Session 1: Circuit, Anticoagulation and Monitoring. Ashita Tolwani, MD, MSc Noel Oabel, BSN, RN, CNN 2019

Transcription

1 Session 1: Circuit, Anticoagulation and Monitoring Ashita Tolwani, MD, MSc Noel Oabel, BSN, RN, CNN 2019

2 Goals n Learn how to set up citrate anticoagulation for CVVH, CVVHD, CVVHDF using Prismaflex n Determine appropriate labs to obtain for citrate anticoagulation and adequacy of anticoagulation. n Trouble-shoot anticoagulation issues based on CRRT parameters, labs, and patient clinical condition.

3 Concepts Covered n Mechanism of regional citrate anticoagulation (RCA) n Appropriate patient selection for RCA n Appropriate labs to obtain for RCA n Technical aspects of citrate prescriptions based on CRRT modality n Appropriate infusion sites for calcium n Determination of citrate toxicity and troubleshooting

4 Simulation Description n Participants will choose CRRT modality after case presentation. n Participants will choose citrate solution and corresponding solutions. n Participants will decide on CRRT prescription (blood flow rate, citrate rate, pre and/or post RF rate if needed, dialysate rate if needed, fluid removal rate, calcium infusion rate). n Participants will calculate prescribed dose based on their choices. n Participants will program the prescription into the CRRT device, demonstrate appropriate placement of CRRT solutions on the device, and demonstrate appropriate sites for obtaining labs for RCA. n Patients will troubleshoot deranged ionized calcium and/or electrolytes.

5 Case Presentation n 48 YO 100 kg M with DM II, HTN, osteoarthritis and normal renal function presents with fevers, chills, and rigors to the ED n Vitals: T 102.6ºF, BP 72/46 mm Hg (MAP 55 mm Hg), HR130 BPM, O 2 Sat 78% on a 100% NRB n He is intubated and given 4L NS without hemodynamic improvement n He is subsequently started on vasopressors and broad spectrum antibiotics for pneumonia and sepsis n Home medications: ACE I, metformin, HCTZ, and Ibuprofen 800 mg TID

6 Case Presentation n 10 hrs later he remains oliguric; nephrology consulted n He remains on vasopressin 0.03 u/min, norepinephrine 10 µg/min; CVP 15 cm H 2 O; MAP 65 mm Hg n Current labs: n ABG: ph 7.32/ pco 2 30/ po 2 78 on Fi (100%) n Sodium 135 meq/l, K 5.6 meq/l, Cl 109 meq/l, Bicarb 15 meq/l, BUN 58 mg/dl, Creatinine 5.4 mg/dl, Lactate 4.0 mmol/l, Ca 8.4 mg/dl, Alb 3.2, ica 0.95 mmol/l n WBC 37K, hgb 10 g/dl, Plt 80K, Hct 30%, n TBili 2.2 mg/dl, AST 100 U/L, ALT 123 U/L, INR 1.5 n Blood cxs: GNR

7 Participants are to decide the following regarding CRRT prescription with RCA n CRRT Modality? n Anticoagulation: Citrate n Citrate formulation? n Blood flow rate? n Dialysate rate? n Replacement fluid? n Pre replacement fluid rate? n Post replacement fluid rate? n Fluid removal rate? n Calcium infusion rate?

8 Citrate Formulations

9 What is the Prescribed Dose of Prescription Chosen?

10 What is the Filtration Fraction of Prescription Chosen? n FF = Ultrafiltrate / Plasma Flow Rate n FF = Q UF / Q P

11 Case 2 n The patient is placed on CVVHDF for 48 hrs with correction of electrolytes n CRRT Parameters (Prismaflex): n BF 200 ml/min n RF 1000 ml/hr n D 1000 ml/hr n FR 100 ml/hr n ACD-A 300 ml/hr on PBP pump n CRRT Labs: n Post Filter ica: 0.25 mmol/l n Systemic ica: 0.9 mmol/l n Serum Total Ca: 8.2 mg/dl n Calcium gtts is at 60 ml/hr

12 q Dose = 2400 ml/hr / 100 kg = 24 ml/kg/hr q FF = ( )/[(0.7*12000)+300] = 16% 2.2% ACD-A Rate: 300 ml/hr Pre-Pump Pre- Dilution Set V Q B 200 ml/min Dialysate: 5 L bag 140 Na/4 K/25 bicarb/0 Ca Rate: 1000 ml/hr Q D Ca 2+ Gluconate 66.4mmol/L Initial Rate: 60 ml/hr Post-filter Fluid: 140 Na/4 K/25 bicarb/0 Ca Rate: 1000 ml/hr Q R PF ica 2+ ( mmol/l) V Patient ica mmol/l

13 Low systemic ica Shift change occurs & nurse rushes to change bags The new nurse calls you with a syst ica 0.67 mmol/l What do you do and what are the questions you ask to determine what is going on? Ask about patient s overall status and if any changes have occurred Ask from where the Ca level has been drawn Ask what is hanging on PBP scale (is it citrate or something else?) Ask what rate citrate is infusing Ask if calcium is infusing and if so, where is it infusing If appropriate, increase Ca infusion 2 hrs later Pt s BP drops & requires escalation of norepinephrine Telemetry reveals prolonged QTc interval The patient starts seizing and stat labs are sent

14 n Stat labs: Determination of Citrate Toxicity n Systemic total Ca 10.8 mg/dl n Systemic ica 0.70 mmol/l n Serum bicarbonate 37 meq/l n Serum Na 154 meq/l n What has happened to the patient? q Citrate toxicity calculation = q Systemic Ca (mg/dl) X 0.25 / Systemic ica q10.9 x 0.25 / 0.70 = 3.9 q If the ratio > 2.5, then the patient is citrate toxic

15 2.2% ACD-A Rate: 300 ml/hr Dialysate: 2.2% ACD-A Rate: 1000 ml/hr Post-filter Fluid: 140 Na/4 K/25 bicarb/0 Ca Rate: 1000 ml/hr Pre-Pump Pre- Dilution Set V Q B 200 ml/min Q D Ca 2+ Gluconate 66.4mmol/L Initial Rate: 60 ml/hr Q R PF ica 2+ ( mmol/L) V Patient ica mmol/l

16 Determination of Citrate Toxicity The Patient s citrate toxicity was the result of the nurse hanging citrate (ACD-A) at the stopcock position and in the dialysate position. The patient was receiving 1300 ml of citrate an hour! Bonus Question: How would you correct this catastrophe?