no yes conventional crrt yes yes

1 downloads 0 Views 3MB Size Report
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 ...
1

RLH ACCU CRRT Treatment Flowchart NOTE: Ideal Body Weight (IBW) is used for all weight based calculations in CRRT

CONVENTIONAL CRRT Is the patient contraindicated for Regional Citrate Anticoagulation (RCA)?

NO RCA CVVH Initial dose 35 mL/kg/h Suboptimal filter lifespan? Optimal venous access?

YES If NOT contraindicated for heparin consider Option If contraindicated for heparin consider Option

YES Choice of Anticoagulation

B Heparin CVVHDF Initial dose 35 mL/kg/h Suboptimal filter lifespan? Optimal venous access? Optimal heparin?

YES

None / Flolan CVVH ~100% pre dilution Initial dose 35 mL/kg/h

Option with heparin may be considered after clinical review

RLH ACCU CRRT Treatment Flowchart

HIGH DOSE TREATMENT ACCU CONSULTANT DECISION ONLY Indications can include: Refractory Metabolic Acidosis Refractory Shock Severe Rhabdomyolysis (CK>20,000)

CVVH 60 mL/kg/h 30% pre-dilution 70% post-dilution Patient IBW 75kg HF 19 filter

2

3

RLH ACCU CRRT Treatment Guideline Absolute Contraindications to RCA: • Serum Sodium 160 mmol/L

Regional Citrate Anticoagulation (RCA)

B Patient unsuitable for RCA but can receive heparin

Patient unsuitable for both RCA & heparin

High dose treatment for specific conditions

 d/w ACCU consultant about CRRT in general)

• Acute Liver Failure (INR>3) • pH > 7.5 or HCO3- > 40 mmol/L

Heparin can be administered via the CRRT machine or systemically

CVVHDF 35 mL/kg/h

No heparin infusion +/Epoprostenol (Flolan®) ~100% pre-dilution

CVVH 35 mL/kg/h

Refractory metabolic Acidosis Refractory Shock Severe Rhabdomyolysis (CK>20,000) ACCU consultant decision

CVVH 60 mL/kg/h 30% pre-dilution 70% post-dilution

Refer to specific RCA Protocol

• Review metabolic goals regularly • Switch to 25 mL/kg/h when appropriate • Refer to programming guideline

IBW < 75kg use HF12 IBW > 75kg use HF19

For all options, please refer to the specific programming guides for exchange rates

4

RLH ACCU CRRT Regional Citrate Anticoagulation Protocol (RCA) STEP 3 – CaCl rates & blood monitoring

STEP 1 – Exclusions and Cautions for the use of RCA 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

Systemic iCa

Only use this table when starting RCA 1.0

0mL/h (0 mmol/h) Use a ‘NO CALCIUM’ bag

STEP 2 – Preparation and Set up 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 1.2

• 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

PROTOCOL 1 IBW (kg)

Initial rate of CaCl solution

STEP 5 – Reducing the CRRT dose, managing metabolic alkalosis & increasing the citrate dose if the filter clots

Protocol 2 25 mL/kg/hr

keeping the filtration ratio at 20% IBW (kg)

Post – dilution (mL/hr)

Blood Pump (mL/min)

ACD-A (Citrate) (mL/hr)

80

1900

160

240

Re-check ABG for pH and HCO3- after 3 hours If pH>7.5 or

HCO3-

>40 on PROTCOL 2 PROTOCOL 3

Protocol 3 25 mL/kg/hr

1. Review the vascular access as per the CRRT guideline 2. Consider protocol 4 - this uses a higher citrate concentration 3. DO NOT change to protocol 4 if the patient was on protocol 3 IBW (kg)

Post – dilution (mL/hr)

Blood Pump (mL/min)

ACD-A (Citrate) (mL/hr)

80

1900

160

300

ADDITIONAL INFORMATION If the filter clots • Note the reason on the observation chart (e.g. high TMP etc.) • Monitor blood glucose in 1h if on Insulin

increasing the filtration ratio to 25% Blood Pump (mL/min)

If the RCA circuit has clotted in < 12 hours PROTOCOL 4

Protocol 4 25 mL/kg/hr

Reducing the dose to 25 mL/kg/h OR Managing metabolic alkalosis (pH > 7.5 / HCO3- > 40) PROTOCOL 2

IBW (kg)

