4 Special warnings and precautions for use Warnings Monitoring frequencies of impacted patient serum values The indicated therapies call for the close monitoring of the patient’s haemodynamic status, fluid balance, glucose level, electrolyte and acid-base balance before and during treatment.
, TPE can invoke these changes more rapidly than CVVHD. The treatment- and RCA protocol must reflect this. When using Cifoban, these may include the following monitoring frequencies and particulars: - The patient ionised calcium, pH and bicarbonate, sodium, and lactate according to clinical need, must be measured at baseline or at least within 1 hour upon start of the therapy.
Further exemplary measurement frequencies are 1-hourly for TPE, 3-4 hourly for SLEDD, up to 6-8-hourly for CVVHD and CVVHDF. - When balanced solutions are used, pre- and post-treatment measurements (TPE, SLEDD) or daily measurements (CVVHD, CVVHDF) of magnesium and total calcium may suffice.
- More intensified monitoring generally calls for a frequency that is 2-4 times higher. - A blood gas analyzer shall directly be accessible. - A separate arterial access is preferred as the sampling location. A sampling port in the access line is often available, however, its use can result in false measurement results in the case of recirculation at the catheter tip.
If circuit ionised calcium monitoring is part of the applied RCA protocol, a respective sampling port is required. The RCA protocol can request a first measurement within 20-30 minutes after treatment initiation to confirm the correct circuit set-up and subsequent measurements after each adaptation of the Cifoban dose (wait > 5 minutes after adjustment before taking the sample for the establishment of the new ionised calcium concentration).
Citrate accumulation due to impaired metabolism In children and in adult patients with reduced citrate metabolism; as for example in patients with reduced hepatic function, hypoxia (hypoxemia) or a disturbed oxygen metabolism, RCA can lead to citrate accumulation.
25 and/or metabolic acidosis. Early signs may include decreased lactate clearance during therapy. It may then become necessary to increase the dialysate flow, reduce the blood flow, reduce the citrate dosing, or stop using Cifoban for anticoagulation.
Intensified monitoring is recommended. Citrate overload Cifoban is hypernatraemic and, once metabolised, a source of bicarbonate. 2 Posology and method of administration). Iatrogenic metabolic alkalosis and hypernatraemia may nevertheless develop and can be managed by reducing blood flow or, when covered by the applied RCA protocol, by increasing dialysate flow.
These interventions reduce the patient sodium citrate load. g. 9% sodium chloride can be considered. g. 5% glucose can be considered. In both cases, the additional volume load shall be considered by the treating physician. e. reduced filter permeability) can result in a citrate overload.
Filter clogging could reduce removal of calcium, citrate, sodium, and other substances, and result in hypercalcaemia, metabolic alkalosis, hypernatraemia, and other deviations from the expected therapy effect. In such a situation, it is likely no longer possible to correct the abnormalities via the interventions mentioned above.
The filter then needs to be changed. 9. Insufficient citrate load If the other solutions used in the RCA protocol overcompensate for the sodium and bicarbonate buffer provision of Cifoban, iatrogenic metabolic acidosis and hyponatraemia may develop.
These serum imbalances can be managed by increasing blood flow or, when covered by RCA protocol, by decreasing dialysate flow. These interventions increase the patient sodium citrate load. Further, persisting metabolic acidosis and hyponatraemia can be managed by the controlled infusion of a sodium hydrogen carbonate solution.
Prolonged patient immobilisation Under RCA, the early sign of an ionised hypercalcaemia may be masked by a decrease in the calcium infusion rate. Especially patients in a prolonged immobilised position may undergo bone remodelling/demineralisation, resulting in the release of calcium from the bones.
This can ultimately lead to bone fractures. In patients under RCA for longer than 2 weeks continuously, or in whom the calcium infusion rate is progressively decreasing, bone turnover markers must be closely monitored. , heparin induced thrombocytopenia type II).
An appropriately chosen systemic anticoagulant may then be required. RCA may be used in addition to further improve filter patency. g. 4 above). 2 must be observed. Pre-existing hypocalcaemia Critically ill patients may have hypocalcaemia.
With RCA, there may be a drop in the systemic ionised […]