Thread by @VTA_Symposium

Dr Shabir Alekar is speaking next on 'Prolonging CRRT Circuit Life' #VTA23 #FOAMcc #critcare

As soon as blood leaves the body, it comes into contact with foreign substances that initiate the clotting/coagulation process. The high surface area of the CRRT filters are usually where these processes are most likely to occur. #VTA23

Preserving filter life is very important, as the circuits are very expensive and cumbersome to replace. More importantly, time off CRRT reduces the efficacy of the RRT and puts the patient at risk. #VTA23

Key factors universal to all anticoagulation strategies actually have nothing to do with anticoagulation. You need to ensure good blood flow so there is not stagnation, and try keep return pressures and access pressures low. #VTA23

You can systemically anticoagulate the patient (if indicated for patient-specific reasons) or you can do regional anticoagulation of the CRRT circuit. The options for regional anticoagulation are heparin or citrate. #VTA23
doi.org/10.1002/146518…

Citrate binds the calcium essential to blood clotting, reducing it to levels of 0.25-0.35mmol/L. The calcium is then replaced systemically in the patient according to blood gas calcium levels. #VTA23

Citrate (vs UFH) reduces the rate of major bleeding and thrombocytopaenia, and prolongs circuit life significantly.
doi.org/10.1001/jama.2…
#VTA23

There is a higher rate of alkalosis, hyperphosphataemia and new infection. Some of these (ie new infection) are unexplained (more sampling, longer circuit life?).
#VTA23

KDIGO suggests citrate anticoagulation, from as long back as 2012! It involves complex regimens, there is a risk of complications, and an implementation lag.
doi.org/10.1002/146518…
#VTA23