Post – dilution (mL/hr)

ACD-A (Citrate) (mL/hr)

80

1900

130

200

Recheck after 3 hours, if pH>7.5 or HCO3- >40 mmol/L d/w consultant and consider discontinuing RCA

Restarting RCA • Calcium: When restarting the filter recheck Cai and chose the initial Calcium dose for the new treatment as set out in Step 3. Protocol • If < 24 hours since the last treatment, restart on the same protocol number (1-4) the patient was on previously • If > 24 hours since the last treatment, start as a completely new treatment (i.e. protocol 1 or 2 as directed by the Medical team) Recirculation • After washing the blood back, recirculation should ideally be no longer than 60 min, circuits should be discarded if recirculation is >90 min. Please see set up guide or find a RCA ‘super-user’ for more information

6

RLH ACCU CRRT Programming Guideline – non RCA protocols CVVHDF 35 mL/kg/h

CVVHDF 25 mL/kg/h

IBW (kg)

Total Exchange (mL/h)

Post Dilution (mL/h)

Dialysate (mL/h)

MINIMUM blood pump speed (mL/min)

OPTIMUM blood pump speed (mL/min)

IBW (kg)

Total Exchange (mL/h)

Post Dilution (mL/h)

Dialysate (mL/h)

MINIMUM blood pump speed (mL/min)

OPTIMUM blood pump speed (mL/min)

≤50

1800

900

900

150

300

≤50

1200

600

600

150

300

60

2100

1100

1000

180

300

60

1500

800

700

180

300

70

2500

1300

1200

200

300

70

1800

900

900

200

300

80

2800

1400

1400

200

300

80

2000

1000

1000

200

300

90

3200

1600

1600

220

300

90

2200

1100

1100

220

300

>100

3500

1800

1700

220

300

>100

2500

1300

1200

220

300

CVVH 25 mL/kg/h – ~100% pre dilution

CVVH 35 mL/kg/h – ~100% pre dilution IBW (kg)

Total Exchange / Pre-dilution (mL/h)

Post Dilution (mL/h)

MINIMUM blood pump speed (mL/min)

OPTIMUM blood pump speed (mL/min)

IBW (kg)

Total Exchange / Pre-dilution (mL/h)

Post Dilution (mL/h)

MINIMUM blood pump speed (mL/min)

OPTIMUM blood pump speed (mL/min)

≤50

1700

100

180

300

≤50

1100

100

180

300

60

2000

100

200

300

60

1400

100

200

300

70

2400

100

220

300

70

1700

100

220

300

80

2700

100

220

350

80

1900

100

220

350

90

3100

100

250

350

90

2100

100

250

350

>100

3400

100

280

400

>100

2400

100

280

400

RLH ACCU CRRT Programming Guideline – non RCA protocols

CVVH 60 mL/kg/h – 30% pre & 70% post-dilution IBW (kg)

Total Exchange (mL/h)

Pre-dilution (mL/h)

Post Dilution (mL/h)

MINIMUM blood pump speed (mL/min)

OPTIMUM blood pump speed (mL/min)

≤50

3000

1000

2000

250

350

60

3600

1200

2400

250

350

70

4200

1400

2800

280

350

80

4800

1600

3200

300

400

90

5400

1800

3600

320

400

>100

6000

2000

4000

350

400

7

RLH ACCU CRRT Programming Guideline – non RCA protocols The filter itself DOES NOT need to be primed with a heparin containing solution

FILTER HEPARIN INFUSION GUIDELINE Unfractionated Heparin to be administered via the Aquarius syringe driver 2000iu of Heparin should be administered via the filter as treatment starts Initial heparin infusion commenced (via the Aquarius syringe driver) at 1000 u/hr, unless actual body weight ≤ 50kg then start at 500 u/hr

APTTr result

Filter or circuit clotting within 24 hours and / or continuous  trend in return or trans membrane pressure over 3 hours

Measure APTTr: • At 6 hours after starting treatment or changing a dose • Then 12 hours after that if no further changes • If APTTr is stable, samples can be taken daily

APTTr ≤ 2 NO change to heparin dose

Increase heparin infusion by 500 u/hr but DO NOT exceed 1500 u/hr

If the filter continues to clot – seek help from senior staff member

APTTr ≥ 2 REDUCE heparin dose by 500 iu/h

Inform ACCU consultant or registrar for review of prescription

Patients on systemic heparin should be monitored and dose adjusted as per the trust systemic heparin protocol

8

RLH ACCU CRRT Programming Guideline – All protocols

POTASSIUM Serum potassium (mmol/L)

ACCUSOL 35 NO potassium – hang 2 bags Monitor K+ every hour Once K+ ≤ 4.7 change the bags as per this table

≥ 6.3

ACCUSOL 35 NO potassium and ACCUSOL 35 with 20 mmol potassium – hang 1 bag each

5 – 6.2 3.5 – 4.9 ≤ 3.4

Which ACCUSOL 35 Bags to hang?

