Tomáš Zaoral1, Michal Hladík1, Jana Zapletalová2 1Pediatric intensive care unit, Department of...

COMPARISON OF CITRATE WITH HEPARIN

IN PEDIATRIC CONTINUOUS VENOVENOUS HAEMODIALYSIS

(CVVHD) Tomáš Zaoral1, Michal Hladík1, Jana Zapletalová2 1Pediatric intensive care unit, Department of Pediatrics,Faculty of Medicine, University Hospital Ostrava 2The Department of Medical Biophysics, Faculty of Medicine, University hospital Olomouc

8th International Conference onPediatric Continuous Renal Replacement

Therapy (PCRRT)16-18 July 2015, London, UK

8th pCRRT Conference ,16-18 July 2015, London TZ

Single center prospective crossover study January 2009 – December 2014

SettingPediatric intensive care unit, Department of

Pediatrics, University Hospital Ostrava, Czech republic

ObjectiveTo compare circuit lifetimes during CVVHD in

children with heparin and citrate Approved by the Ethics Committee, parental

consent was obtained before recruitment


All children indicated for CVVHD were eligible to participate

Age: 0 – 18yearsAll children were on ventilator and sedatedEach child received a maximum of 4 circuits with

anticoagulants in the following order: heparin, citrate, heparin, citrate (HACG-heparin, citrate –CACG )

The maximum length of one circuit 72 hCircuit life ended when TMP was ≥250mmHg

for≥60 min Circuits failed for other reasons were censored8th pCRRT Conference ,16-18 July 2015,

London TZ



Exclusion criteria:liver failure, high risk of bleeding or

posttraumatic bleeding, thrombocytopenia (below 50 × 109/L)

8 children excluded: 1x LF, 1x ↓PLT, 6x bleeding or high risk of bl.



71 children started Premature termination 8children 3x surgery, 3x CT, 2x hemorrhage 63 children received at least 24h of CVVHD (age 89.24±62.9 months, weight 30.37±20.62 kg)Of the 63 children included, 8 received only 2

circuits (1x HACG and 1x CACG), 55 received all four circuits

(2x HACG and 2x CACG) we analyzed a total of 118 pairs of HACG and CACG



Indication for CVVHD: 37 children (58.7%) with oliguria and >10%

fluid overload (pRIFLE )21 children (33.3%) with elevated creatinin

(pRIFLE)5 children (7.9%) with poisoning


METHODS

All circuits rinsed with heparin 10.000IU/5L NSHACG: bolus of 30 IU, than 10 IU/kg/h ivTarget APTT 1,5 – 2 of the normal rangeCACG: 4% trisodium citrate (136 mmol/L) and

CaCl2 (500 mmol/L)Basic setting: citrat 4.0 mmol/L Ca

1,7mmol/LiCa ++ the target range of 0.25-0.35 mmol/L

iCa++ in the patient’s blood (1.1 – 1.3 mmol/L)


METHODS

Postfilter iCa++ checked q 1h, 6h and 12hAfter target was achieved q 12h

CVVHD Citrate protocol in our UNIT INITIAL SETTING :


Weight CVCBlood

flow rate ml/min

4% Citrateflow rate

ml/hrCaCl 10%

ml/hr

Dialysate flow rate

ml/hrHemofilter

/ m2

Over 30kg11-12FrArrow 100 160 10 2000 AV 1000S/1,8

15 - 25kg

8-12FrMedcomp

proVencare 80 140 8 1500 AV600S/1,4

10 - 15kg

8FrMedcomp

proVencare 60-70 120 5 1000 AV400S/0,75

3 - 10kg6,5 - 8Fr

proVencare 50-60 100 4 800

AV400S/0,75Ultraflux AV

ped./0,2

≤ 3kg 6,5Fr vas.surg. ≥ 40 80 3 - 4 600Ultraflux AV

ped./0,2


DIALYSIS SOLUTION

Nammol/L

Clmmol/L

Mgmmol/L

Kmmol/L

Ca mmol/L

HCO3mmol/L

Glucoseg/L

Ph Osmolaritymosmol/L

Ci-Ca dialysateFresenius MC

CITRATE133 116.5 0.75 2-4 0 20 1 7.4 277.8

multiBicFresenius MC

HEPARIN140 109 - 113 0.5 0 - 4 1.5 35 1 7.2 300

Characteristic pts enrolled in the studyAll group Survivors Not survivors

PNumber of pts 63 42 (66,7%) 21 (33,3%)

Gender: M/F35/28

(55,6% / 44,4%)22/20

(52,4% / 47,6%)13/8

(61,9% / 38,1%)0,473

Age (months) 84.0 (1w – 204) 88.46 (4 -204) 81.42 (1w - 192) 0,770

Weight (kg) 26,5 (2,8-82) 26,0 (3,3-82) 26,5 (2,8-65) 0,625

CVC: VJI/SC/VF41/14/8

(65%/22%/13%)29/9/4

(69%/21%/10%)12/5/4

(57%/24%/19%)0,528

FO >10%(fluid overload)

