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CS187
Using Citrate as an Anticoagulant during Continuous Renal Replacement Therapy (CRRT)
By: Carol Boswell; Virginia Commonwealth University Hospital, VA
For further information, please contact: cboswell@mcvh-vcu.edu
Purpose: Due to increased incidence of heparin-induced thrombocytopenia, our organization abandoned the use of heparin in CRRT circuits. However, this change resulted in lost treatment time due to filter clotting. A team was formed to develop a protocol to anti-coagulate CRRT circuits using sodium citrate.
Description: A review of the literature demonstrated that citrate has been used extensively in blood banking and that other organizations had successfully implemented citrate anticoagulation protocols. The team developed a protocol to simultaneously infuse a 4% solution of sodium citrate before the CRRT filter and a calcium chloride solution to the patient. The citrate infusion provides anticoagulation to the CRRT filter. The calcium infusion reverses the anticoagulation effects of citrate in the patient. The protocol was piloted in one ICU. The pilot study revealed that more details were needed to effectively manage the titration of sodium citrate and calcium. The team developed titration tables that were similar in format to other titration tables already in use in the organization. After another pilot period in the initial ICU, an organization-wide policy was developed and approved by the Critical Care Committee and the Critical Care Nursing Practice Council. An education program was developed for the remaining ICU’s, including the Pediatric ICU.
Evaluation and Outcomes: The sodium citrate anticoagulation protocol was successfully implemented in all ICU’s except the Transplant ICU. Citrate is not used consistently in liver transplant patients because they tend to develop metabolic alkalosis. CRRT filter life has dramatically increased, with many circuits lasting until circuit replacement is required at 72 hours. This has resulted in increased renal replacement treatment time for patients.
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