Literature Synthesis1.Citrate reactions are uncommon and usually mild when they do occur.2.Consider prophylactic calcium in donors with low body weight, liver or kidney dysfunction, or those with a history of citrate reactions. 3.Intravenous calcium gluconate is associated with extravasation necrosis and multiple drug interactions.

BackgroundCitrate is an anticoagulant used during

apheresis procedures. It achieves anticoagulation of the extracorporeal apheresis circuit by temporarily binding to free calcium in the blood causing symptoms of hypocalcemia in some patients. Current practice at our facility is to administer prophylactic intravenous calcium gluconate to every apheresis patient to prevent citrate reactions. An additional dose is given for any type of citrate reaction., regardless of severity.

ProblemThere have been national shortages of

intravenous calcium gluconate. This has led to time-consuming efforts for the apheresis nursing staff. Those efforts include additional communication with the physicians , re-scheduling lower priority procedures, and coordinating with pharmacy.

Project DescriptionThis project was focused on the donor

population served at our facility. Donor citrate reactions were managed based on clinical assessment of symptoms rather than prophylactically.

PICO QuestionAre oral calcium carbonate supplements

as effective as intravenous calcium gluconate in managing mild citrate reactions in apheresis donors?

Citrate ReactionsMILD•Circumoral numbness and tinglingMODERATE•Chills•Vibration sensation•Non-cardiac chest heaviness•NauseaSEVERE•Tetany

DataThe pre-implementation period from December to February included 115 donor procedures. The total intravenous calcium cost was $616. Implementation with full staff compliance was achieved for May through July with 77 donor procedures and $124 in intravenous calcium charges..

OutcomeCalcium cost decreased by 80% after eliminating the prophylactic calcium infusion. Patient safety and comfort were maintained while decreasing labor and cost of calcium infusions allowing these resources to be utilized more efficiently. RecommendationsProphylactic calcium is not needed in most cases and oral calcium is sufficient in managing mild reactions in apheresis donors.

Implementation Prophylactic intravenous

calcium infusions were not given.

The “Apheresis Order Set” was changed to include both oral calcium carbonate and intravenous calcium gluconate PRN medications..

Staff administered oral calcium carbonate for mild reactions and intravenous calcium gluconate was reserved for moderate and severe reactions.

Decreasing Labor and Cost of Calcium in Apheresis DonorsJeannette Mastrovich RN, BSN, OCN, HP (ASCP)cm

TCU Evidence Based Practice Fellow