Anticoagulation for CRRT - CRRT Explained!

In this fifth lesson, we are talking anticoagulation for CRRT! I cover quickly why we use anticoagulation, and then get in to talking about our different anticoagulation strategies. These consist of no anticoagulation, systemic anticoagulation, and regional anticoagulation.
❗️❗️CORRECTION: 100u Heparin = 1mg of Protamine (not 1g)❗️❗️
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0:00 Intro
1:07 Why?
2:12 Strategies
2:30 None
3:29 Systemic
5:06 Regional
11:14 Conclusion
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Check out these other great lessons and series of lessons below!
✅ Hemodynamics: • Hemodynamic Principals
✅ Shock: • Shock
✅ ECG/EKG Rhythm Interpretation: • ECG/EKG Interpretation
✅ ICU Drips: • ICU Drips
✅ ECMO: • ECMO
✅ CRRT: • CRRT Explained!
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#ICUAdvantage #CRRT #Nursing

[@yaaragiladi1199]

I am anesthesiologist and icu fellow. Your lectures are the best! Thank you so much for these wonderful lessons.

[@ICUAdvantage]

Very cool! Truly happy to be able to help!

[@carsonwong2710]

I would definitely pay to attend your lectures. Thank you so much

[@ICUAdvantage]

Haha thank you! Maybe one day 😉

[@sasagalal]

I am a pediatric intensivist, your CRRT videos helped me alot, thank you so much 😊

[@travisf150r]

Im a biomed that maintains and repairs these machines. Your videos are very helpful to understand how these devices are being used on the floor. Will be sharing with younger techs going forward as part of their training.

[@melodies92]

this channel and all of your videos are so amazing and helpful. THANK YOU!!

[@shiminwong2327]

I have been watching since the first lesson of CRRT ! It was clear and easy to understand !

[@ICUAdvantage]

Yay so happy to hear this!

[@viosaa3899]

You are a wonderful person, thank you for your time!

[@ICUAdvantage]

Thank you so much. Too kind!

[@fencer5411]

Thanks for all the work you put into these videos!

[@ICUAdvantage]

You are very welcome. I'm glad to hear that you and others are enjoying them!

[@kathleenclairecaneja9157]

so good!!! loving most of your lectures ive seen

[@ICUAdvantage]

So awesome Kathleen! Really glad you are liking them! :)

[@puterinuriman7943]

The entire CRRT explained series is super informative and well-explained. Thank you so much for your wonderful videos! Greetings from Malaysia 🇲🇾

[@ICUAdvantage]

How cool! Hello in Malaysia Puteri! Glad you liked the series!

[@icudangmateo9776]

You are so, soooo helpful to a lot of people like myself. Thank you so much for sharing these CRRT lectures. God bless you!

[@ICUAdvantage]

Very happy to hear this. Glad to be able to help!

[@watsupnook1]

Thank you to made such a wonderful videos. I feeling like fall in love today since i watched some of them.

[@ICUAdvantage]

So glad to hear that you like it! :) So nice of you

[@Zeeman999]

Your CRRT videos are magic

[@vedranstojanovic9848]

Very useful. Thank u!

[@jmw77]

WOW. Amazing work, I have to say I learned so much about this topic which is a common frustrating issue I encounter when Im administrating CRRT. My hospital has not set a proper protocol for anticoagulation for CRRT, and your explanation of the use of Citrate/Calcium will help me advocate for my patients. Thank You!

[@ICUAdvantage]

Thank you so much! I'm sorry to hear that things are not setup well where you are when it comes to being able to effectively care for these patients. Protocols really make it easy to know what to do and can ensure consistency in care too. I will say I do love Citrate/Calcium combo. The first place I started doing CRRT was Heparin syringes, and I'm glad those days are over!

[@xolanisikhakhane8654]

Great lecture, learnt something new today. Thanks a lot!!!

[@ICUAdvantage]

Awesome to hear this! You are very welcome.

