haemofiltration (CvvHF)
 Continuous venovenous haemodifiltration (CvvHDF)
GENERAL RENAL REPLACEMENT PARAMETERS
Please complete the targets for the following parameters -
Desired blood flow (Normal 180-300ml/min) ________________________________________ml/min
Dialysate rate (if applicable) ___________ml/kg/Hr Total dose __________ml/hr
Replacement/exchange rate ___________ml/kg/Hr Total dose __________ml/hr
Total desired renal dose (Normal 35ml/kg/HR) ___________ml/kg/Hr Total dose __________ml/hr
Pre-dilution volume ___________________________________________%
Post-dilution volume ___________________________________________%
Fluid removal range ______________ml/Hr Starting rate _________ml/Hr
BUFFER SOLUTION
Please select the renal replacement fluid -
 Bicarbonate based buffer (Accusol)
 Lactate based buffer - Avoid in severe liver dysfunction, acidaemia (pH<7.2), hyperlactaemia (>8mmol/L))
 Citrate based buffer
Additional potassium prescription if needed (Target serum potassium ______________mmol/L)
 10-40mmol KCL incorporated into replacement fluid (Pre-prepared 20mmol bags available)
 10-40mmol KCL via central venous catheter over 1 hour
RENAL SUPPORT
Please select the anticoagulant to be used for RRT-
 Unfractionated Heparin Dose (normal 5-20 iu/kg/Hr)__________iu/Hr
 Prostacyclin (Flolan) Dose (normal 0-10)______________ng/kg/min
 Other (e.g.Citrate, include CaCl replacement prescription) Dose _________________________________
 None, please state reason for this decision ____________________________________________________
Please select method of monitoring to be used -
 Activated Partial Thromboplastin Time (APTT) Target Range __________ Frequency of measurement
APTTR (normally 1.5-2.0) ____ hourly (Normally 4-6°)
 Activated Clotting time (ACT) Target Range __________ Frequency of measurement
seconds (normally 160-200) ____ hourly (Normally 4-6°)
 Other, please specify (i.e. Calcium, TEG, Target Range ___________ Frequency of measurement

2. platelet count etc)______________________ _______________________ _____ hourly (Normally 6°)
In the event of multiple clotted filters, please select an appropriate intervention (inform on-call prior to initiation) -
 Use of more than one anticoagulant Please specify which ones _____________________
 Increase pre-dilution dose Please specify new dose ______________________
 Increase target range for anticoagulation ACT / New target _____________________
APTT
 Nothing
PRESCRIBING PROFESSIONAL
Doctor _____________________________________________ Grade _________________________________
Signature __________________________________________ Date __________________________________