1. What form of anticoagulation is the “best” Or why is Citrate better then Heparin or Prostacyclin

2. Anticoagulation and clotting Any blood surface interface – Hemofilter – Bubble trap – Catheter – Areas of turbulence resistance Luer lock connections / 3 way stopcocks

3. Sites of Action of Citrate Contact Phase (intrinsic) XII activation XI IX Ca ++ Tissue Factor (extrinsic) TF:VIIa THROMBIN Ca ++ fibrinogen prothrombin XXa VaVIIIa Ca ++ platelets CLOT platelets / monocytes / macrophages CITRATE Citrate

4. ACD-A (Baxter, Deerfield, IL) – 1000 cc bag, industry standard CaCl 8 gms/1 liter of NS – pharmacy made Normocarb Dialysis/Replacement Soln (Dialysis Soln Inc) – Can be prepared at bedside or pharmacy Normal Saline Solutions needed for Citrate Protocol (Pediatric Nephrology 2002 17:150-154 )

5. (Citrate = 1.5 x BFR 150 mls/hr) (Ca = 0.4 x citrate rate 60 mls/hr) Normocarb Dialysate Normal Saline Replacemen t Fluid Calcium can be infused in 3 rd lumen of triple lumen access if available. (BFR = 100 mls/min) ACD-A/Normocarb Wt range 2.8 kg – 115 kg Average life of circuit on citrate 72 hrs (range 24-143 hrs) Pediatr Neph 2002, 17:150-154

6. Citrate: Technical Considerations Measure patient and system iCa in 2 hours then at 6 hr increments Standing protocol on nursing flow sheet adjusted by bedside ICU nurse Pre-filter infusion of Citrate – Aim for system iCa of 0.25-0.4 mmol/l Adjust for levels Systemic calcium infusion – Aim for patient iCa of 1.1-1.3 mmol/l Adjust for levels

7. Orders for citrate and Ca rates ( adapted for N Gibney ) CITRATE INFUSION SLIDING SCALECALCIUM INFUSION SLIDING SCALE PRISMA iCa++INFUSION ADJUSTMENTPATIENT iCa++INFUSION ADJUSTMENT >20 kg< 20 kg> 20 kg< 20 kg < 0.25  by 10 ml/hr  by 5 ml/hr > 1.3  by 10 ml/hr  by 5 ml/hr 0.25 – 0.4 (Optimum range) No adjustment No adjustment 1.1 – 1.3 (Optimum range) No adjustment No adjustment 0.4– 0.5  by 10 ml/hr  by 5 ml/hr 0.9 – 1.1  by 10 ml/hr  by 5 ml/hr > 0.5  by 20 ml/hr  by 10 ml/hr < 0.9  by 20 ml/hr  by 10 ml/hr NOTIFY MD IF CITRATE INF. RATE > 200 ML/HRNOTIFY MD IF CALCIUM INF. RATE > 200 ML/HR

8. 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

10. ppCRRT ACG Side Effects 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

11. Complications of Citrate: Citrate Lock – Seen with rising total Ca with dropping patient ionized Ca due to citrate delivery exceeds citrate clearance – Rx of “citrate lock” Increase clearance and decrease citrate rate Metabolic Alkalosis – Resolved with NaHCO3 bath of 25 meq/l

12. Incidence In a recent survey of PICU and CRRT databases in NA 70% of all programs use citrate as a primary mode of anticoagulation to avoid bleeding risks