Heparin - CriticalCareMedicine
Transcription
Heparin - CriticalCareMedicine
Patient I.D. Label Patient Care Orders PRISMAFLEX CRRT orders Heparin Refer to previous CRRT orders. Please write firmly with a black ballpoint pen. All orders must be signed by the physician. All co-signatures must be timed and dated within 24 hours. Orders may be deleted by stroking the order out, initialing and dating the entry. Patient estimated dry weight…………Kg Orders Prismaflex Filter Set ST100 ST150 Mode CVVH ///////////////////////////////////////////////////////////////////////// Priming Solution Heparin 5000units/L No heparin Blood Flow Rate mL/min 200-450 mL/min Other________ Replacement Solution Concentrations Prism0cal HCO3 32mmol/L 42mmol/L 52mmol/L Potassium chloride …….. mmol/L (whole numbers only) Do not thin from chart Comments/Suggestions The ST100 hemofilter is the standard filter for adult CRRT. ST150 hemofilter is used when high blood flow is required. This membrane is surface treated and adsorbs heparin. Use CVVH when using heparin as anticoagulant or no anticoagulant as predilution CVVH may increase hemofilter life. Use of heparin in priming solution will allow heparin binding to the surface treated membrane and further reduce risk of clotting. Adjust blood flow depending on normal access and return pressures. Higher blood flows are associated with better clearance and filter life. Prism0cal with compartment A added to B contains (mmol/L): Na 140, Cl 106, Mg 0.5, lactate 3, HCO3 32. Addition of the HCO3 pouch provides HCO3 32 mmol/L. Addition of more NaHCO3 increases the HCO3 concentration by 10 mmol/L for each 50 mmol added. Calcium must be added unless contraindicated e.g. hypercalcemia. Calcium chloride 1 gm (10 mL) per 5 Litre bag Total Replacement Pump Rate mL/h 2000 2500 3000 Other________ % Prefilter 50% Other ……………(to max 90%) Patient Fluid Removal Rate:............... mL/h Include Urine Gastric Drains Heparin Bolus into pre-filter circuit No bolus ……………units Anticoagulant- Pre Blood Pump (PBP) Heparin Infusion, start at……………..units/h Replacement solution is used for hemofiltration (convective clearance of solutes). The total fluid that is used/hour (effluent) is considered the dose of hemofiltration and is normally between 25-30 mL/kg/h depending on percentage pre-filter (higher prefilter requires higher volume for same solute clearance), patient acuity and circuit downtime. Dose should be modified frequently based on patient urea and creatinine levels and acid base status. The replacement fluid may be infused pre-filter or post-filter. Pre-filter decreases the viscosity of the blood and lessens risk of circuit clotting but reduces solute clearance. Post-filter hemofiltration improves solute clearance. At least 10% must be infused post-filter to provide a fluid/blood interface in the de-aeration chamber. Enter the patient fluid removal rate hourly on the Prismaflex System: Patient fluid removal =(Net fluid removal rate + IV intake) - Output Usually 50-100 units/kg. Give bolus via the red injection port on the access line closest to patient. Hang Heparin infusion bag on PBP scale. Usually commence at 10-15 units/kg/h and then monitor ACT/PTT. Heparin bag: 5000 units/1000mL = 5 units per mL. Usually aim for ACT between 160 and 180 seconds or PTT 60-110 seconds. Draw blood for ACT/PTT from the blue injection port (post filter). Anticoagulation monitoring: ACT q…....h until stable then Q 6h PTT q …..h until stable then Q 6h Laboratory Monitoring Electrolytes Q 8h Q 12h Urea, Cr, Mg, P04: q 24h Daily CBC (for hematocrit) other___________________________ Orders to be completed on a Daily Basis (minimum requirement) Physician Signature:_____________________________________________Date/Time_____________ (Residents/Fellows must confirm orders with the ICU Attending Physician) Prismaflex/HEPARIN Revised May 2015 HEPARIN NOMOGRAMS (1) Monitoring PTT PTT <45 secs 45 – 59 secs 61 – 110 secs 111 -115 secs 116 – 120 secs 121 – 125 secs > 125 secs BOLUS 3000 units 0 0 0 0 0 0 DOSAGE CHANGE+ +100 units/h +50 units/h 0 -50 units/h -100 units/h -150 units/h -300 units/h PTT after restart of Heparin Note: P.T.T. obtained from venous side (post-filter) of Prismaflex circuit. Document on Physician’s Order Sheet time for next PPT Obtain PTT 2 hours after each dosage change. When P.T.T. 55–80 secs check P.T.T. q4h X 2, then q6h. Document changes in dosage. (2) Monitoring ACT The optimal goal range for the ACT is between 160 to 200 seconds unless the hemofilter had previously clotted at this range ACT Level Change in Heparin Infusion Rate < 160 seconds Increase rate by 500 units / hour and re-bolus with 1000 units. 161 – 200 seconds No change to rate. > 200 seconds Stop heparin infusion for 60 minutes, then restart at 250 units / hour less than the previous rate. Please note the ACT must be rechecked 60 minutes following each subsequent intervention. CRRT Dosing Nomogram Weight 25 ml/kg/h 30 ml/kg/h 50 1250 1500 60 1500 1800 70 1750 2100 80 2000 2400 90 2250 2700 100 2500 3000 110 2750 3300 120 3000 3600 Prismaflex/HEPARIN Revised May 2015