CRRT Updates and Reminders for practice

1. So You are
Starting
CRRT?

2. Break frangible pin or peel seal
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3. No claves on effluent bag
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4. Do NOT
try to
fool the
scales
CRRT
• Only the prescribed bag on each scale
• Do NOT add extra bag/wt to scale
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5. Blood flows through the circuit in the
same direction
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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.
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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
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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
• Most 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.
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13. Two (2) Different iCa++ Titrations
• Post-Filter iCa++ = assess the adequacy of
anticoagulation
• Pt’s Systemic iCa++ = pt calcium
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