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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. Introduction. CVVH is being increasingly utilized for the care of PICU patients Imperative need :

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Regional Citrate Anticoagulation during CVVH in the Pediatric Intensive Care Unit


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slide1
Regional Citrate Anticoagulation

during CVVH in the

Pediatric Intensive Care Unit

T Gaillot, V Phan, P Jouvet, F Gauvin, C Litalien

introduction
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
introduction1
Introduction

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
introduction2
Introduction

RCA and mean circuit lifetime:

  • Adult studies

Monchi et al, 2004:RCA vs heparin: 70 h vs 40 h

Dorval et al, 2003: 44  24 h

  • Pediatric studies

Chadha et al, 2002: 51  8 h

Elhanan et al, 2004: 56  22 h

Bunchman et al, 2002: 71  7 h

introduction3
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"

objective
Objective

Toevaluate the mean circuit lifetime and

metabolic complications of RCA in critically ill

children after the introduction of this

anticoagulation technique in our PICU

material and methods
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
material and methods1
Material and methods

Normocarb

Rate: 2 L/1.73 m2/h

Systemic infusion

Calcium chloride (8g/1L NS)

Rate: 0.4 X ACD-A rate

ACD-A

Rate: 1.5 X BFR

DIALIZER

Prisma

M-10, M-60 or M-100

(AN-69)

From patient

To patient

BFR: 2-8 ml/kg/min

Ultrafiltrate

Normocarb

Rate: 2 L/1.73 m2/h

Bunchman et al , 2002

slide9

5 patients

mean age 5.5  6.8 y and weight 28.1  33 kg

37 circuits

Mean circuit lifetime (MCL) = 29  36 h

10 elective discontinuations(27%) MCL= 29  32 h

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

Medical cause (n=1, 4%)

1 bleeding

results
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
conclusion
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
perspectives
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