CRRT & Citrate

03/02/04
Dear Colleagues
Our unit is looking at using citrate containing fluid in specific patients requiring CRRT as an anticoagulant. We have received information from Baxter who manufacture the fluid as well as a protocol from the Austin Hospital in Melbourne. Just wondering if anyone has any other policies / experiences using citrate in CRRT?
Regards

A/Clinical Nurse Consultant
Intensive Care Unit

03-02-04
We have been using the Baxter fluid and Austin protocol as a pilot, possibly leading into a clinical trial which Rinaldo Bellomo will coordinate. We have had problems with calcium and magnesium replacement and are wondering whether this 'two in one' approach of using the single fluid as both renal replacement fluid and also anticoagulant is the best way to go, or whether we might be better off using separate citrate anticoagulation and some other HRF. Dr Bellomo I believe has taken this on board and will hopefully be reformulating the fluid.
May be best to get specifics from the horse's mouth before committing yourselves. I agree however that in principle citrate is the way to go.

Staff Specialist Tertiary Referral Metropolitan

04/02/04
XX - ICU chose not to use citrate solutions as we do not have the ability to get a fast calcium result when required.
Maureen.
CNC
ICU, Tertiary Referral Metropolitan

04/02/04
I would support the previous email- you need to have point of care or immediately accessible Ionised Calcium to manage citrate optimally in sick ICU patients - you can't assume citrate metabolism is the same as a healthy patient having, say, citrate based apherisis.

Director Level 5 (JFICM 2) Rural ICU

04/02/04
Didn't the CNC from the Austin present some work showing that if you use big catheters and predilution, anticoagulation didn't make a lot of difference to kidney life?

Director Level 5 (JFICM 2) Rural ICU

04/02/04

See reference below.
However some patients at high risk of bleeding do need anticoagulation. WE do not get very long filter life without anticoagulation in most patients. And citrate would appear to be the best option for prolonging filter life. I take your point about ionised calcium needing to be freely available.

Tan HK. Baldwin I. Bellomo R. Department of Intensive Care, Austin and Repatriation Medical Centre, Melbourne, Victoria, Australia. Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Medicine. 26(11):1652-7, 2000 Nov

Staff Specialist Tertiary Referral Metropolitan 2