[@R3lly88]

just took the class yesterday and this definitely helped to make things clearer in terms of rationale. Ty.

[@ICUAdvantage]

Awesome. Glad it was able to help cement the stuff you learned in class!

[@Laringoskop]

Thank you for your lectures,it makes me understand rrt more deeply.

[@ICUAdvantage]

You are welcome! Glad you are enjoying the series.

[@mirandaalexis]

always a good refresher

[@ICUAdvantage]

Awesome! 😊

[@forever4uuu]

Sir love your lectures and Thanks for being so passionated about your field

[@ICUAdvantage]

I enjoy teaching and sharing this info. Also great to hear its well received! Thank you!

[@salimohammed7012]

Very easy to understand

[@ICUAdvantage]

Thanks for liking

[@henriquelopes9596]

Thanks. Very helpful.

[@ICUAdvantage]

Awesome! So glad to hear this!

[@Wisdom-courqge-serenity]

It’s an interesting lesson!! I enjoyed watching it.😊👍

[@or_-]

thank you, very helpfull

[@ICUAdvantage]

Happy to hear!

[@astrid5870]

These videos are sooo helpful. Thank you for this series! Could you add a more PRACTICAL hands-on video on how exactly to set up the Prismaflex, as well as how connect and disconnect it from the patient? That would be fab😘

[@ICUAdvantage]

Hey, thank you Astrid. So the problem with the more practical videos is 2 part... 1) Having access to the equipment to be able to actually film things. Unfortunately I can't just go into the hospital and use the equipment for my own personal purpose. 2) These videos have a wide reach, not just around the US but around the world. I try and generalize as best I can on a lot of topics as some people use different equipment, but the same fundamentals apply. Hope that makes sense. I get the request. I just don't know if its best for this channel.

[@sayannathcmc286]

Thanks for the simplification of such a complex topic. One small observation: the dose of protamine is 1mg for every 100 units of heparin. In this video you have mentioned 1g for every 100 units of heparin.

[@judithtankam4851]

Thank you

[@dorothyotogbolu6485]

awesome videos

[@leenunn3515]

Thanks!

[@ICUAdvantage]

Thank you so much Lee!!

[@vimohankumar9151]

Thanks for such a lucid lecture

[@ICUAdvantage]

Glad you liked it!

[@Pinoykid53]

at 6:28, I think you meant 1 MG of protamine to every 100 units of heparin, instead of 1 gram. Amazing video, and easy to follow. Much appreciated!

[@ICUAdvantage]

Yup! Unfortunately I can't go back and fix it. I tried to include the correct info in the lesson description.

[@tomriley5790]

Not come accross people using DTIs for renal filtration but interesting to see people do. We nearly always use regional citrate failing that systemic heparin, personally I find citrate works really well for the majority of patients.

[@sohazouwail2974]

Hi, I am a chemical Pathologist and I enjoyed the lecture explaining clearly the role of citrate and impact on ionised calcium. Thank you

[@ICUAdvantage]

Awesome! glad you liked it!

[@FastLikePuma]

Your awesome!!!

[@ICUAdvantage]

You're too kind!

[@SamanthaWhite-if5bz]

I just went back bedside after being an ARNP for 7 years. I am trying to revisit all the ICU topics. Thank you for all your help and videos. They explain things so easily. I did wonder since this video is 3 years old, is calcium citrate still being used? it seems like such a great option, but being back only 6 months, I don't see it in many order sets anymore. Just wondering if research changed or its just the doctors at my hospital. Thank you so much!

[@muneermangalath]

Thank you sir

[@ICUAdvantage]

Welcome

[@ronniemarshall7482]

I love this video

[@ICUAdvantage]

Yay!! So glad to hear this!

