Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation.
BACKGROUND
Continuous venovenous hemofiltration (CVVH) may be preferable over continuous venovenous hemodialysis (CVVHD) in sepsis; however, CVVH use is limited by the lack of commercially produced bicarbonate replacement solutions in the United States. Anticoagulation used for hemofiltration traditionally has been either heparin or citrate based, but to date, citrate protocols have been used predominately in CVVHD. When CVVH has been used with citrate anticoagulation, replacement solutions have had to be custom made in the pharmacy.


METHODS
We describe a protocol used in a series of 9 children with sepsis who underwent CVVH with the use of a commercially available bicarbonate solution (Normocarb; Dialysis Solutions Inc, Richmond Hill, Ontario, Canada) and a commercially available citrate solution (Anticoagulant Citrate Dextrose Solution Formula A [ACD-A]; Baxter Health Care, Deerfield, IL). This simplified approach to citrate anticoagulation with CVVH used Normocarb as a prefilter replacement solution under provisions of the 1997 Food and Drug Administration Modernization Act.


RESULTS
All patients had acceptable levels of solute and ultrafiltration clearance with this approach. CVVH circuit life averaged 71 hours (range, 37 to 131 hours), influenced in part by the industry recommendation to change the circuit at 72 hours, whereas no complications from this protocol were identified.


CONCLUSIONS
Similar to CVVHD, this protocol is effective and simple in its components, using industry-produced solutions, avoiding the need for pharmacy-made solutions, and limiting cost and potential risk for compounding errors. Although not the purpose of this report, the patient survival rate was 55%.
Bunchman
Timothy E
TE
Pediatric Nephrology and Transplantation, DeVos Children's Hospital, Grand Rapids, MI 49503, USA. timothy.bunchman@spectrum-health.org
Maxvold
Norma J
NJ
Brophy
Patrick D
PD
D000293:Adolescent; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001639:Bicarbonates / Q000008:administration & dosage / Q000737:chemistry / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D019343:Citric Acid / Q000008:administration & dosage / Q000627:therapeutic use*; D002985:Clinical Protocols; D018481:Convection; D005260:Female; D005947:Glucose / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000627:therapeutic use*; D006440:Hemofiltration / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008274:Magnesium / Q000008:administration & dosage / Q000737:chemistry / Q000627:therapeutic use*; D008297:Male; D009102:Multiple Organ Failure / Q000209:etiology / Q000628:therapy; D011188:Potassium / Q000008:administration & dosage; D018805:Sepsis / Q000150:complications / Q000628:therapy; D012965:Sodium Chloride / Q000008:administration & dosage / Q000737:chemistry / Q000627:therapeutic use*; D012996:Solutions / Q000008:administration & dosage / Q000737:chemistry / Q000627:therapeutic use*
D000925:Anticoagulants; D001639:Bicarbonates; C483808:Normocarb; D012996:Solutions; C002113:acid citrate dextrose; D019343:Citric Acid; D012965:Sodium Chloride; D008274:Magnesium; D005947:Glucose; D011188:Potassium