Thread by @adequator_app

Regional Citrate Anticoagulation (RCA) for CRRT

Prescription with the ADEQUATOR adequatorapp.com
And some Rationale

#CRRT #AKI #nephrology #citrate #adequator
@luck_urine

Follow the Thread

1/10 RATIONALE OF RCA

Forms Ci-Ca complexes--> i Ca drops --> coagulation stops

1. NO bleeding
2. Better circuit life
3. KDIGO -> Citrate for everyone
4. Complex protocols
5. Adequator help us

2/10 RATIONALE OF RCA

Ci-Ca complexes are:

1. Biologically inactive
2. Lost in the effluent 30-50%
3. Quick metab -> liver,muscle,kidney-> 3 bicarb & i Ca
4. Behave as anions

- 1 & 2: Systemic hypocalcemia
- 3: Buffer effect
- 4: AG M. acidosis, when toxicity

3/10 RATIONAL OF RCA PROTOCOLS

FOUR numbers to remember

1. CIRCUIT i Ca goal -> 0.2-0.35 mmol/L
2. Citrate dose to achieve #2 -> 2.5-6 mmol/L of processed blood

3. SYSTEMIC i Ca -> 1-1.2 mmol/L
4. Elemental Ca infusion-> 2-6 mmol/hour To achieve #3

4/10 PRESCRIPTION

-50 years, 100kg, male
-Prescribe 25 ml/kg/hr
-Use RCA

STEPS
1. Choose a Cit Solution
2. Determine Cit concentration in solution
3. Choose a blood flow (Qb)
4. Determine Cit infusion rate
5. Complete rest of prescription

5/10 PRESCRIPTION

STEP 1
-Check comercial Cit solutions (image)
-we will use ACD-A & Prismocit18

STEP 2
-Cit concentration = citrate + citric acid
- ACD-A 113 mmol/L
- Prismocit18 18mmol/L

6/10 PRESCRIPTION

STEP 3
- We will use low Qb -> 120 ml/min

Rationale for low Qb
1. With RCA, filtration fraction is not a big deal
2. Total citrate load depends on Qb--> low Qb--> less citrate load

7/10 PRESCRIPTION

STEP 4
To achieve a cit dose of 2.5-6 mmol/L of processed blood
Cit infusion= (Qb*60)*(Cit dose)/(Cit concentration)

ACD-A
(120*60)*(3)/(113)= 191 ml/hr

Prismocit18
(120*60)*(3)/(18)= 1200 ml/hr

Or use the ADEQUATOR 👇

8/10 PRESCRIPTION

STEP 5
-Cit infusion needs to be prefilter or prepump (when using prismaflex)
-Cit Infusion-> accounted as PRE replacement fluid

ACD-A --> account for a small fraction of the dose
Prismocit18 --> account for near 50% of the dose

9/10 PRESCRIPTION

STEP 5
Our prescription will distribute volume to achieve exactly 25ml/kg/hr starting with:

1. REPLACEMENT PRE (Cit infusion)
2. Dialysate
3. Fluid removal
4. Replacement POST

Both prescriptions 👇
Check filtration fraction and Delivered Dose

10/10 FINAL NOTES

When using RCA it will be smart to:

1. Use NO calcium dyalisate (so it works)
2. Use Standard Bicarb 22-25 (Cit is buffer)
3. Use systemic Ca infusion (hypocalcemia)
4. Monitor circuit and systemic Ca to adjust prescription