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Intensive Care Medicine
Published in: Intensive Care Medicine 10/2010

01-10-2010 | Original

Normal citratemia and metabolic tolerance of citrate anticoagulation for hemodiafiltration in severe septic shock burn patients

Authors: Filippo Mariano, Luisa Tedeschi, Maurizio Morselli, Maurizio Stella, Giorgio Triolo

Published in: Intensive Care Medicine | Issue 10/2010

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Abstract

Purpose

Anticoagulation during renal replacement therapy remains an important challenge for burn patients due to their high risk of bleeding. In this study we compared the efficacy and safety of citrate anticoagulation to heparin anticoagulation for hemodiafiltration (HDF) in severe burn patients, focusing on metabolic tolerance and handling of citrate.

Methods

Retrospective observational study (January 2000–December 2007) at a university teaching hospital. Among 548 patients admitted with burns, 70 severe burn septic shock patients (median age 57.5 years, interquartile range 42–76 years; median burned surface area 40%, interquartile range 30–60%) who underwent HDF for more than 24 h were included.

Results

Of the 70 HDF patients, 31 at high risk of bleeding were treated with citrate and 39 with heparin, with a mortality rate of 70.9 and 71.8%, respectively. In continuous venovenous hemodiafiltration (CVVHDF), the filter survival was higher with citrate, and hemorrhagic complications were lower (0.035 vs. 0.145 episodes/day, respectively). During citrate CVVHDF [median delivered dialysis dose: 578.9 ml kg−1 day−1 (461.5–769.2 ml kg−1 day−1)] in catecholamine-supported patients (norepinephrine 0.53 μg kg−1 min−1), no metabolic derangements in pH, bicarbonates, Na+, K+, Ca++, and ionized calcium were observed. Systemic citratemia was within the normal range (<0.4 mmol/l) and was associated with a marked citrate removal in the effluent (5 patients, 36–60% of infused amount).

