In the analysis of research into the use of Citrate in the dialysis of ICU patients, there seems to be a positive swing towards the use of Citrate over other anticoagulants. With so many different types of modality being used with Citrate, Which mode seems to have the least complications? All suggestions welcome.
Both CVVH and CVVHDF are suitable fro citrate although probably CVVH would be the simpler technique in order to modify calcium and citrate administration.
I agree with dr Perez's answer, both CVVH and CVVHDF are suitable modes for local Citrate anticoagulation. CVVH is the simpler technique, you can use citrate in both the pre and postdilution modes in CVVH. One additional comment, if you are looking for the safest technique with the least complications you must choose a machine with an integrated citrate pump. When the blood pump shuts down, then automatically the citrate pump shuts down to avoid access citrate infusion in your patient. In these modes (integrated citrate pump) a less concentrated citrate solution can be applied (4% instead of 13%) due to the advanced software of the RRT machine and the use of additional Bicarb buffered substitution fluids.
I agree with dr Perez and dr De Geus. Continuous veno-venous hemodialysis is the simplest. CVVHDF is also not difficult. Machines with integrated citrate pumps, software and kits for these options are available and possibly the safest. In our ICU we do not have any serious complications using them.
I agree with all previous comments, all systems are safe if delivered with a dedicated monitor and management is almost equal (I have tried all modalities and concentrated or diluted solutions as well) and appart from training in the specifics of the monitor you will get same results with same (low) percentage of complications.
The only "but" for me (and is really a theoretical one) is that when reposition fluid is the carrier of the citrate it must be delivered as pre-dilution and in this setting, CHDF is the less eficient modality (because a lower final dose of clearance) but on the other side, changing dialysis flow is a good way to control acid-base and citrate acumulation problems.
Administering citrate in the postdilution bag makes control more dificult in some way because the load of citrate for the patient is higher and even when need for calcium replenishment diminishes, risk for citrate acumulation is higher.
For me, the key point is a good knowledge of the workabouts of citrate because then it is simple to shift from one modality to other without problems. So, my opinion would be: use the monitor and modality your staff is more confortable with.
CVVH is the simplest and most efficient system. Adding dialysate does not increase efficiency as many believe! And if you have pre-dilution, that reduces efficiency as well. CVVH also makes calculations easier and is predictable!
Do not know what do you mean with CVVHf, but CVVH, CVVHDF and CVVHD offer the same versatility in relation to RCA. Sieving coefficient for citrate is about 0.99 thus convective or diffusive transfer makes no difference. This implies to application of concentrated citrate (e.g. 4%TSC) in predilution, in case of isotonic citrate you are limited in configuration because you need larger amount of special predilution fluid with low citrate concentration and special calcium containing fluid in postdilution.
Good luck in BRI, practiced there in 93-94.
Thanks Dr Batik for pointing out how pre-dilution affects citrate anticoagulation. This is why I say that post-dilution CVVH is simplest, very efficient and predictable form of CRRT. Not sure why others use anything else?
Because with postdilution CVVH you have to keep often higher blood flow to avoid the filter filtration fraction above 20-25%. Thus with higher Qb (for example about 150 ml/min instead of 100-110 ml/min) you need higher load of citrate to anticoagulate which may increase side effects and costs of RCA.
Dr Balik. You are right, of course. However, post-dilution CVVH is easier to manage, is predictable in terms of creatinine clearance and drug dose calculations and fluid removal. I take the point that higher blood flows are required (not only necessary for an appropriate Qb but also to produce enough(undiluted) filtrate volumes to maintain creatinine clearance! Hence my comments.
CVVH as access through fistula can at times be complicated due to clotting or even collaped fistula access. I would choose CVVH.
I would like to thank all those whom have added to this debate, and your comments have been warmly welcomed. The information you have provided has been collated and passed onto the relevent people for their consideration.
Again, Thank You.
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