39 (61,9%) 23 (54,8%) 16 (76,2%) 0,099

Creatinine (umol/l) 259,9(76-570,2) 271,4(80,4-611,7) 249,3(89,3 -480) 0,672

Urea (mmol/l) 58,8 (19,3-132) 56,4 (19,3-131,6) 58,8 (21,8-120,5) 0,678

PRISM III 19 (13-46) 16 (13-26) 24 (16-46) < 0,0001

MODS 23 (36,5%) 5 (11,9%) 18 (85,7%) < 0,0001


All values represent the number (%) or the mean (range); CVC–central venous catheter; VJI - internal jugular vein; SC - subclavian vein; VF – femoral vein; FO – fluid overload; %FO = ((CRRT initiation weight – ICU admission weight) / ICU admission weight) x 100; PRISM III – pediatric risk of mortality; MODS- multiorgan dysfunction syndrome


DIAGNOSIS

Sepsis

Septic

shoc

k

Traum

a, M

ODS

Burn

s

Mal

ignan

cy

Dru

g in

toxica

tion AK

I

HUS

Cardi

ac d

isea

se

Pulmon

ary fa

ilure

0

2

4

6

8

10

12

14

16

1816

No of pts

Total duration of CVVHD

(hrs)9381

Duration of CVVHD (hrs)

4219 (HACG) 5162(CACG)

One circuit duration (hrs)

36(18-56)*HACG 41(22-72)*CACG

BFR(ml/kg/min) 90 (40-180)

Dialysateml/kg/hr

60,34 (22,2-121,4)

Heparin dose (IU/kg/hr)

15 (9,6 - 23,3)


Data are presented as median (min – max) CACG – citrate anticoagulation, HACG - heparin anticoagulation, BFR – blood flow rate , CVVHD – continuous venovenous hemodialysis, NSS –not statistically significant

Citrate Heparin

P

APTT sec50,3(40,3 -

74,9)65,4(21,3-

81,7) < 0,0001

Na

(mmol/l) 140(135-147) 142(137-147)

< 0,0001

iCa

(mmol/l)1,13(0,87-

1,31)1,12(0,99-

1,24)NSS

pH7,41(7,38-

7,48)7,40(7,37-

7,44) < 0,0001

HCO3

(mmol/l)25,20(22,9-

28,7)24,45(23,1-

26,2)< 0,0001

BE (mmol/l)0,8(-1,2 -(+)5,5)

0,20(-0,9-(+)1,9) < 0,0001

p 0,0001

Parameters for CVVHD Circuit parameters 6h after initiation CVVHD


Indication Number (%) total=113

Restoration of diuresis 38 (33.6)

Alarms 12 (10.6)

Clotting: TMP ≥250 mmHg

54 (47.8)

CVC 2 (1.76)

Death 1 (0.88)

CT scan/Surgery 6 ( 5.3)

CACG (%) total=59

HACG (%) total=59

HypoCa: < 0.9 mmol/L 4 (6.77) 0 (0)

HyperCa: > 1.25 mmol/L 2 (3.4) 0 (0)

HypoNa: Na < 130 mmol/L 0 (0) 0 (0)

HyperNa: Na > 145 mmol/L 4 (6.77) 1 (1.7%)

HypoMg: Mg < 0.70 mmol/L 0 (0)

pH < 7.36 or BE< - 3 1 (0.88) 0 (0)

pH >7.46 or BE> +3 4 (6.77) 0 (0)

Reasons for terminating circuits Metabolic and electrolytes imbalances q.6h

118 circuits were evaluated, 5 circuits achieved the maximum 72-h duration; 113 circuits ended before 72 h; CVVHD – continuous venovenous hemodialysis; TMP –transmembrane pressure; CVC–central venous catheter; CT-computed tomography


RESULTS

The total mean circuit lifetime 39.75±10.73

Median lifetime for HACG (36.0 h, CI: 35.4 – 36.6) was shorter than for CACG (41.0 h, CI: 37.6 – 44.4 p< 0.0001)

Total mortality was 33.33%, ≤ 5KG was 75%

Dialysis dose was not SS higher in the citrate

group (60.34 vs. 53.27mL/kg/h p= 1.28)


ConclusionCitrate lifetimes were shorter for heparin than for

citrateCircuit lifetime was significantly correlated to pt age, weight and blood flow rateMortality was similar to the other studiesMortality was significantly correlated to MODS,

PRISM III but not to FO over 10%Metabolic, electrolyte imbalances was readily resolvedCitrate was feasible and safe even for infants and

newborns

Tomáš Zaoral1, Michal Hladík1, Jana Zapletalová2 1Pediatric intensive care unit, Department of...

Documents

Transcript of Tomáš Zaoral1, Michal Hladík1, Jana Zapletalová2 1Pediatric intensive care unit, Department of...