Conclusions

In septic shock burn patients, citrate for CVVHDF was efficient and safe, and superior to heparin for hemorrhagic complications and filter survival. Observed metabolic stability was most likely due to a marked loss of citrate in effluent volume and subsequent low total citrate load for the patient.
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Literature
1.
Sheridan RL, Ryan CM, Yin LM, Hurley J, Tompkins RG (1998) Death in the burn unit: sterile multiple organ failure. Burns 24:307–311CrossRefPubMed
2.
Greenhalgh DG, Saffle JR, Holmes JH 4th, Gamelli RL, Palmieri TL, Horton JW, Tompkins RG, Traber DL, Mozingo DW, Deitch EA, Goodwin CW, Herndon DN, Gallagher JJ, Sanford AP, Jeng JC, Ahrenholz DH, Neely AN, O’Mara MS, Wolf SE, Purdue GF, Garner WL, Yowler CJ, Latenser BA; American Burn Association Consensus Conference on Burn Sepsis and Infection Group (2007) American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 28:776–790
3.
Mustonen KM, Vuola J (2008) Acute renal failure in intensive care burn patients (ARF in burn patients). J Burn Care Res 29:227–237PubMed
4.
Mariano F, Cantaluppi V, Stella M, Romanazzi GM, Assenzio B, Cairo M, Biancone L, Triolo G, Ranieri VM, Camussi G (2008) Circulating plasma factors induce tubular and glomerular alterations in septic burn patients. Crit Care 12:R42CrossRefPubMed
5.
Mariano F, Gangemi EN, Stella M, Tedeschi L, Gregoretti C, Triolo G (2009) Burns and acute renal failure. In: Ronco C, Bellomo R, Kellum JA (eds) Critical care nephrology, 2nd edn. Philadelphia, WB Saunders, pp 312–316
6.
Davies MP, Evans J, McGonigle RJS (1994) The dialysis debate: acute renal failure in dialysis patients. Burns 20:71–73CrossRefPubMed
7.
Hubsher J, Olshan AR, Schwartz AB, Zoranski B, DeClement F, Bendlin A, Hensell D, Brezin JH, Krevolin LE, Chinitz JL (1986) Continuous arteriovenous hemofiltration for the treatment of anasarca and acute renal failure in severely burned patients. ASAIO Trans 32:401–404CrossRefPubMed
8.
Gueugniaud PY (1999) Apport de l’hemodiafiltration continue au traitement des bruleès graves. In: Journois D (ed) Hemofiltration continue. Elsevier, Paris, pp 209–219
9.
Weksler N, Chorni I, Gurman G, Roy-Shapira A (1997) Improved survival with continuous veno-venous hemofiltration in nonoliguric burned septic patients [Abstract]. Blood Purif 15:137
10.
Abdel-Rahman EM, Moorthy AV, Helgerson RB et al (1997) ARF requiring dialysis in patients with burns: 16 years’ experience in one center [abstract]. J Am Soc Nephrol 8:121A
11.
Leblanc M, Thibeault Y, Querin S (1997) Continuous hemofiltration and hemodiafiltration for acute renal failure in severely burned patients. Burns 23:160–165CrossRefPubMed
12.
Holm C, Horbrand F, von Donnersmarck GH, Muhlbauer W (1999) Acute renal failure in severely burned patients. Burns 25:171–178CrossRefPubMed
13.
Tremblay R, Ethier J, Querin S, Beroniade V, Falardeau P, Leblanc M (2000) Veno-venous continuous renal replacement therapy for burned patients with acute renal failure. Burns 26:638–643CrossRefPubMed
14.
Hladlik M, Tymonova J, Zaoral T, Kadicik M, Adamkova M (2001) Treatment by continuous renal replacement therapy in patients with burns injuries. Acta Chir Plast 43:21–25
15.
Mariano F, Tetta C, Stella M, Biolino P, Miletto A, Triolo G (2004) Regional citrate anticoagulation in critically ill patients treated with plasma filtration and adsorption. Blood Purif 22:313–319CrossRefPubMed
16.
Chung KK, Lundy JB, Matson JR, Renz EM, White CE, King BT, Barillo DJ, Jones JA, Cancio LC, Blackbourne LH, Wolf SE (2009) Continuous venovenous hemofiltration in severely burned patients with acute kidney injury: a cohort study. Crit Care 13:R62PubMed
17.
Housinger TA, Brinkerhoff C, Warden GD (1993) The relationship between platelet count, sepsis, and survival in pediatric burn patients. Arch Surg 128:65–66PubMed
18.
Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265CrossRefPubMed
19.
Kutsogiannis DJ, Gibney RT, Stollery D, Gao J (2005) Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 67:2361–2367CrossRefPubMed
20.
Tolwani AJ, Prendergast MB, Speer RR, Stofan BS, Wille KM (2006) A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin J Am Soc Nephrol 1:79–87CrossRefPubMed
