Regional Citrate Anticoagulation during CVVH in the Pediatric Intensive Care Unit
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Transcript of Regional Citrate Anticoagulation during CVVH in the Pediatric Intensive Care Unit
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Regional Citrate Anticoagulation
during CVVH in the
Pediatric Intensive Care Unit
T Gaillot, V Phan, P Jouvet, F Gauvin, C Litalien
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Introduction
• CVVH is being increasingly utilized for the care of PICU patients
• Imperative need :Effective anticoagulation to prevent recurrent clotting of the extracorporeal circuit and to achieve efficient and uninterrupted therapy
• Historically, systemic anticoagulation with heparin mainstay of anticoagulation for CVVH
• Limits/contraindications :• High risk for bleeding• Active bleeding• Heparin-induced thrombocytopenia• Use of activated Protein C
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Regional citrate anticoagulation (RCA):
• Attractive alternative to systemic heparinization with less risk of bleeding
• Citrate chelates ionized Ca2+, an essential cofactor in the clotting cascade
• Anticoagulation is limited to the extracorporeal circuit by infusing citrate solution into the arterial limb of the circuit
• Systemic anticoagulation is avoided by restoring ionized Ca2+ in the systemic circulation by infusing Ca2+ solution through a separate central line
Introduction
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Introduction
RCA and mean circuit lifetime:
• Adult studiesMonchi et al, 2004: RCA vs heparin: 70 h vs 40 h Dorval et al, 2003: 44 24 h
• Pediatric studiesChadha et al, 2002: 51 8 hElhanan et al, 2004: 56 22 hBunchman et al, 2002: 71 7 h
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Introduction
RCA and complications:
• Citrate is metabolized in the liver and produces HCO3-
and citric acid can result in metabolic alkalosis
• Accumulation of citrate may occur if liver metabolism is impaired can result in citrate toxicity or "citrate gap"
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Objective
To evaluate the mean circuit lifetime and
metabolic complications of RCA in critically ill
children after the introduction of this
anticoagulation technique in our PICU
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Material and methods
• Retrospective chart review • Children who underwent hemofiltration with RCA from
March 2003 to December 2003 were included
• Mean circuit lifetime (MCL) and reasons for circuit discontinuation were determined
• Metabolic alkalosis : pH 7.45 and HCO3- 30 mmol/L
• Citrate gap : total to ionized Ca2+ ratio > 2.5
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Material and methods
DIALIZERPrisma
M-10, M-60 or M-100(AN-69)
From patient To patient
Ultrafiltrate
ACD-A
Rate: 1.5 X BFR
Normocarb
Rate: 2 L/1.73 m2/h
BFR: 2-8 ml/kg/min
Normocarb
Rate: 2 L/1.73 m2/h Systemic infusion
Calcium chloride (8g/1L NS)
Rate: 0.4 X ACD-A rate
Bunchman et al , 2002
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27 involuntary discontinuations (73%) MCL= 28 35 h
Circuit failure (n=23, 85%) 10 Catheter dysfunction 13 High transmembrane
pressure and/or clotting
Technical failure (n=3, 11%) 1 impossible auto-test 1 screen failure 1 unknown failure
5 patientsmean age 5.5 6.8 y and weight 28.1 33 kg
37 circuitsMean circuit lifetime (MCL) = 29 36 h
10 elective discontinuations (27%) MCL= 29 32 h
Medical cause (n=1, 4%)1 bleeding
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Results Kaplan-Meier curve of time to circuit discontinuation
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Results
•Post filter ionized Ca2+ : 0.40 0.10 mmol/L
•Patient ionized Ca2+ : 1.14 0.13 mmol/L
•13 episodes (35 %) of metabolic alkalosis in 4 patients
•9 episodes (24 %) of citrate gap in 2 patients
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Conclusion
• In our PICU, the mean circuit lifetime using RCA was much shorter than those reported despite post-filter ionized Ca2+ within the optimum range
• Metabolic alkalosis was frequently encountered
• Citrate toxicity occurred in 2 patients out of 5
• The use of RCA may be somewhat problematic in some critically ill children
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Perspectives
• RCA remains an attractive option to provide anticoagulation in those patients with heparin contraindications
• Prospective, randomized controlled trials comparing RCA and systemic heparinization are needed before RCA replaces heparin in all critically ill children