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Citrate Flushing
We have been asked by the Nephrologist to start flushing PICCs and  triple lumens with Citrate. I am not familiar with Citrate. How much? How ofter? Our response is "to just flush with NS if the patient can not receive Heparin." However, the doctor has asked us to develop a policy and procedure for flushing catheters with Citrate. Please help! Thanks so much.
Daphne Broadhurst
Our nephro dept. converted
Our nephro dept. converted from Heparin flush to Citrate 4%. Please find attached our Citrate flush pre-printed Rx & Hemodialysis/Plasmapharesis policy for the nsg units (I've requested an electronic copy of our Nephro Citrate policy & will post it upon receipt). Lynn H. recently stated that Citrate was not yet commercially available in the US- that may be a hurdle for you.

Some published benefits of Citrate:
Grudinski's study concluded "
citrate lock avoids heparin-associated bleeding complications, improves reliability of INR assays and provides an effective alternative for patients with suspected or confirmed heparin-induced thrombocytopenia" and Lok demonstrated that "Citrate 4% has equivalent or better outcomes with regards to catheter exchange, TPA use and access-related hospitalizations compared with heparin locking."

Daphne Broadhurst,
Ottawa, Canada

Grudzinki L et al. Sodium citrate 4% locking solution for central venous dialysis catheters—an effective, more cost-efficient alternative to heparin. Nephrol Dial Transplant (2007) 22: 471–476
2. L
ok C et al. Trisodium citrate 4%—an alternative to heparin capping of haemodialysis catheters. Nephrol Dial Transplant (2007) 22: 477–483 
Pepper RJ et al. Inadvertent postdialysis anticoagulation due to heparin line locks. Hemodial Int. 2007 Oct;11(4):430-4.

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

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