21.
Oudemans-van Straaten HM, Bosman RJ, Koopmans M, van der Voort PH, Wester JP, van der Spoel JI, Dijksman LM, Zandstra DF (2009) Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 37:545–552CrossRefPubMed
22.
Mariano F, Tetta C, Ronco C, Triolo G (2006) Is there a real alternative anticoagulant to heparin in continuous treatments? Expert Rev Med Devices 3:5–8CrossRefPubMed
23.
Dries DJ (2009) Management of burn injuries—recent developments in resuscitation, infection control and outcomes research. Scand J Trauma Resusc Emerg Med 17:14–27CrossRefPubMed
24.
Kramer L, Jordan B, Druml W, Bauer P, Metnitz PGH, for the Austrian Epidemiologic Study on Intensive Care, ASDI Study Group (2007) Incidence and prognosis of early hepatic dysfunction in critically ill patients—a prospective multicenter study. Crit Care Med 35:1099–1104CrossRefPubMed
25.
Martin PY, Chevrolet JC, Suter P, Favre H (1994) Anticoagulation in patients treated by continuous venovenous hemofiltration: a retrospective study. Am J Kidney Dis 24:806–812PubMed
26.
De Pont AJ, Oudemans-van Straaten HM, Roozendaal KJ, Zandstra DF (2000) Nadroparin vs dalteparin anticoagulation in high volume, continuous venovenous hemofiltration: a double-blind, randomized, crossover study. Crit Care Med 28:421–425CrossRefPubMed
27.
Uchino S, Fealy N, Baldwin I, Morimatsu H, Bellomo R (2003) Pre-dilution vs. post-dilution during continuous veno-venous hemofiltration: impact on filter life and azotemic control. Nephron Clin Pract 94:c94–c98CrossRefPubMed
28.
Möllering H, Gruber W (1966) Determination of citrate with citrate lyase. Anal Biochem 17:369–376CrossRef
29.
Chadha V, Garg U, Warady BA, Alon US (2002) Citrate clearance in children receiving continuous venovenous renal replacement therapy. Pediatr Nephrol 17:819–824CrossRefPubMed
30.
Ahmad S, Yeo K, Jensen WM, Landicho D, Gregory B, Moritz J, Kenny M (1990) Citrate anticoagulation during in vivo simulation of slow hemofiltration. Blood Purif 8:177–182CrossRefPubMed
31.
Morgera S, Scholle C, Voss G, Haase M, Vargas-Hein O, Krausch D, Melzer C, Rosseau S, Zuckermann-Becker H, Neumayer HH (2004) Metabolic complications during regional citrate anticoagulation in continuous venovenous hemodialysis: single-center experience. Nephron Clin Pract 97:c131–c136CrossRefPubMed
32.
Joannidis M, Kountchev J, Rauchenzauner M, Schusterschitz N, Ulmer H, Mayr A, Bellmann R (2007) Enoxaparin vs. unfractionated heparin for anticoagulation during continuous veno-venous hemofiltration: a randomized controlled crossover study. Intensive Care Med 33:1571–1579CrossRefPubMed
33.
Ferguson REH, Critchfield A, LeClaire A, Ajkay N, Vasconez HC (2005) Current practice of thromboprophylaxis in the burn population: a survey study of 84 US burn centers. Burns 31:964–966CrossRefPubMed
34.
Faucher LD, Conlon KM (2007) Practice guidelines for deep venous thrombosis prophylaxis in burns. J Burn Care Res 28:661–663CrossRefPubMed
35.
Morgera S, Schneider M, Slowinski T, Vargas-Hein O, Zuckermann-Becker H, Peters H, Kindgen-Milles D, Neumayer HH (2009) A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med 37:2018–2024CrossRefPubMed
36.
Kramer L, Bauer E, Joukhadar C, Strobl W, Gendo A, Madl A, Gangl A (2003) Citrate pharmacokinetics and metabolism in cirrhotic and noncirrhotic critically ill patients. Crit Care Med 31:2450–2455CrossRefPubMed
37.
Meier-Kriesche HU, Gitomer JJ, Finkel KW, DuBose T (2001) Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. Crit Care Med 29:748–752CrossRefPubMed
38.
Hetzel GR, Taskaya G, Sucker C, Hennersdorf M, Grabensee B, Schmitz M (2006) Citrate plasma levels in patients under regional anticoagulation in continuous venovenous hemofiltration. Am J Kidney Dis 48:806–811CrossRefPubMed
Metadata
Title
Normal citratemia and metabolic tolerance of citrate anticoagulation for hemodiafiltration in severe septic shock burn patients
Authors
Filippo Mariano
Luisa Tedeschi
Maurizio Morselli
Maurizio Stella
Giorgio Triolo
Publication date
01-10-2010
Publisher
Springer-Verlag
Published in
Intensive Care Medicine / Issue 10/2010
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-010-1909-2

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