CITRATE ANTICOAGULATION AND ADVERSE EVENTS

Use of High-Flow Continuous Renal Replacement Therapy with Citrate Anticoagulation to Control Intracranial Pressure by Maintaining Hypernatremia in a Patient with Acute Brain Injury and Renal Failure

Traumatic brain injury and intracranial hypertension often require treatment to optimize patient outcome. There are a variety of complex medical conditions that can preclude standard approaches to the treatment of intracranial hypertension. We describe a case where a novel approach using continuous dialysis with trisodium citrate was used to optimize the outcome of a young male with acute renal failure and acute respiratory distress syndrome in the setting of acute traumatic brain injury.

Citrate plasma levels in patients under regional anticoagulation in continuous venovenous hemofiltration

BACKGROUND

Different methods of regional anticoagulation using citrate in continuous hemofiltration have been described. To date, only such surrogate parameters as pH, anion gap, total calcium concentration, or total calcium-ionized calcium ratio have been proposed to reflect increased plasma citrate levels and thus risk for side effects. However, none of these parameters has been correlated with plasma citrate levels in critically ill patients.

METHODS

Sixteen patients were treated with continuous venovenous hemofiltration (CVVH) and citrate anticoagulation for a mean of 13 +/- 9 days. Citrate levels were measured every other day, and correlations were calculated with the mentioned parameters.

RESULTS

Steady-state citrate levels on treatment day 3 were 16.39 +/- 15.77 mg/dL (range, 2.63 to 73.49 mg/dL [853 +/- 821 micromol/L; range, 137 to 3825 micromol/L]). The highest correlation was found between citrate plasma level and total calcium-ionized calcium ratio (R = 0.85; P < 0.001). pH (R = -0.15) and anion gap (R = 0.36) were not helpful in estimating citrate plasma levels in patients treated with citrate-CVVH.

CONCLUSION

Calculating total calcium-ionized calcium ratio is a simple tool that correlates best with citrate plasma levels. We recommend close monitoring of this parameter in all patients administered high doses of citrate as part of regional anticoagulation protocols.