Regional Citrate Anticoagulation Protocol

1. Protocol1
35mL/kg/hr
IBW
(kg)
Post – dilution
(mL/h)
Blood Pump
(mL/min)
ACD-A (Citrate)
(mL/h)
<50 1400 120 180
50-59 1800 150 230
60-69 2100 180 270
70-79 2400 200 300
>80 2700 230 350
EXCLUSIONS
• Acute Liver Failure (INR>3)
• Serum Sodium < 120 or >
160 mmol/L
• pH > 7.5 or HCO3 > 40
mmol/L
CAUTIONS – may need more frequent ABGs
• Chronic liver disease
• Post hepatic Resection
• Requiring >6 u/h insulin infusion
• IBW> 90 kg (Use protocol 1 only)
• Lactate >5 mmol/L
STEP 1 – Exclusions and Cautions for the use of RCA
i Set up an RCA equipped haemofilter in CVVH mode using
an RCA circuit and HF12 Filter – All patients start on protocol 1
ii(a) Check systemic ionised calcium – if iCa is <1.0
• Add 10 mL of Calcium Chloride (These are specific 10 mmol
ampules for RCA) to 990 mL NaCl 0.9% (this makes CaCl
solution at 10 mmol/L) & mix well
• Ensure CaCl solution is clearly labeled with date and time
• CaCl solution MUST be changed every 24hours
ii(b) Check systemic ionised calcium – if iCa is ≥1.0
• Connect a 1 L bag of N-saline with a ‘NO CALCIUM’ sticker,
in place of the calcium bag
Monitoring
Baseline:
ABG iCa+ & HCO3
-
Lab U&E, Mg2+ & Ca2+
After one hour: ABG iCa+ & HCO3
-
Thereafter every 6 hourly:
ABG iCa+ & HCO3
- (if iCa <0.8 check
1 hour)
Every 12 hours: Lab U&E, Mg2+ &
Ca2+ (Aim Mg2+>1 mmol/L)
Systemic
iCa
Initial rate of CaCl
solution
Only use this table when starting RCA
<0.8
Do NOT commence RCA
Medical team to review &
correct Calcium
0.8-0.9 75 mL/h (0.75 mmol/h)
0.9-1.0 50mL/h (0.5 mmol/h)
>1.0
0mL/h (0 mmol/h)
Use a ‘NO CALCIUM’ bag
STEP 3 – CaCl rates & blood monitoring
ABG
[iCa]
CaCl infusion adjustment
(MAXIMUM RATE = 175 mL/h)
Repeat
< 0.8
• Doctor to give 5ml, 10% CaCl (3.4 mmol) ‘minijet’ by slow IV
bolus via a central line immediately
• Increase CaCl infusion rate by 50 mL/hr
• If patient not on CaCl, change the bag and start at 100 mL/hr
• If CaCl infusion already at 175 mL/hr stop RCA & inform
ACCU Consultant immediately
After
1 hour
0.8 –
0.89
• Increase 1CaCl infusion by 25ml/hr
• If patient not on CaCl, change the bag and start at 75 mL/hr
• If CaCl infusion already at 175 ml/hr cease citrate &
inform ICU Consultant immediately
After
3 hours
0.9 –
1.2
• No change
After
6 hours
> 1.2
• i. Decrease CaCl infusion by 25ml/hr
• ii. If CaCl infusion off then check systemic [iCa] in 3 hours
• Inform Doctor if [iCa] rises to >1.5
After
3 hours
STEP 2 – Preparation and Set up
STEP 4 – Calcium adjustment
Medway Maritime CRRT Regional Citrate Anticoagulation Protocol (RCA)
PROTOCOL 1
4acknowlegement
to Barts Health Trust