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Mutually compatible
solutions in citrate
anticoagulation
Differences between
Ci-Ca CVVHD and
Ci-Ca postCVVHDF
Laboratory tests during
citrate anticoagulation
Fresenius Medical Care multiFiltrate IFU-EN-UK 15A-2015
For patients with systemic blood coagulation activation, e.g., HIT
syndrome, a systemic anticoagulation may therefore be indicated in
addition to the citrate anticoagulation.
The different continuous renal replacement therapies with regional
citrate anticoagulation described in the literature can differ
considerably, also with regard to the adaption of the treatment to the
specific patient.
Regional citrate anticoagulation requires mutually compatible solutions
(solutions with citrate, other CRRT solutions depending on the
procedure, solutions with calcium). These solutions must also be used
with matching flows to minimise the risk of electrolyte concentration and
acid-base status disorders.
The following is a specific description of the Ci-Ca CVVHD and
Ci-Ca postCVVHDF treatment modes of the device.
In contrast to Ci-Ca CVVHD, an additional calcium-containing,
bicarbonate-buffered substituate is infused in postdilution when
performing a Ci-Ca postCVVHDF treatment. The haemoconcentration
at the filter outlet should, if possible, not exceed 20%. The substituate
flow can, for example, be selected as 1/6 of the blood flow (16.7 ml/min
= 1000 ml/h with a blood flow of 100 ml/min). With regard to the values
set on the display, this corresponds to a ratio of "10:1".
If the haemoconcentration at the filter outlet exceeds 20% due to the
required calcium flow and a clinically required ultrafiltration, the
substituate flow can be reduced so that this limit is not exceeded.
As a result of the substituate flow, there are also certain differences
between Ci-Ca CVVHD and Ci-Ca postCVVHDF regarding the control
of the acid-base status and selecting the appropriate citrate dose
(see chapter 7.3.2.4 on page 7-25).
If citrate anticoagulation is used, the electrolyte checks that are usual in
continuous renal replacement therapy (sodium, potassium, calcium,
magnesium, phosphate, acid-base status) must be supplemented by
close monitoring of the concentration of the systemic ionised calcium
concentration and the systemic acid-base status. Usually, the same
systemic blood sample can be used to determine these values.
In addition, appropriate citrate anticoagulation must be checked by
determining the ionised calcium in the extracorporeal blood circuit.
When performing a Ci-Ca treatment, this is checked downstream of the
filter.
Note
It is absolutely necessary to ensure that the two measurements of the
ionised calcium are not mistaken for each other.
Chapter 7: Functional description
7-19
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