Dear Ramin,

CRRT using regional citrate anticoagulation is a first choice CRRT technique in my ICU. We use heparin anticoagulation when contraindications to citrate technique exist. We have Prismaflex system (Gambro) and infuse calcium chloride using external infusion pump according to the protocol recommended by Gambro.

Dear Ramin,

The calcium infusion protocol is multiparameters dependents and this is often the CRRT Hardware distributor who is providing such protocol. However, by this way you are becoming linked to the hardware provider solution and cannot anymore do your own choice for the full procedure.

Calcium gluconate pills concentrations are used to be near 2 to 3 times LOWER than Calcium Chloride. (it depends of countries and manufacturers). Most of the time Calcium Chloride is prefered to avoid extra-glucose delivery.

London kings college Hospital (John Prowle) is today experimenting a RCA protocol without most of the time needs for calcium infusion. This is also due to the fact that in this case Substitution solutions used are containing 1,75 mmol/L of ionized calcium.

Therefore this is fondamental to report about machine,, procedure (CVVH, CVVHD, CVVHDF), citrate anticoagulant (ACD-A, TSC 4%, Citrate diluted ...) and dialysate and/or substitution solutions used before defining a calcium delivery protocol.

Dear Ramin,

We use citrate as method of choice for CRRT. Via CVL calciumgluconate is administered according to labvalues (Ca++ is ordered every 6 hours to steer the calciumdosage. Only elevated liverenzymes or rising lactate levels are reasons to switch to systemic heparine or regional heparine and protamine.

Dear Ramin,

We use citrate as method of choice for CRRT. Via CVL calciumgluconate is administered according to labvalues (Ca++ is ordered every 6 hours to steer the calciumdosage. Only elevated liverenzymes or rising lactate levels are reasons to switch to systemic heparine or regional heparine and protamine.

Citrate Anticoagulation for Continuous Renal Replacement Therapy in Critically Ill Patients: Success and Limits

Filippo Mariano,1 Daniela Bergamo,1 Ezio Nicola Gangemi,2 Zsuzsanna Hollo',1 Maurizio Stella,2 and Giorgio Triolo.

Abstract

Citrate anticoagulation has risen in interest so it is now a real alternative to heparin in the ICUs practice. Citrate provides a regional anticoagulation virtually restricted to extracorporeal circuit, where it acts by chelating ionized calcium. This issue is particularly true in patients ongoing CRRT, when the “continuous” systemic anticoagulation treatment is per se a relevant risk of bleeding. When compared with heparin most of studies with citrate reported a longer circuit survival, a lower rate of bleeding complications, and transfused packed red cell requirements. As anticoagulant for CRRT, the infusion of citrate is prolonged and it could potentially have some adverse effects. When citrate is metabolized to bicarbonate, metabolic alkalosis may occur, or for impaired metabolism citrate accumulation leads to acidosis. However, large studies with dedicated machines have indeed demonstrated that citrate anticoagulation is well tolerated, safe, and an easy to handle even in septic shock critically ill patients.

For more please read at following link.

Warm Regard

http://www.hindawi.com/journals/ijn/2011/748320/

thanks to all replays  . 

thanks to all replays  . 

There is a protocol from Berlin has been quite successful. 

Abstract

Objective: Citrate anticoagulation is an excellent alternative to heparin anticoagulation for critically ill patients requiring continuous renal replacement therapy. In this article, we provide a safe and an easy-to-handle citrate anticoagulation protocol with variable treatment doses and excellent control of the acid–base status.

Design: Prospective observational study.

Setting: University hospital.

Patients: One hundred sixty-two patients with acute renal failure requiring renal replacement therapy were enrolled in the study.

Intervention: A continuous venovenous hemodialysis-based citrate anticoagulation protocol using a 4% trisodium solution, a specially designed dialysate fluid, and a continuous calcium infusion were used. The study period was 6 days. Hemofilters were changed routinely after 72 hours of treatment. The patients were grouped according to body weight, with patients below 60 kg body weight in group 1, patients with at least 60 kg and up to 90 kg body weight in group 2, and patients with a body weight of above 90 kg in group 3. Dialysate flow was adapted according to body size and matched approximately 2 L/hr for a patient with average body size. Blood flow, citrate flow, and calcium flow were adjusted according to the dialysate flow used.

Measurements and Main Results: Median filter run time was 61.5 hours (interquartile range: 34.5–81.1 hours). Only 5% of all hemofilters had to be changed because of clotting. The prescribed treatment dose was achieved in all patients. Acid–base and electrolyte control were excellent in all groups. In the rare cases of metabolic disarrangement during citrate anticoagulation, acid–base values were rapidly corrected by modifying either the dialysate flow or alternatively the blood flow rate. Eight patients (5%) developed signs of citrate accumulation indicated by an increase of the total calcium >3 mmol/L or a need for high calcium substitution.

Conclusions: We provide a safe and an easy-to-handle citrate anticoagulation protocol that allows an excellent acid–base and electrolyte control in critically ill patients with acute renal failure. The protocol can be adapted to patients’ need, allowing a wide spectrum of treatment doses.