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CRITICAL CARE

Regional Citrate Anticoagulation for PrismaFlex Continuous Renal Replacement Therapy

Clinical Pharmacy Specialist, Department of Pharmacy, Associate Scientist, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

David D Tung, PharmD

at the time of the project, Pharmacy Resident, Department of Pharmacy, Mount Sinai Hospital; now, Staff Pharmacist, Medisystems Pharmacy, Toronto

David Hallett, MSc

Biostatistician, University of Toronto

Toni Bailie, BScPharm

Clinical Pharmacist, Mount Sinai Hospital

Virginia Carvalhana, PharmD

Department of Pharmacy, Mount Sinai Hospital

David Lee, MSc

DDS student, School of Dentistry, University of Toronto

Steve Ramganesh, RN

ICU Nurse Educator, Department of Nursing, Mount Sinai Hospital

Robert Richardson, MD

Director of Dialysis, Department of Nephrology, University Health Network, University of Toronto

Sangeeta Mehta, MD

ICU Research Director, Department of Medicine, Mount Sinai Hospital

Stephen E Lapinsky, MB BCh

ICU Site Director, Department of Medicine, Mount Sinai Hospital

Reprints: Dr. Burry, Department of Pharmacy, Mount Sinai Hospital, 600 University Ave., Room 1504, Toronto, ON M5G 1X5, Canada, fax 416/586-8353, lburry{at}mtsinai.on.ca

BACKGROUND: Since Mehta et al. reported the first successful use of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) in 1990, RCA is increasingly used for CRRT because it provides filter patency with minimal risk of bleeding. However, RCA has been associated with significant metabolic complications including hypocalcemia, hypernatremia, metabolic alkalosis, and citrate toxicity.

OBJECTIVE: To describe our experience with a newly implemented RCA protocol with acid citrate dextrose formula A (ACD-A) and intravenous calcium gluconate, for use with PrismaFlex CRRT in critically ill patients with acute kidney injury.

METHODS: A retrospective chart review was conducted from May 1, 2006, until May 1, 2007, in a 16-bed medical-surgical university-affiliated intensive care unit. Data collected included dialysis filter life, patient and circuit metabolic parameters, and units of packed red blood cells transfused.

RESULTS: Forty-eight patients received dialysis with citrate (n = 178 filters). Circuit clotting occurred in 24% of all filters. Mean ± SD filter life was 38.4 ± 25.9 hours, and filter survival at 48 hours was 38.2%. Persistent metabolic alkalosis while on CRRT was identified in 6 of 45 (13.3%) patients. Mild hypocalcemia (ionized calcium <3.6 mg/dL) occurred in 11 (23%) patients, but no patient had an ionized calcium level less than 2.8 mg/dL. Six patients, 3 with acute leukemia, required transfusion of 2 or more units of packed red blood cells in 24 hours.

CONCLUSIONS: We found that anticoagulation of PrismaFlex CRRT with ACD-A and intravenous calcium gluconate provided reasonable filter patency, but with minor metabolic complications. Close monitoring of electrolyte and acid-base balance is required to minimize metabolic derangements.

Key Words: ACD-A, citrate, CRRT, dialysis, regional anticoagulation

Published Online, August 18, 2009. www.theannals.com, DOI 10.1345/aph.1M182