Review rationale for anticoagulation

Review rationale for anticoagulation

• Review rationale for anticoagulation

• Options

• Heparin/citrate

• Available data

Functional circuit life is imperative to:

• Functional circuit life is imperative to:

• Dose delivery
• Staff statisfaction
• Patient morbidity (changing lines)
• Cost of therapy—multi circuit use

Should be:

• Should be:

• Readily available
• Consistently delivered (protocols)
• Safe!!!!
• Easily monitored
• Commercially available
• Be associated with minimal side effects

Saline Flushes

• Saline Flushes

• Heparin Peds

• Citrate regional anticoagulation Peds

• Low molecular weight heparin

• Prostacyclin

• Nafamostat mesilate

• Danaparoid*

• Hirudin/Lepirudin

• Argatroban (thrombin inhibitor)*

Any blood surface interface

• Any blood surface interface

• Hemofilter
• Bubble trap
• Catheter (Especially Pediatrics)

Reduced risk of bleeding

• Reduced risk of bleeding

• Less risk of HIT

No difference in risk of bleeding

• No difference in risk of bleeding

• No quick antidote

• Increased cost

• No difference in filter life

• Heparin infusion prior to filter with post filter ACT measurement and heparin adjustment based upon parameters

• Bolus with 10-20 units/kg

• Infuse heparin at 10-20 units/kg/hr

• Adjust post filter ACT 180-200 secs

• Interval of checking is local standard and varies from 1-4 hr increments

Benefits

• Benefits

• Heparin infusion prior to filter with post filter ACT measurement

• Bolus with 10-20 units/kg Infuse at 10-20 units/kg/hr

• Adjust post filter ACT 180-200 secs

Clotting is a calcium dependent mechanism, removal of calcium from the blood will inhibit clotting

• Clotting is a calcium dependent mechanism, removal of calcium from the blood will inhibit clotting

• Adding citrate to blood will bind the free calcium (ionized) calcium in the blood thus inhibiting clotting

• Common example of this is blood banked blood

In most protocols citrate is infused post patient but prefilter often at the “arterial” access of the dual (or triple) lumen access that is used for hemofiltration (HF)

• In most protocols citrate is infused post patient but prefilter often at the “arterial” access of the dual (or triple) lumen access that is used for hemofiltration (HF)

• Calcium is returned to the patient independent of the dual lumen HF access or can be infused via the 3rd lumen of the triple lumen access

Measure patient and system iCa in 2 hours then at 6 hr increments

• Measure patient and system iCa in 2 hours then at 6 hr increments

• Pre-filter infusion of Citrate

• Aim for system iCa of 0.3-0.4 mmol/l
• Adjust for levels

• Systemic calcium infusion

• Aim for patient iCa of 1.1-1.3 mmol/l
• Adjust for levels

No need for heparin

• No need for heparin

• Commercially available solutions exist (ACD-citrate-Baxter)

• Less bleeding risk

• Simple to monitor

• Many protocols exist

Has zero effect upon patient bleeding as opposed to heparin which effects system and patient bleeding

• Has zero effect upon patient bleeding as opposed to heparin which effects system and patient bleeding

• Easy to monitor with ionized calcium assay

• Activated Clotting Time (ACT) nor PTT needed

• Programs report less clotted circuits = less disposable cost and less overtime nursing hours

• Bedside surveys demonstrate less work of machinery allowing more attention to patient

Metabolic alkalosis

• Metabolic alkalosis

• Metabolized in liver / other tissues
• May be associated with post CRRT raclcitrant hypercalcemia

• Electrolyte disorders

• Hypernatremia
• Hypocalcemia
• Hypomagnesemia

• Cardiac toxicity

• Neonatal hearts

Metabolic alkalosis due to

• Metabolic alkalosis due to

• citrate conversion to HCO3
• Solutions with 35 meq/l HCO3
• NG losses
• TPN with acetate component

Seen with rising total calcium with dropping/Stable patient ionized calcium

• Seen with rising total calcium with dropping/Stable patient ionized calcium

• Essentially delivery of citrate exceeds hepatic metabolism and CRRT clearance

• Treatment of “citrate lock”

• Decrease or stop citrate for 1 hr then restart at 70% of prior rate or Increase D or FRF rate to enhance clearance

In adults: Monchi M et al. Int Care Med 2004;30:260-65

• In adults: Monchi M et al. Int Care Med 2004;30:260-65

• Median filter life was 70 hr Citrate, 40 hr Heparin
• Fewer PRBC transfused in Citrate group (surrogate of bleeding per study) 0.2 units/day of CVVH Citrate vs 1 units/day of CVVH Heparin

single center - 209 adults

• single center - 209 adults

• regional anticoagulation : trisodium citrate vs standard heparin protocol ( customized calcium-free dialysate)

• CitACG was the sole anticoagulant in 37 patients, 87 patients received low-dose heparin plus citrate, and 85 patients received only hepACG.

• Both groups receiving citACG had prolonged filter life when compared to the hepACG group.

• significant cost saving due to prolonged filter life when using citACG.

Seven ppCRRT centers

• Seven ppCRRT centers

• 138 patients/442 circuits
• 3 centers: hepACG only
• 2 centers: citACG only
• 2 centers: switched from hepACG to citACG

• HepACG = 230 circuits

• CitACG= 158 circuits

• NoACG = 54 circuits

• Circuit survival censored for

• Scheduled change
• Unrelated patient issue
• Death/witdrawal of support
• Regain renal function/switch to intermittent HD

Heparin

• Heparin

• 11 cases of systemic bleeding on heparin
• 5 cases no ACG used secondary to bleeding
• 1 case of HIT

• Citrate

• 19 cases of metabolic alkalosis
• 1 change to heparin for hyperglycemia
• 1 change to heparin for alkalosis
• 3 cases of citrate lock

Heparin and citrate anticoagulation most commonly used methods

• Heparin and citrate anticoagulation most commonly used methods

• Heparin: bleeding risk

• Citrate: alkalosis, citrate lock

Adqi.net-web site for information on CRRT

• Adqi.net-web site for information on CRRT

• AKIN.org

• Crrtonline.com-web site for info on Dr Mehta’s meeting

• www.PCRRT.com Pediatric CRRT with links to other meetings, protocols, industry

• PCRRT list serve (contact Tim Bunchman)

ppCRRT members

• ppCRRT members

• Bedside ICU and Dialysis Nurses

• Mary Lee Neuberger/Rhonda Cass

• patients