Citrate anticoagulation for pediatric continuous venovenous hemodiafiltration

Abstract

Objective: Feasibility and safety evaluation of citrate anticoagulation for hemodiafiltration (CVVHD) procedure in a pediatric critical care unit. Patients and Methods:From 08–2002 to 12–2003, five patients were treated by CVVHD with regional citrate anticoagulation, age range 1.4–16 yrs, body weight 6.7–38 kg. Inclusion criteria: oligoanuria and hypervolemia and/or uremia, hemodynamic instability, and impossibility of peritoneal dialysis. The patient's primary diseases were: liver disease (4/5) and chronic renal disease (1/5). All patients were on mechanical ventilation and on vasopressor support and presented with thrombocytopenia. Hepatic dysfunction was observed in four patients. The CVVHD prescription was: blood flow rate: 2–5 ml/min, dialysate and replacement flow rate: 3000 ml/1.73 m2/h. Citrate regional anticoagulation (4% trisodium citrate) was used according to a previously described protocol (Bunchman et al., Pediatr Nephrol 2002: 17:150–154). The duration of each individual procedure was 9–72 hours, and the total time range of CVVHD was 2 to 19 days. A bicarbonate based solution (Na 140 mEq/L and bicarbonate 35 mEq/L) was prepared in our hospital pharmacy. Prisma system (GAMBRO) and polycrylonitrile M‐60 Pre‐set hemofilter was used in 4/5 patients and M‐10 Pre‐set hemofilter in one patient. Results:The use of M‐10 filter was associated with a higher rates of ACD‐A and calcium infusion (ml/h). Metabolic alkalosis was observed in one patient and hypernatremia in three patients. All patients died of causes other than renal failure (sepsis and multiple organ dysfunction syndrome). No bleeding related to citrate occurred. Conclusion: Citrate anticoagulation proved to be feasible with minor side effects in pediatric ICU patients. The high mortality can be related to the severity of multiple organ failure.