40 Years of Continuous Renal Replacement Therapy. Группа авторов. Читать онлайн. Newlib. NEWLIB.NET

Автор: Группа авторов
Издательство: Ingram
Серия: Contributions to Nephrology
Жанр произведения: Медицина
Год издания: 0
isbn: 9783318063073
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After gaining sufficient experience, monitoring circuit anticoagulation can subsequently be limited to particular cases (e.g., unexplained early filter clotting). Some centers still prefer intensive monitoring of anticoagulation in the extracorporeal circuit and repeatedly titrate citrate dose because this, although unproven, tends to increase FLS. The anticoagulation effect is evaluated by measuring post-filter ionized calcium concentration (level below 0.35 mmol/L [0.8 and 1.3 mg/dL]), activated clotting time, or activated partial thromboplastin time [15, 17, 18]. Several algorithms for adjusting the citrate infusion rate are described in the literature. Yet, continuous monitoring of ionized calcium in the circuit remains the gold standard.

      Side Effects and Complications of RCA

      A Practical Bedside Approach. How to Handle…

      Citrate Accumulation?

      –Cause: liver failure, poor muscle perfusion.

      –Metabolic alterations: metabolic acidosis, increased anion gap, decreased ionized calcium, rising calcium ratio and calcium gap, increased lactate.

      Citrate Intoxication?

      –Cause: accidental over-infusion of citrate or decrease of UF flow below the lower limit at constant citrate infusion rate.

      –Metabolic alterations: metabolic alkalosis, low ionized calcium, and proportional rise of calcium ratio as a result of alkalosis.

      –Treatment: withdraw citrate infusion.

      Hypocalcemia?

      –Cause: citrate accumulation.

      –Therapy: calcium infusion. Since most critically ill patients have some degree of hypocalcemia, the targeted ionized calcium level should be approximately 1.0 mmol/L (4 mg/dL).

      Metabolic Alkalosis?

      –Cause: excessive bicarbonate substitution relative to UF flow.

      –Specific situations:

      a. Declining UF flow while citrate infusion remains fixed adjusted to blood flow. Treatment: filter change if UF flow is less than 1,500–2,000 mL/h (depending on blood and citrate flow).

      b. Metabolic conversion of accumulated citrate with recovering liver function. Treatment: replacement with buffer-free solution or halving citrate dose in pre-dilution.

      c. Accidental over-infusion of citrate. Treatment: withdraw citrate infusion, replacement with buffer-free solution, increase UF flow as needed.

      Hypomagnesemia?

      –Cause: increased loss of citrate-bound magnesium by ultrafiltration.

      Hypokalemia?

      Potassium levels must be kept strictly between 4 and 5 meq/dL.

      Steadily Increasing Calcium Infusion Rate?