Citrate anticoagulation in a piglet model of pediatric continuous renal replacement therapy

Nuthall, Gabrielle; Skippen, Peter; Daoust, Christopher; Aljofan, Fahad; Seear, Michael

doi:10.1097/00003246-200204000-00031

Cited by 9 publications

(12 citation statements)

References 22 publications

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“…Citrate also inhibits platelet aggregation. Nuthall et al found a linear relationship between iCa and serum citrate levels in an animal model of RCA in continuous venovenous hemofiltration [26]. Bakker et al found a hyperbolic relationship between iCa and measured serum citrate levels in ten adult patients with RCA [27].…”

Section: Discussionmentioning

confidence: 99%

Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium

et al. 2010

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Recent years has seen an increasing use of regional citrate anticoagulation in pediatric dialysis. Several approaches have been described for monitoring anticoagulation in the extracorporeal circuit, such as serum citrate levels, post-filter ionized calcium (iCa), and activated coagulation time (ACT). However, no standard recommendations have yet been established for applying any of these parameters, especially for iCa. The objective of this retrospective analysis was to establish adequate coagulation management using post-filter iCa values. Normal values for ACTester-based ACT were established using a group of 64 children who were divided into two subgroups, with one subgroup comprising children without chronic kidney disease or coagulation disorder (age 1.2-17.5 years, median 9.7 years) and one consisting of 32 uremic patients (age 0.6-17.5 years, median 13.7 years). In a second group of 13 patients (aged 7-17 years), all of whom were undergoing high-flux dialysis (HD) with regional citrate anticoagulation (RCA), we assessed 73 post-filter blood samples for ionized calcium and ACT. A receiver operating characteristic graph was used to identify the iCa threshold needed to achieve adequate anticoagulation. Normal values for ACT were 90 s [2 standard deviations (SD) 72-109] in healthy children and 94 s (2 SD 75-113) in the uremic children. There was no statistically significant difference between the groups. In the children undergoing HD with RCA, the post-filter iCa level correlated with ACT (r = -0.94, p < 0.001). A post-filter iCa level of < or = 0.30 mmol/l reliably predicted an ACT >120 s. Our citrate protocol [citrate 3% rate (ml/h) approximately blood flow rate (ml/min) x 2] meets the established criteria with a high sensitivity. Based on these results, we conclude that the post-filter iCa level can be reliably used for the management of extracorporeal anticoagulation with citrate in pediatric HD. We recommend the application of our citrate prescription protocol in the setting of pediatric intermittent hemodialysis.

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Section: Discussionmentioning

confidence: 99%

Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium

et al. 2010

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“…Our citrate anticoagulation protocol was based on earlier work using an animal model [20], but was similar in all major respects to pediatric protocols published by Bunchman et al [17] and Chadha et al [18]. The PRISMA hemofiltration system with M-60 size filter (COBE, Lakewood, Colo., USA) was used for all patients.…”

Section: Cvvh Protocolmentioning

confidence: 99%

“…The rate was adjusted following a published protocol [20] but, in practice, the citrate flow (in ml/min) was 1.5-2 times the blood flow (in ml/h). For example, to anticoagulate a circuit blood flow of 5 ml/kg per min requires an ACD-A flow of 8-10 ml/kg per hour.…”

Section: Cvvh Protocolmentioning

confidence: 99%

“…Pre-filter N. Elhanan · P. Skippen · G. Krahn · M. Seear ( ) ) administration of citrate chelates calcium and prevents it acting as an essential co-factor at multiple steps in the coagulation cascade [19]. Pre-filter ionized calcium (iCa) levels provide the most-convenient means of monitoring the degree of anticoagulation (target range 0.3-0.4 mmol/l) [20].…”

Section: Introductionmentioning

confidence: 99%

“…We introduced citrate anticoagulation into our own practice after studying the technique in a small animal model [20]. We now wish to report our practical experience with regional citrate anticoagulation in critically ill children undergoing CVVH.…”

Section: Introductionmentioning

confidence: 99%

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Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Nahum

Skippen

Nuthall

et al. 2004

Pediatric Nephrology

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Regional citrate anticoagulation has become a common alternative to systemic heparinization in adult continuous venovenous hemofiltration (CVVH) practice. We report our experience with the technique in critically ill children. We carried out a retrospective chart review of a 22-bed pediatric intensive care unit. CVVH with pre-filter citrate and systemic calcium replacement infusions was performed according to a strict protocol in nine consecutive critically ill children. All charts were reviewed for patient characteristics and CVVH circuit parameters, including filter survival. All complications were noted. Nurse specialists were interviewed about the practical management of citrate anticoagulation. All patient measurements of blood urea nitrogen, creatinine, sodium, ionized calcium (iCa), potassium, and bicarbonate were collected over the CVVH period. In seven patients, 12 simultaneous citrate measurements were taken from patient blood, pre-filter blood, and hemofiltrate fluid. Nine patients (mean age 8.8+/-6.8 years) were treated with CVVH and regional citrate anticoagulation for 1-14 days (mean 5.2+/-4.0 days). Of 19 filters used, 15 were replaced non-electively (mean filter survival 55.6+/-22.0 h). Control of azotemia and hyperkalemia was good. Sodium and iCa levels were well maintained. Bicarbonate levels were elevated in four patients without adverse effects. The mean systemic citrate level at equilibrium was 1.6+/-0.23 mmol/l. No systemic bleeding complications were observed. In children, regional citrate anticoagulation provides equivalent filter survival to heparin without bleeding complications. With good staff preparation, it is simple to perform and safe with respect to metabolic side effects.

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Regionale Zitratantikoagulation bei Nierenersatzverfahren auf der Intensivstation

Schmitz

Joannidis

Czock

et al. 2018

Med Klin Intensivmed Notfmed

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The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.

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Citrate anticoagulation in a piglet model of pediatric continuous renal replacement therapy

Cited by 9 publications

References 22 publications

Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium

Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium

Citrate anticoagulation in pediatric continuous venovenous hemofiltration

Regionale Zitratantikoagulation bei Nierenersatzverfahren auf der Intensivstation

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