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/h	The Patient’s Ionized Calcium Level Checked Every 6 h
	<0.95 mmol/L	0.95–1.04 mmol/L	1.05–1.25 mmol/L	1.26–1.4 mmol/L	>1.4 mmol/L
	Increase Rate +20%; Notify ICU and Nephro Fellows	Increase Rate +10%	No Change	Reduce Rate −10%	Reduce Rate −20%; Notify ICU and Nephro Fellows
≤15	+2	+1	No change	−1	−2
16–25	+4	+2	No change	−2	−4
26–35	+6	+3	No change	−3	−6
36–45	+8	+4	No change	−4	−8
46–55	+10	+5	No change	−5	−10
56–65	+12	+6	No change	−6	−12
66–75	+14	+7	No change	−7	−14
76–85	+16	+8	No change	−8	−16
86–95	+18	+9	No change	−9	−18
96–105	+20	+10	No 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.