[@dysondt2239]

Verithanam

[@rma3899]

Like always, you are the best

[@ICUAdvantage]

Thank you!! 😊

[@rma3899]

@@ICUAdvantageXOXO

[@mohammada.samaan8195]

Thank you very much for this lecture, but i think still we need to know more for the regional Citrate A.G in terms of the ratios Ci-Ca, mixing ratio for Ci-Ca , how can we control & manage the therapy Ci-Ca ( parameters setting )

[@arshadhussain8797]

Hi! Pls make a series on standard protocol treatment that is followed in ICU for treating common ICU cases.... Thanks

[@almuntheralaalem362]

plz we need explain about fluid calculation and adjustment thank you

[@user-qe8mg9en3c]

شكرًا جزيلا 👍♥️

[@ICUAdvantage]

Not sure what you said, but with the thumbs up and heart I'll assume it was good 😊 So thank you lol

[@andreng9904]

Awesome lecture. Currently on my Renal Med rotation and this goes a long way toward helping me understand CRRT!

[@ICUAdvantage]

So cool! Glad this video was able to help!

[@Nursevive]

Hi. Do we need to follow the Baxter recommendation that filter should change every 72 hrs? since we are using citrate/ca anticiloagulant?

[@nikhilchakravarthy5593]

You are awesome bro;-)

[@ICUAdvantage]

Too kind! I really appreciate you and glad you liked it!

[@heatherevery3796]

What are the downfalls of using Calcium/Citrate for anti coagulation? I rarely see this used and the times I have, you’re infusing a large volume of just those two medications which makes it difficult to remove via CRRT. Also, could this be an option for anticoagulation on ECMO? Thank you for the informative videos!

[@WaleedElShatshat]

Man u r awesome your videos are helpful specially here in 3rd world countries

[@jadecopperstone4621]

Great videos. Do you mind explaining why some nephrologist will transition from citrate to non-citrate? Is it once they are likely going to be coming off of crrt soon?

[@ICUAdvantage]

Great question. In my experience, its usually only if there is so contraindication to continuing the citrate and/or anticoagulation. Bleeding, hypernatremia not corrected with changes to replacement fluid. But we stop therapy with citrate running all the time.

[@ragdakarim1919]

Thank you for a great seminar. I would like to know what happens with the calcium citrate that will reneter the patients blood? Since the kidneys cant get rid of the calcium citrate how will it be excreted?

[@lum859]

Citrate is metabolized by the liver

[@ICUAdvantage]

As mention, citrate is metabolized by the liver. It becomes citric acid, H2O and bicarb. This can pose a problem is patients with cirrhosis and liver failure.

[@gtrmageddon]

I will most likely begin using Prisma. Could you recommend reading material ? I would like to get a head start.

[@ICUAdvantage]

I would say just search around on the internet. There is a lot of good information out there about CRRT and even specifically Prismaflex and Prismax.

[@nier7889]

Thx for your great presentation! Why i didn't find this channel earlier?! But it would be good if you correct 1 mistake on 6:33 min please: every 100U Heparin = 1 MG protamine (not G). All Drs know it's just mistake, but some residents may remember that ) Thank you again, Dr. Watson )

[@ICUAdvantage]

Ugh, I swear I also manage to fit at least one mistake in to every video! 🤦🏻‍♂️ Yup MG not GRAM! Unfortunately KZbin doesn't have a way for me to insert a correction so I've added it to the description. Thanks for pointing that out and thanks for the ind words!

[@karenmartinez9596]

How can I tell the difference between the CRRT Heparin syringe (systemic anticoag), vs the Heparin given pre-filter (regional anticoag)?? During my orientation we used a Heparin syringe only attached to a slot on the Prismaflex but how can I tell if the CRRT Heparin is going pre-filter or post filter. And we didnt use any Protamine.

[@ICUAdvantage]

Hey Karen, so the built in syringe delivers the heparin pre filter. Systemic anticoagulation would just be a regular heparin infusion you'd be giving to the patient like normal.

