Regional citrate anticoagulation high-cut-off continuous veno-venous hemodialysis for COVID-19 and AKI patients in intensive care unit

2021 ◽  
Author(s):  
Federico Nalesso ◽  
Laura Gobbi ◽  
Leda Cattarin ◽  
Georgie Innico ◽  
Lorenzo A. Calò
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation

scholarly journals Citrate versus non-citrate anticoagulation in continuous renal replacement therapy: Results following a change in local critical care protocol

2016 ◽  
Vol 18 (1) ◽  
pp. 47-51
Author(s):  
Samina R Chowdhury ◽  
Tom Lawton ◽  
Aaqid Akram ◽  
Robert Collin ◽  
James Beck
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Regional Citrate Anticoagulation ◽  
Nursing Workload ◽  
Citrate Anticoagulation ◽  
Care Protocol ◽  
Transfusion Requirements

Continuous renal replacement therapy necessitates the use of anticoagulation. The anticoagulant of choice has traditionally been heparin. Emerging evidence has highlighted the deleterious effects of systemic heparin anticoagulation in the critically ill. Regional citrate anticoagulation has been used as an alternative in the setting of continuous renal replacement therapy. Our retrospective before-and-after cohort study aimed to ascertain if regional citrate anticoagulation is associated with any benefit in terms of circuit longevity, rates of complications, blood transfusion requirements and mortality, when introduced to a large general intensive care unit with a case mix of acute medical patients and acute and elective surgical patients. The switch to regional citrate anticoagulation for continuous renal replacement therapy in our intensive care unit has been associated with a dramatically longer circuit life, with major implications for cost savings in terms of reduced nursing workload. We hope to look at fiscal aspects of the change in protocol in greater depth.

scholarly journals Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Eloy F. Ruiz ◽  
◽  
Victor M. Ortiz-Soriano ◽  
Monica Talbott ◽  
Bryan A. Klein ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Quality Assurance ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Health Care Professionals ◽  
Regional Citrate Anticoagulation ◽  
Quality Assurance System ◽  
Assurance System

AbstractCritically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.

scholarly journals Flexitrate regional citrate anticoagulation in continuous venovenous hemodiafiltration: a retrospective analysis

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Ilan Lenga ◽  
Wilma M. Hopman ◽  
Adam J. O’Connell ◽  
Francesca Hume ◽  
Charles C. Y. Wei
Keyword(s):  
Intensive Care ◽  
Metabolic Control ◽  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation ◽  
Intensive Care Patients ◽  
Filter Life ◽  
Heparin Anticoagulation ◽  
Metabolic Outcome ◽  
Extended Filter

Abstract Background Flexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA (tRCA) and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT). Methods A single-center, retrospective, cohort study, was done in a 26-bed intensive care unit in a large community hospital. Eighty dialysis sessions (Flexitrate = 2852 h, tRCA = 3580 h and Heparin = 2026 h), performed in 53 patients, were evaluated for filter life, RCA control, and metabolic control. Results In the Flexitrate cohort, 3.8% of filters clotted, compared to 16.9% with tRCA and 28.3% with Heparin (p < 0.001 for Flexitrate compared to either tRCA or Heparin). Filter survival was significantly improved with Flexitrate compared to tRCA (HR 0.24, p = 0.018) or Heparin (HR 0.14, p = 0.004). Anticoagulation control was superior with Flexitrate with Patient Ionized Calcium out of target a median of 16% of the time, compared to 27% for tRCA (p < 0.001). Filter Ionized Calcium was out of target a median of 6.8% of the time, compared to 23% for tRCA (p = 0.03). Flexitrate produced significantly less alkalosis, hypernatremia, and hypocalcemia than tRCA, and overall metabolic control was comparable to Heparin anticoagulation. The only adverse metabolic outcome with Flexitrate was increased hypomagnesemia. Conclusions The Flexitrate protocol extended filter life, delivered more consistent anticoagulation, and provided superior metabolic control compared to a tRCA protocol. Filter life was superior to Heparin anticoagulation, with similar metabolic control. A randomized control trial comparing these protocols is recommended.

scholarly journals Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes

2021 ◽  
Vol 9 ◽  
Author(s):  
Emanuele Buccione ◽  
Francesco Guzzi ◽  
Denise Colosimo ◽  
Brigida Tedesco ◽  
Stefano Romagnoli ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Mortality Rate ◽  
Protective Factors ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Fluid Overload ◽  
Pediatric Intensive Care ◽  
Citrate Anticoagulation

Introduction: Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), however, Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting. This study aims to describe our experience in the rate of application of CRRT, patients' clinical characteristics at admission and CRRT initiation, CRRT prescription, predictors of circuit clotting, short- and long-term outcomes.Methods: A 6-year single center retrospective study in a tertiary PICU.Results: Twenty-eight critically ill patients aged 0 to 18 years received CRRT between January 2012 and December 2017 (1.4% of all patients admitted to PICU). Complete clinical and CRRT technical information were available for 23/28 patients for a total of 101 CRRT sessions. CRRT was started, on average, 40 h (20–160) after PICU admission, mostly because of fluid overload. Continuous veno-venous hemodiafiltration and systemic heparinization were applied in 83.2 and 71.3% of sessions, respectively. Fifty-nine sessions (58.4%) were complicated by circuit clotting. At multivariate Cox-regression analysis, vascular access caliber larger than 8 Fr [HR 0.37 (0.19–0.72), p = 0.004] and regional citrate anticoagulation strategy [HR 0.14 (0.03–0.60), p = 0.008] were independent protective factors for clotting. PICU mortality rate was 42.8%, and six survivors developed chronic kidney disease (CKD), within an average follow up of 3.5 years.Conclusions: CRRT is uncommonly applied in our PICU, mostly within 2 days after admission and because of fluid overload. Larger vascular access and citrate anticoagulation are independent protective factors for circuit clotting. Patients' PICU mortality rate is high and survival often complicated by CKD development.

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