Presentation Details
| Clinical Experience Using Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy in a Neonate with Acute Kidney Failure: Case Report Jessica Santoyo Cueva1, Luis Ruben Miranda Ramirez1, Michelle Cecilia Arechiga Andrade1, Erendira Reyes Ramirez1. 1Instituto Pediacritica Hospital Puerta de Hierro Andares, Zapopan, Mexico.2Instituto Pediacritica Hospital Puerta de Hierro Andares, Zapopan, Mexico.3Instituto Pediacritica Hospital Puerta de Hierro Andares, Zapopan, Mexico.4Instituto Pediacritica Hospital Puerta de Hierro Andares, Zapopan, Mexico |
Abstract
Objective: To describe our clinical experience using citrate as a regional anticoagulant during continuous renal replacement therapy in a critically ill neonate with acute kidney failure Case Report : 9-day-old neonate was admitted to the intensive care unit in the postoperative state for arterial switch operation for transposition of the great arteries with an inverted coronary pattern. The patient was connected to extracorporeal membrane oxygenation for eight days, then later presented acute renal failure and met the criteria to start continuous renal replacement therapy using citrate as the anticoagulant. Background: Continuous renal replacement therapy (CRRT) is the standard supportive therapy for kidney injury. During CRRT, regional citrate anticoagulation (RCA) is favored by many intensivists, nephrologists and hematologists because it avoids systemic anticoagulation as it inhibits the clotting cascade by chelating ionized calcium (iCa) and reduces bleeding as opposed to heparin anticoagulation. Discussion: Current pediatric and adult studies support regional citrate anticoagulation as an effective alternative to systemic heparin anticoagulation. Regional anticoagulation with citrate, only inhibiting the clotting cascade within the extracorporeal circuit, is an ideal option in the critically ill child with multiple organ failure at high risk for bleeding. Citrate should be infused into the access line of the extracorporeal circuit as proximally as possible because blood contacting the plastic tubing induces thrombogenesis. The citrate dose was set at 2.5-3.1 mmol/L to obtain a post filter ionized calcium concentration (iCa) of 0.25-0.35mmol/L. We suggest checking prefilter iCa levels within 1 hour of initiation to ensure a goal of less than 0.35 mmol/L, and once achieved, monitor proactively every 6–12 hours thereafter. There is a direct dose-effect relationship between citrate and calcium. Our patient was given supplemental IV calcium to avoid life-threatening arrhythmias from hypocalcemia. Beyond the filter, calcium was continuously infused on the return line of the hemofiltration catheter to restore the blood calcium levels. Calcium infusions were performed with calcium gluconate at 22mg.kg.hr. We suggest calcium replacement to occur through a separate central catheter and not within the extracorporeal circuit because calcium repletion reactivates the clotting cascade and calcium infused into the return line increases the risk of clotting within the catheter and the loss of the circuit due to catheter malfunction. We recommend monitoring serum calcium levels every 6-8 hours to ensure appropriate calcium replacement. Routine monitoring consists of: circuit/patient IoCa every 6 hours and international normalized ratio, complete blood cell count, urea, creatinine, magnesium, potassium, and phosphate every 24 hours; filter pressures and signs of bleeding or clotting were monitored continuously. Hemodynamic status and fluid balance, pH, bicarbonate were closely monitored. Conclusion:Citrate has emerged as the recommended first line anticoagulant for continuous renal replacement therapy in the intensive care unit based on its efficacy and safety profile. Several clinical studies support the superiority of RCA over standard heparin in terms of both prolonged circuit lifespan and reduced incidence of hemorrhagic complications and transfusional needs.
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