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Educational Objectives: 1) Discuss the interest of anticoagulation. 2) Describe use and regiment of heparin and LMWH. 3) Implication of Antithrombin (AT). A17 Anticoagulation: Mechanisms and Techniques Oliver Joannes-Boyau MD 10:00-11:30 Wednesday, February 15 Content Description: Thrombosis and clotting filter stay a major concern during hemofiltration and the choice of the best anticoagulant is always a terrible dilemma. Even if bad anticoagulation is not the primary reason of clotting problems it is an obligatory part of the good operation of hemofiltration treatment. Most of clotting circuit are the results of mechanical problems (50%) with the catheter, the site of catheter insertion, the nursing of the patients and others. The anticoagulation is responsible of less than 40% of clotting problems. However the misuse of anticoagulation is a capital point who must be to improve. The unfractionated heparin (UFH) is the anticoagulant that is the most widely used in hemofiltration because it is usable, low cost, measurable in blood and its possible complete inhibition by protamine. But there are two major concern with UFH, bleeding problems (less than 10%) and heparin induced thrombocytopenia (HIT). The regional anticoagulation has been presented in the past like the absolute solution, currently this way is near completely abandoned except the citrate. The low molecular weight heparin is still widely used in chronic hemodialysis but less and less used in acute cases. It is more expensive than UFH, there is not antidote available, monitoring is difficult and there is 10% of cross reaction for HIT with UFH. The Antithrombin (AT) is the mandatory co-factor for heparin efficacy and its level activity is often reduced in sepsis and in that case the efficacy of heparin decrease dramatically. High doses of At has been used in the past to treat the sepsis, as APC does, but without beneficial effect. But some articles have demonstrated an increase of mortality rate in case of AT deficiency and supplementation with low doses of AT should be beneficial. We have conducted a study to show if supplementation should be the good way to avoid the problem of early thrombosis of the circuit. We have followed 28 patients in two centers to show the impact AT on filter lifespan and the interest of AT supplementation in that case and we have also compared two different methods for supplementation management : continuous infusion and bolus. The critical level of AT activity seems to be 60% and below this point the filter lifespan is twice reduced. A simple supplementation in AT increase filter longevity <strong>from</strong> 15 h to 33 h. The continuous infusion is a better method than bolus one. In summary, anticoagulation is not the only parameter to avoid the thrombosis problems during hemofiltration but it is simple to improve it. Heparin stay the first anticoagulant in ICU but other ways are possible. AT level may be a important concern during hemofiltration with heparin using. Suggested Reading: 1. Davenport A: The coagulation system in the critically ill patient with acute renal failure and the effect of an extracorporeal circuit. Am J Kidney Dis 1997, 30(5 Suppl 4):S20-27. 2. du Cheyron D, Bouchet B, Bruel C, Daubin C, Ramakers M, Charbonneau P: Antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study. Crit Care 2006, 10(2):R45. 3. Kutsogiannis DJ, Gibney RT, Stollery D, Gao J: Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005, 67(6):2361-2367. 4. Ranucci M: Antithrombin III. Key factor in extracorporeal circulation. Minerva Anestesiol 2002, 68(5):454-457. 5. Shulman RI, Singer M, Rock J: Continuous renal replacement therapy. Keeping the circuit open: lessons <strong>from</strong> the lab. Blood Purif 2002, 20(3):275-281. 6. Joannes-Boyau O, Lafargue M, Honoré P, Gauche B, Fleureau C, Roze H, Janvier G: Short Filter lifespan during Hemofiltration in Sepsis : Antithrombin (AT) Supplementation Should be A Good Way To Sort Out This Problem. Blood Purif 2005, 23:149-174 (Abstract 145). 93
A17 Anticoagulation: Mechanisms and Techniques Ashita Tolwani MD 10:00-11:30 Wednesday, February 15 Educational Objectives: 1. Discuss the mechanism of citrate anticoagulation and metabolic consequences. 2. Discuss the composition of commercially available citrate solutions. 3. Discuss citrate circuit options and protocols for CVVH, CVVHD, CVVHDF. and SLED Content Description: This presentation describes the use of regional citrate anticoagulation for CRRT using a case-based approach. Several published citrate protocols for each CRRT modality will be discussed in detail, including the description of the technique, components, circuit, target parameters and dialyzer patency rates. Metabolic complications of citrate, including citrate toxicity, will be discussed. Suggested Reading: 1. Davenport A, Tolwani A. Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit. NDT Plus. 2009; 2:439-447. 2. Mariano F, Bergamo D, Gangemi EN,Hollo Z,Stella M,Triolo G. Citrate anticoagulation for continuous renal replacement therapy in critically ill patients: success and limits. <strong>International</strong> Journal of Nephrology. 2011 3. Oudemans-van Straaten HM. Citrate anticoagulation for continuous renal replacement therapy in the critically ill. Blood Purif. 2010; 29:191-96. 4. Tolwani A, Prendergast M, Speer R, Stofan B, Wille K. A practical anticoagulation CVVHDF protocol for metabolic control and high solute clearance. CJASN 2006;1:79-87 5. Wu M, Hsu Y, Bai C, et al. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials. Am J Kidney Dis. 2012. 6. Zhang Z, Hongying Ni. Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy. Intensive Care Med. 2012; 38:20–28. 94
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CRRT 2012 SEVENTEENTH INTERNATIONAL
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FACULTY DISCLOSURES CRRT 2012 Facul
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CRRT 2012 ORGANIZING COMMITTEE USA
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CRRT 2012 FACULTY Patrick Honoré,
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ACKNOWLEDGEMENTS CRRT 2012 ACKNOWLE
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PLENARY SESSIONS CRRT 2012 PROGRAM/
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WORKSHOPS CRRT 2012 PROGRAM/INDEX T
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WORKSHOPS CRRT 2012 PROGRAM/INDEX W
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POSTER ABSTRACTS C
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POSTER ABSTRACTS C
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NURSING FORUM LUNCHEON Communicatio
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Nutritional Support in ICU Patients
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Educational Objectives: The Endothe
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SPECIAL LECTURE Engineering Critica
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Nishimura R, Ornato JP, Page RL, Ri
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Do Vasoactive Drugs and Fluids Impr
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Blood Transfusions are Important fo
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Thinking Outside of the Box: A Nove
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Nursing Forum 2 Luncheon Benchmarki
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