Table 3.

Rate change of 136 mM CaCl2 in 0.9% saline based on systemic ionized Ca every 6 h: GOAL 1.15 (1.05–1.25) mM

Current Ca Infusion Flow Rate, ml/hThe Patient’s Ionized Calcium Level Checked Every 6 h
<0.95 mmol/L0.95–1.04 mmol/L1.05–1.25 mmol/L1.26–1.4 mmol/L>1.4 mmol/L
Increase Rate +20%; Notify ICU and Nephro FellowsIncrease Rate +10%No ChangeReduce Rate −10%Reduce Rate −20%; Notify ICU and Nephro Fellows
≤15+2+1No change−1−2
16–25+4+2No change−2−4
26–35+6+3No change−3−6
36–45+8+4No change−4−8
46–55+10+5No change−5−10
56–65+12+6No change−6−12
66–75+14+7No change−7−14
76–85+16+8No change−8−16
86–95+18+9No change−9−18
96–105+20+10No change−10−20
  • Systemic iCa is checked within 1 h before start of CKRT and at 2, 4, and 6 h, and every 6 h thereafter. If the iCa is outside the limits of the “no change” range at h 2, 4, and 6, the CKRT prescribing team is notified for advice but no titration per protocol is initiated by the nurse. Subsequently, the Ca rate is adjusted in increments of +/−10%–20% of the current rate on the basis of the systemic iCa value obtained every 6 h. Even with severe liver dysfunction and shock, most patients will have some citrate clearance in the range of 1–6 L/h, and will have systemic citrate levels in the 0.5–1.5 mM range. Therefore, it is expected the initial Ca rate will be titrated down 10%–25% in the first 24 h of CKRT-RCA according to Shock protocol unless citrate metabolism is completely absent. CKRT, continuous KRT; RCA, regional citrate anticoagulation; iCa, ionized Ca.