1
Introduction
RRT treats physiological disturbances when renal function is impaired: acidosis, hyperkalaemia, uraemia, and fluid overload. Also enhances clearance of water-soluble toxins/drugs.
Scope: All adult ICUs within Royal Sussex County Hospital and Princess Royal Hospital
2
Catheter Selection
Site & Length Selection
| Site | Length | Tip Position |
|---|---|---|
| Right IJV | 15 cm | Distal SVC / Right atrium |
| Left IJV | 20 cm | Distal SVC / Right atrium |
| Femoral | Longest available | Proximal IVC |
Avoid subclavian veins! Causes stenosis impairing AV fistula formation.
3
RRT Prescription
- RRT Dose: 25 ml/kg/hr using Predicted IBW
- Type: CVVHF unless directed otherwise
- Prescription: Critical Care medical staff only
Higher dose (35 ml/kg/hr): CONSULTANT DECISION ONLY
4
Anticoagulation
| Priority | Agent | Indication |
|---|---|---|
| 1st Line | Regional Citrate (RCA) | Default - better filter longevity, no systemic effect |
| 2nd Line | Unfractionated Heparin | When RCA contraindicated |
| Low Platelets | Epoprostenol (Flolan) | 5 ng/kg/min - protects platelets |
| HIT | Argatroban | HIT + systemic anticoag needed |
Recurrent clotting? Most likely vascular access problem!
5
Regional Citrate Protocol
Protocol 1 — Standard (25 ml/kg/hr, 20% FF)
| Weight | Blood Pump | Citrate | Exchange |
|---|---|---|---|
| <50 kg | 100 mL/min | 150 mL/hr | 1200 mL/hr |
| 51-60 kg | 120 mL/min | 180 mL/hr | 1400 mL/hr |
| 61-70 kg | 140 mL/min | 210 mL/hr | 1700 mL/hr |
| 71-80 kg | 160 mL/min | 240 mL/hr | 1900 mL/hr |
| >80 kg | 190 mL/min | 285 mL/hr | 2300 mL/hr |
Protocol 2 — Alkalosis (25 ml/kg/hr, 25% FF)
Use if pH >7.5, HCO₃⁻ >40, or Ca ratio >2.5
| Weight | Blood Pump | Citrate | Exchange |
|---|---|---|---|
| <50 kg | Too low — discontinue RCA | ||
| 51-60 kg | 100 mL/min | 150 mL/hr | 1500 mL/hr |
| 61-70 kg | 120 mL/min | 180 mL/hr | 1800 mL/hr |
| 71-80 kg | 130 mL/min | 195 mL/hr | 2000 mL/hr |
| >80 kg | 150 mL/min | 225 mL/hr | 2300 mL/hr |
Protocol 3 — High Dose (35 ml/kg/hr, 20% FF)
CONSULTANT DECISION ONLY
| Weight | Blood Pump | Citrate | Exchange |
|---|---|---|---|
| <50 kg | 150 mL/min | 225 mL/hr | 1800 mL/hr |
| 51-60 kg | 180 mL/min | 270 mL/hr | 2100 mL/hr |
| 61-70 kg | 200 mL/min | 300 mL/hr | 2400 mL/hr |
| 71-80 kg | 240 mL/min | 360 mL/hr | 2800 mL/hr |
| >80 kg | 270 mL/min | 405 mL/hr | 3200 mL/hr |
6
Calcium Protocol
Solution: 10 mL of 10 mmol CaCl₂ in 990 mL 0.9% NaCl = 10 mmol/L. Hang on SILVER scale.
| Systemic iCa | Initial Rate | Monitor |
|---|---|---|
| <0.80 | DO NOT start RCA | — |
| 0.80-0.90 | 75 mL/hr | 1 hour |
| 0.91-1.00 | 50 mL/hr | 1 hour |
| >1.00 | Nil | 1 hour |
| iCa | If Not Started | If Running | Monitor |
|---|---|---|---|
| <0.80 | 5mL bolus → 100 mL/hr | 5mL bolus → ↑50 (max 175) | 1 hr |
| 0.80-0.90 | 75 mL/hr | ↑25 (max 175) | 3 hr |
| 0.91-1.00 | 50 mL/hr | No change | 6 hr |
| 1.01-1.10 | Nil | ↓25 | 6 hr |
| 1.11-1.20 | Nil | ↓50 | 3 hr |
| >1.20 | Nil | STOP | 1 hr |
7
IBW Calculator
8
Heparin Dosing
| Weight | Exchange | Pre | Post | Pump |
|---|---|---|---|---|
| <50 | 1300 | 500 | 800 | 140 |
| 51-60 | 1500 | 500 | 1000 | 180 |
| 61-70 | 1800 | 600 | 1200 | 200 |
| 71-80 | 2000 | 700 | 1300 | 220 |
| 81-90 | 2300 | 900 | 1400 | 250 |
| >90 | 2500 | 1000 | 1500 | 280 |
| Weight | Exchange | Pre | Post | Pump |
|---|---|---|---|---|
| <50 | 1800 | 700 | 1100 | 180 |
| 51-60 | 2100 | 700 | 1400 | 200 |
| 61-70 | 2500 | 700 | 1800 | 220 |
| 71-80 | 2800 | 900 | 1900 | 220 |
| 81-90 | 3200 | 1100 | 2100 | 250 |
| >90 | 3500 | 1100 | 2400 | 280 |