i Set up an RCA equipped haemofilter in CVVH mode using an RCA circuit and HF12 Filter â All patients start on protocol 1 ii(a) Check systemic ionised calcium ...
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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)?
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)
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
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
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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
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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
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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
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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)
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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
