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Chapter 2: Important information
2.6.7
Contraindications
Systemic anticoagulation
Regional anticoagulation
with citrate
2-6
For more detailed information on situations where these risks might
occur and on the options of reducing the occurrence of these risks,
please refer to (see chapter 7.3.2 on page 7-17).
Systemic anticoagulation is often contraindicated for bleeding patients
or patients at a high risk of bleeding. Here, measures should be taken
within the treatment regimen which permit a renal replacement
treatment with little or no anticoagulation. A regional anticoagulation
with citrate can be used, if required.
– Disordered citrate metabolism
An established disordered citrate metabolism is an absolute
contraindication. In case of a disordered citrate metabolism, a CRRT
treatment should be checked with a bicarbonate-containing HF solution
(e.g., multiBic). Here, anticoagulation of the extracorporeal blood circuit
may not be necessary under certain circumstances.
If, for example, a disordered citrate metabolism is suspected because
of a restricted liver function, citrate anticoagulation can still be started,
however under particularly intensive monitoring. In this case, the signs
of systemic citrate accumulation must be observed closely. This applies
especially to a decrease in the systemic ionised calcium, high calcium
substitution requirements for stabilising the ionised calcium, and to an
increase in systemic total calcium (see chapter 7.3.2.5 on page 7-27).
– Poisoning events that severely impact oxidative metabolism
With regional citrate anticoagulation, a quantity of citrate is unavoidably
infused systemically and must be metabolised by the patient by
consuming oxygen. Poisoning events that adversely influence this
oxidative metabolism therefore present a contraindication for citrate
anticoagulation. Evidence suggests that this is the case for poisoning
with paracetamol and metformin.
– Hypocalcaemia
Any hypocalcemia already existing before the beginning of the
treatment should in general be balanced by calcium substitution, for
example, provided there is no different clinical indication.
Note
Any treatment in connection with citrate anticoagulation may only be
performed in intensive care units or under similarly close medical
monitoring.
Fresenius Medical Care multiFiltrate IFU-EN-UK 15A-2015
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