title: Citrate anticoagulation in pediatric continuous venovenous hemofiltration.
abstract: Regional citrate anticoagulation has become a common alternative to systemic heparinization in adult continuous venovenous hemofiltration (CVVH) practice. We report our experience with the technique in critically ill children. We carried out a retrospective chart review of a 22-bed pediatric intensive care unit. CVVH with pre-filter citrate and systemic calcium replacement infusions was performed according to a strict protocol in nine consecutive critically ill children. All charts were reviewed for patient characteristics and CVVH circuit parameters, including filter survival. All complications were noted. Nurse specialists were interviewed about the practical management of citrate anticoagulation. All patient measurements of blood urea nitrogen, creatinine, sodium, ionized calcium (iCa), potassium, and bicarbonate were collected over the CVVH period. In seven patients, 12 simultaneous citrate measurements were taken from patient blood, pre-filter blood, and hemofiltrate fluid. Nine patients (mean age 8.8+/-6.8 years) were treated with CVVH and regional citrate anticoagulation for 1-14 days (mean 5.2+/-4.0 days). Of 19 filters used, 15 were replaced non-electively (mean filter survival 55.6+/-22.0 h). Control of azotemia and hyperkalemia was good. Sodium and iCa levels were well maintained. Bicarbonate levels were elevated in four patients without adverse effects. The mean systemic citrate level at equilibrium was 1.6+/-0.23 mmol/l. No systemic bleeding complications were observed. In children, regional citrate anticoagulation provides equivalent filter survival to heparin without bleeding complications. With good staff preparation, it is simple to perform and safe with respect to metabolic side effects.
authors.affiliation: Intensive Care Unit, Children's and Women's Health Centre of British Columbia, 4480 Oak Street, V6H 3V4, Vancouver, British Columbia, Canada.
authors.forename: Nahum
authors.initials: N
authors.lastname: Elhanan
authors.forename: Peter
authors.initials: P
authors.lastname: Skippen
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Nuthall
authors.forename: Gordon
authors.initials: G
authors.lastname: Krahn
authors.forename: Michael
authors.initials: M
authors.lastname: Seear
mesh_terms: D000293:Adolescent; D000925:Anticoagulants / Q000097:blood / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D002951:Citrates / Q000097:blood / Q000627:therapeutic use*; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D006440:Hemofiltration; D006801:Humans; D006947:Hyperkalemia / Q000517:prevention & control; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D014511:Uremia / Q000517:prevention & control
chemical_list: D000925:Anticoagulants; D002951:Citrates