Hi all,
I’m looking for insight from other institutions regarding a recurring anticoagulation workflow challenge with CRRT (Prismaflex) in our ICU.
Background
Our nephrology team often requests pre‑filter heparin anticoagulation using 1,000 units/mL heparin in a 20 mL syringe attached to the Prismaflex syringe pump. The standard dose is 500 units/hr, but occasionally providers request lower rates (e.g., 250 units/hr) due to bleeding risk or per nephrology’s preference.
The Issue
The Prismaflex syringe pump cannot deliver rates below 0.5 mL/hr, meaning we cannot safely or accurately deliver <500 units/hr using the standard 1,000 units/mL syringe concentration.
This leads to confusion and workaround pressure:
Nursing escalates to nephrology and pharmacy.
To achieve <500 units/hr, nurses sometimes advocate for hanging a therapeutic heparin infusion (25,000 units/250 mL) via a standard IV pump and connecting that to the CRRT line.
This workaround creates multiple safety concerns:
Different route on the MAR
Bypassing weight‑based safety limits
Epic manipulations that defeat dose checking
Potential mismatches between IV heparin protocols and CRRT‑specific anticoagulation
At the moment, our choices feel like:
Discourage workarounds but accept that we cannot meet the requested lower dose,
Ask pharmacy to manually dilute heparin to a concentration that allows the Prismaflex to run <500 unts/hr, or
Continue the workaround of using a therapeutic heparin bag, which is far from ideal from a medication‑safety standpoint.
For those managing CRRT anticoagulation:
How does your institution deliver pre‑filter heparin at rates <500 units/hr?
Do you use diluted heparin syringes?
Do you restrict nephrology from ordering below certain rates?
Do you use an alternate concentration stocked specifically for CRRT?
How do you maintain safety controls in the EHR?
Do you have a dedicated CRRT heparin order set with selectable concentrations?
How do you prevent nurses/providers from using IV heparin order sets to solve this problem?
Have you created policy, hard stops, or education to prevent unsafe workarounds when the pump cannot deliver the requested dose?
Any examples, policies, or experience you can share would be extremely helpful. This will support our internal medication‑safety review and an SBAR proposal for a more standardized approach.
Thank you!
Christopher Garcia, PharmD
Lead Pharmacist