Adult CRRT Citrate Protocol (PRISMAFLEX)

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Pre – Initiation

1. Obtain patient ionized calcium (iCa++) and renal panel (including albumin) just before starting CRRT.
   1. If iCa++ < 1 mmol/L, contact physician for further instructions. Consider calcium chloride dose (1 gm CaCl2 IV) prior to initiation. There are situations where administration of calcium chloride is not advised, such as in cases of severe hyperphosphatemia.
2. Set up, prime and program flow rates per physician orders.
3. Citrate ACD-A infused via the Pre-Blood Pump (PBP) on the Prismaflex CRRT machine.
4. Calcium chloride (20 mg/mL in NS) infusion line connected to the return extension line port.

Initiation

1. Citrate ACD-A via PBP rate (mL/hour) is selected per physician orders. Recommended start is 2.5 times the blood flow rate (mL/min) at blood flow rate 60 or 100 ml/min and 2 times the blood flow rate at blood flow rate of 150 ml/min
2. The initial calcium chloride infusion is based on filter effluent rate and patient systemic albumin level.   It is prescribed by the nephrologist or the ICU physician (in 5 D only) based on the effluent rate and the last measured serum albumin
3. Ensure calcium chloride infusion started just prior to starting CRRT machine.

Initial Flow Rate Recommendations table 1

Blood Flow Rate (ml/min)	Citrate Rate (PBP) (ml/hour)	Calcium Chloride Rate (ml/hour)
60 (Very Rare)	150	Per Physician Orders
100	250	Per Physician Orders
150	300	Per Physician Orders

Maintenance/Monitoring

1. Patient I Ca++ “Systemic” – is drawn via arterial or peripheral line (labeled “arterial” sample)
2. Circuit I Ca++– is drawn post-filter from return (blue) sample port (labeled “circuit” sample)
3. Circuit is checked:
   1. Every 12 hours.
4. Patient I Ca++ levels
   1. At 0=before start, 2, 4 and 6 hours after start. This is the period with greatest risk of citrate build up. Call the physician if patient iCa++ is outside the goal (No Change) range of Table 2 or 3 for advice on Ca-rate adjustments.
   2. Every 6 hours thereafter and use Table 2 and 3 to make Ca-rate adjustments.
5. Titration Guidelines – Adjust rates according to table below
   1. Citrate is fixed
   2. Calcium infusion is adjusted per table 2 for goal systemic ionized calcium target of about 1.05 - 1.25mmol/L and table 3 for goal systemic ionized calcium target of 1.2-1.4 mmol/L. Calcium is adjusted only every 6 hours unless otherwise ordered by physician in Chart.

Table 2: 136 mM CaCl2 Infusion Rate Adjustment Based on Systemic iCa Every 6 hours
Systemic ionized calcium target of about 1.05 -1.25mmol/L

	The patient's ionized calcium level checked every 6 hours
	More than > 1.4 mmol/L	1.4 0 1.26 mmol/L	1.25 - 1.05 mmol/L	1.04 - 0.9 mmol/L	Less than <0.9 mmol/L
Current Ca-infusion Flow Rate ml/h	Decrease Rate -20%; notify ICU and Nephro fellows	Decrease Rate - 10%	No Change	Increase Rate +10%	Increase Rate +20%; notify ICU and Nephro fellows
≤15	-2 ml/h	-1 ml/h	No Change	+1 ml/h	+2 ml/h
16-25	-4 ml/h	-2 ml/h	No Change	+2 ml/h	+4 ml/h
36-45	-8 ml/h	-4 ml/h	No Change	+4 ml/h	+8 ml/h
56-65	-12 ml/h	-6 ml/h	No Change	+6 ml/h	+12 ml/h
76-85	-16 ml/h	-8 ml/h	No Change	+8 ml/h	+16 ml/h
96-105	-20 ml/h	-10 ml/h	No Change	+10 ml/h	+20 ml/h

Table 3: 136 mM CaCl2 Infusion Rate Adjustment Based on Systemic iCa Every 6 hours
Systemic ionized calcium target of about 1.20 -1.40 mmol/L

	The patient's ionized calcium level checked every 6 hours
	More than > 1.55 mmol/L	1.55 - 1.41 mmol/L	1.4 - 1.2 mmol/L	1.19 - 1.05 mmol/L	Less than <1.05 mmol/L
Current Ca-infusion Flow Rate ml/h	Decrease Rate -20%; notify ICU and Nephro fellows	Decrease Rate - 10%	No Change	Increase Rate +10%	Increase Rate +20%; notify ICU and Nephro fellows
≤15	-2 ml/h	-1 ml/h	No Change	+1 ml/h	+2 ml/h
16-25	-4 ml/h	-2 ml/h	No Change	+2 ml/h	+4 ml/h
36-45	-8 ml/h	-4 ml/h	No Change	+4 ml/h	+8 ml/h
56-65	-12 ml/h	-6 ml/h	No Change	+6 ml/h	+12 ml/h
76-85	-16 ml/h	-8 ml/h	No Change	+8 ml/h	+16 ml/h
96-105	-20 ml/h	-10 ml/h	No Change	+10 ml/h	+20 ml/h

6. Notify Physician for the following:
   1. Unexpected clotting in the extracorporeal system – poor access flow is likely.
   2. Ionized calcium >20% outside goal range as specified in Table 2 or 3.

Standards and Precautions:

1. Routine labs done at least daily include: basic metabolic profile, magnesium, phosphorus.
2. Basic dialysate bags contain: Na 136 mEq/L, Cl 115 mEq/L, HCO3 25 mEq/L, Mg 1.5 mg/dL, K 2 mEq/L; there is NO calcium, phosphorus or glucose.
3. Additional modifications (as needed per physician order): KCl (1-2 mEq/L, totaling 3 or 4 mEq/l) and/or KHPO4 (at 0.75 mmol or 1.5 mmol/L) and/or bicarbonate (5 to 25 mEq/L totaling 30 to 50 mEq/L). If the sum of dialysate plus replacement fluid rate changes, it must be accompanied by a proportional adjustment to the calcium infusion rate. If such a change is warranted, call nephrology or ICU physician (only in 5 D) to discuss. EXAMPLE: Replacement fluid plus dialysate fluid rate decreased from 3000 mL/hr to 2000 mL/hr (ie. 33% decrease), then calcium chloride infusion rate must be decreased by 33% at the same time. Call nephrology to suggest that change (the nurse will not be making this change without an order). 
4. The calcium pump must be paused (or turned off) when the blood pump stops for any period of time (more than several minutes) to avoid unneeded calcium administration to the patients. 
5. For therapy interruptions (e.g. diagnostic tests, surgery in OR, catheter change, system clotting and replacement), restart all the CRRT system settings, citrate- and calcium infusions at the rates they were prior to stopping therapy unless otherwise ordered by physician. For restarts, resume previously mentioned blood draw recommendations.
6. Additional calcium chloride doses for treatment of low systemic ionized calcium should be infused into central venous access over 10 minutes.