【持续性肾脏替代治疗CRRT英文精品课件】Regional Citrate Anticoagulation (RCA) in CRRT.pptVIP

Regional Citrate Anticoagulation (RCA) in CRRT Dr Anne Leung QEH ICU 2010 Overview Mechanism of action and metabolism of citrate Formulation of citrate Advantage and disadvantage of using citrate anticoagulant RCA CRRT circuit options –Gambro vs Fresenius Monitoring during citrate anticoagulation QEH ICU Citrate anticoagulation regime CRRT circuit Vascular access Blood Flow Machinery Dialyzer Circuit volume Dialysate/Replacement fluid Anticoagulant Anticoagulation for CRRT CRRT increasing in popularity in management of acute renal failure in critically ill Need ongoing anticoagulation Risk of bleeding with heparin 2% per day 3.5-10% of deaths 25% of new hemorrhagic episodes Contact activation by membrane Impact of filter clotting Decrease in dialysis dose Blood loss through the circuit with increase in transfusion requirement Wasted nursing time Increase in cost Anticoagulation options None (- if marked coagulopathy) Unfractionated heparin LMW Heparin Citrate Direct Thrombin Inhibitors r-Hirudin Argatroban Prostacycline Continuous renal replacement therapy:  B.E.S.T. Kidney (The Beginning and Ending Supportive Therapy for the kidney).a worldwide practice survey. 23 Countries, 54 ICUs, 1006 patients with ARF on CRRT Mechanism of Regional Citrate Anticoagulant Normal range: Total serum calcium: 2.2-2.6 mmol/L Serum ionized calcium: 0.9 -1.2 mmol/L Chelate Ca and induce deep hypoclacemia in filter Aim post-filter iCa of 0.25-0.35 mmol/l Fate of the citrate-calcium complex in the CRRT circuit Partly lost in ultrafiltrate across the membrane Those enter the systemic circulation is diluted in venous blood Citrate entering the body will be cleared by liver, skeletal muscle or kidney to HCO3 in 1:3 ratio Half-life of calcium-citrate complex is ~ 5 minutes, therefore systemic effect on anticoagulation not occurred Fate of the citrate calcium complex in the CRRT circuit What is the citrate dose required? To achieve a steady state whole blood ci