[@etlay5684]

Hi Eddie, is it safe to prime the circuit with 5000u Heparin for patients who have risk of bleeding? Thanks

[@ICUAdvantage]

I've never seen a set primed with heparin, but 5000u could certainly be an issue for someone with bleeding risks. We typically don't anticoagulate those with bleeding risks.

[@ahmedtwahir8334]

What is the recommended ratio of HD to HF when you are doing CVVHDF

[@ICUAdvantage]

I don't know if I have a good answer to that. I typically see the dialysate running at about 1.5-2x that of both the pre and post combined. 500 pre, 1500 dialysate, 500 post is a common ratio.

[@viviliberton6196]

Doesn't 1 mg of protamine reverse 100 IU of heparine? I found online that 1 ml (10 mg protamine sulfaat) neutralises about 1400 I.E. heparine. 1 gram seems a bit much ;)

[@ICUAdvantage]

Haha yeah, its a little excessive. Slip of the tongue which I had corrected in the video description when it was first noticed.

[@icuicu1187]

this CRRT series is amazing. I have a query. When we start CRRT for fluid overload and AKI, patient becomes anuric. This is probably due to fall in concentration gradient across renal tubules ( this is what i have learnt. Not read it anywhere). We had started CRRT for fulminant hepatic failure for ammonia and high lactaes without signs of fluid overload, his urine output remained normal. Is there any explanation for this difference? thank you for this video

[@ICUAdvantage]

Great question. I think there can be a lot at play here. Certainly we are starting CRRT as the kidneys are failing so a good part is just them reaching that point. Certainly the decreased concentration gradients play a role as they help drive the functioning of cells in the nephrons and ducts. I also think decreasing fluid volume also plays a role. But as they start recovering, even with CRRT going we start to see them increasing urine output. As for your hepatic failure, we’re you pulling fluid at all or running them even? If not pulling excess fluid, and having functioning kidneys, I’d expect them to continue making urine as before.

[@icuicu1187]

@@ICUAdvantage thanks for replying.

[@aman1644]

Its 1mg of protamine sulphte for 100u of heparin if given within 30 mins. Isnt it?

[@ICUAdvantage]

Correct, the dose goes down after 30 minutes. That said, while I have never run the regional anticoagulation setup with Heparin personally, I would imagine from what I've read on it that it is similar to the Citrate which is what I have my experience with. Our goal in regional is to not have any anticoagulation reach the patient (or minimal). It sounds as if, and I would imagine it to be as such, that the protamine is given via a continuous infusion either to the patient or via a y-connector with the returning blood. This rate would be adjusted based on the rate of the heparin infusion being given via y-connector to the blood at the access line.

[@wemurray4]

@@ICUAdvantage it should read mg not grams

[@mohsinrasheed7811]

6:30 1mg of protamine (not gram). Otherwise excellent work :-)

[@ICUAdvantage]

Yup! I've got that correction I had put in the video description, but yeah not sure what happened there!

[@osaheniosas4731]

Please on the average how much heparin have you administered to a 70kg man over 24 hours? Can you do CRRT continously for 5 days non stop?

[@ICUAdvantage]

Honestly its been a while since I've used heparin for anticoagulation for CRRT. As for the runs, we've had people run MUCH longer than 5 days straight.

[@osaheniosas4731]

@@ICUAdvantage Watched the anticoagulant video. For an average 70kg what will be the dose of citrate and calcium you would need For CRRT CVVHDF how do you calculate the fluid balance. Do you do both pre filter and post filter fluid replacement at the same time? How will you tranafuse blood and give drugs with a patient on CRRT? Do you need to increase vasopressor dose and antibiotics? Which filter will you prefer to use? Is it the intensivist or nephrologist that is in charge of ICU CRRT in your center and country?

[@sirishgauni]

correction: 1 mg of protamine for 100 units of heparin, not 1gm

[@ICUAdvantage]

Yup. Slip of the tongue and corrected in video description.