Citrate CVWH prese Ward 21: Date_>»l Name___Soe_& DoB__»x/» fre Pt Weight (ke) _V2 Filter used _SV1000 Access (@)IJ Tene Dressing Change _____ Device number (Fiker generally AV2000) : Date oe) x [x Treatment. ( Ci-Ca) Gia COMHO, 7 Calcium start rate(then APP.) 3:2 mono J 2 * Citrate start rate (then AP.P.) 0 enero | Dialysate — K4 x 4 bags Ork2 x2 bags if K>6.Smmoy/t | C}G KU Oratyssbe! * Dialysate flow rate: 2260 mat fe * Blood flow rate Mo eat Lenin Dialysis Temp (35-39°#C) Re Doctor's Signature D MFT PRO SET UP Date/time/ Signature nurse 1 | Signature nurse 2 Set up by: (date/time/ 2 signatures) Set up by: (date/time/?2 signatures) Set up by: (date/time/2 signatures) (tse table 1 below /*- See table 2 below / AP.P—As Per Protocol ) Ultrafiltration rate and changes — Medical prescription Date and time mete [oe UF rate (mis/hr} 50 mol | vt Signature/Print Note: Need to prescribe in Kardex (see exemplar} / See “Quick guide” for exceptions ~ CiCa Dialysate K4- rate 25mls/ka/hr (use table 1 for rough estimate. Qd:Qb 20:1 ratio) = Sodium Citrate 4% 1500 mls- as per protocol = Calcium Chloride 100mmol/1000mls ~ as per protocol Calcium start rate — note: prescribe rate as adh adjust for filtrate volume) Calcium chloride Yes Yes No No pre-treatment bolus? ‘Starting prescription of calcium 22 20 19 is ia |L chloride (mmol/L of filtrate) ‘Table 2— Citrate/Dialysate and blood flow rates. Based on approx. 25ml/kg/hour Weight <60kg 60-69kg | 70-79kg | 80-89kg >90kg Dialysate flow rate (mi/hr) 1400 1600 1800 2000 2200 Blood flow rate (mi/min} 0 80 30 | (100 30 Gitrate dose (mmol/L) 40 40. 40 40 40 Ultrafiltration rate (mi/hr) CLINICIAN DECISION ON INDIVIDUAL PATIENT BASISota _ Con Aen-Cike COUHD VB AS REQUIRED THERAPY Name Patent: “Yee Bloggs CHINumbes Dos: we Cre (ee Patients PRESCRIPTION Onn (ss pied ieee Medicine Medtcne (approved Name) Forte [one Cia Oialysoke KY Fie Bose Frequency =max [Route | Cant | pone owip ‘neat | indication + notes Star Omte | Date [oar As Per Paoroce | anh Tine [Prescriber - sign + print Pharmacy | Dove t o=— hia |Medine capproved Name) Foros [owe i Careuss Choate. re Doe « raquency «max Route] Qian | pee t Woommal ficcoml | CUD os 7 indieaion-+ notes tat Bate | Dat Tome As Pex Facto | yy (e Tine Prexcriber- sign + pain Thame Loose ee int Nedicne appraved Nar) Fore [ove Sonu Crane rine [ base Fequeney + max Route] Quan | boxe HL J\S000ks| Cav up nts I indicatonnotes —ftaeOate | Date Tou i veel ine —_— Frame Loose Be Inia | Wedicine ipproved Nome) Tortie Tome = Tine Bose rFequency+ max fits | Quantiy [aor ta indieaton-> notes Stare Date | Bate Toe seiber sgn + pint Tra [oo t Kedicine pproves Nam) Tarte Tone asa Raqueney + max Plow | “Gua Tose ae jndienion-> notes Start ate | Date Tome resciber -agn + pint Pra Looe! hi | ecteine Gpproved Name Tare Tone i Murreie _4y Tie eee» raquency vmx Rowe | GARRET | poe GIVHD Inivals inaieabon emotes [Sta Date | Date Tone As Per Peoroace. | wef Te | T reseber sgn «print Tra [oe 4S ints I Ef‘Non- Citrate CVVH prescription- Ward 215 Date_xx] x Name. whe Bogs pop__xxfy/we Pt Weight (ke)_42 Filter used Avicoo Access _) LJ Tew? Dressing Change Device number, 4 Blood Flow __ 26g mats ( Ww om K/Blo0d Flow >250%5/he) Exchange/hr_S0CO~d) ne Type Fluid _ wer (xchange /he— minimum 2600mis/hr or approx B5mV/kg/hr Fuld type MultiBie 4 oF 2~ Anticoagulant (Circle) Ni (fepatin > Heparin Strength — 250iu / 10001 per ml Pre-anticoagulation ACT Target Machine No Prime Fluid (cireley 0.5% safe J HAS Straight connect (Y/N) ¥_ Washback removed (V/N)_Y_ Prescribed by (OR) Sign On 1 Nurse Sign on 2" Nurse (capitals) (capitals) (capitals) “ime | 6P [HR [AP [RP] TP ] Blood | Prejpost | Total | Fuid [ACT [Ac [AC [AC [CC | initials Flow | Exchrate | Excha | loss rate | Bolus | level otal ‘Crcuk Check to be completed as required but minimal hourly during treatment tick €C—2™ last column