ACCUSOL 35 with 20 mmol potassium – hang 2 bags

ACCUSOL 35 with 20 mmol potassium – hang 2 bags Supplement with iv potassium – refer to iv infusion policy If hypokalaemia persists, discuss with medical team

Serum potassium (mmol/L) ≥ 6.3 or ≤ 3.4 or Just starting treatment Once stabalised

Monitoring hourly 3 – 4 hourly

9

RLH ACCU CRRT Programming Guideline – All protocols

FLUID REMOVAL / ULTRAFILTRATION (UF) Ultrafiltration rate is set in mL/hr

Ultrafiltration rate should be adjusted to daily fluid balance goal:  Existing goal may need revising in patients who have just started CRRT – e.g. they could be unachievable  Must account for expected fluid inputs and outputs to achieve the goal e.g. feed, medications, drains etc.  A catch up rate may be needed after down time

New haemodynamic instability during fluid removal should prompt a clinical re-assessment of the intra-vascular fluid status of the patient  A medical review of the fluid balance targets should take place

10

RLH ACCU CRRT Programming Guideline – All protocols

FLUID REMOVAL / ULTRAFILTRATION (UF) Calculation of target UF rate mL/hr This is a +ve number despite it representing fluid removal

NB: for this calculation inputs are +ve numbers and outputs are –ve numbers

Expected hourly inputs from feed and medications (average of last 24 hour non resuscitation fluids)

− Desired fluid removal per hour (24 hours fluid balance target ÷ 24 often a –ve number)

+ Expected fluid losses e.g. urine, drains etc. (average of last 12 hour non filter fluid loss this will be 0 or a –ve number)

e.g. (1) a set -ve fluid balance

e.g. (2) a set +ve fluid balance

100 mL/hr of feed and medications Target balance -1.2L (1200/24 = -50 mL/hr) Fluid losses = -10 from a drain 100 − -50 + -10 = 140 mL/hr UF rate

100 mL/hr of feed and medications Target balance +600 mL (600/24 = 25 mL/hr) Fluid losses = -10 from a drain 100 − 25 + -10 = 65 mL/hr UF rate

11

12

RLH ACCU CRRT Programming Guideline – All protocols

VASCULAR ACCESS FOR CRRT NB: haemodialysis patients often have abnormal vascular anatomy and / or central venous stenosis – seek advice from the renal team for vascular access history LINE TIP SITE • The line tip MUST be in or close to the right atrium for lines inserted in the internal jugular or subclavian veins (see picture) • B is a poorly positioned line

LINE INSERTION SITE • The preferred vein for line insertion is the internal jugular ahead of femoral • AVOID the subclavian vein if possible especially if the patient may need long term dialysis

Avoid if possible

LINE LENGTH 20 cm - Internal Jugular / subclavian - (if the patient is very short (250 mL/min • The SCUF mode may be used for pure ultrafiltration (fluid removal) (see next sheet)

13

RLH ACCU CRRT Programming Guideline – SCUF

SCUF – Slow Continuous Ultra-filtration • SCUF (Slow Continuous Ultra-filtration ) is used primarily to manage fluid overload through ultrafiltration alone without any exchange of buffered fluids (i.e. ACCUSOL 35) • During SCUF blood is driven through a haemofilter via an extracorporeal circuit as per ‘usual’ CRRT • Anticoagulation can only occur using Heparin or Prostacyclin (Flolan) as the absence of fluid exchange rules out pre-dilution and RCA (due to lack of calcium contained in the ACCUSOL). • Fluid removal is controlled and balanced by the filtrate pump and the scales. • Follow the on screen set up instructions on the Aquarius to set the system to SCUF mode. • See the fluid removal section for guidance on how to set the fluid removal targets for your patient

14