A resource of Calculate by QxMD at https://www.qxmd.com/calculate
Over 400 decision support tools available • get the app for iOS or Android at qx.md/calculate
The risk of bleeding is considered high in patients with recent (within 7 days) or active bleeding, with recent trauma or surgery (especially in head trauma and neurosurgery), recent stroke, intracranial arteriovenous malformation or aneurysm, retinal hemorrhage, uncontrolled hypertension, or presence of an epidural catheter. In these patients, the benefit of anticoagulation may not outweigh the risk of bleeding, and they should (at least initially) be treated without anticoagulation, or with CRRT with regional citrate anticoagulation.
We suggest performing RRT without anticoagulation in patients with increased bleeding risk. A possible exception can be made for patients who do not have contraindications for citrate. Randomized trials comparing citrate with heparins have been performed in patients without increased bleeding risk. However, since citrate results in strictly regional anticoagulation, it seems reasonable to also suggest its use during CRRT in AKI patients with increased bleeding risk.
Another approach to achieve regional anticoagulation is regional heparinization combining a prefilter dose of heparin, aiming at a prolongation of the extracorporeal aPTT, with postfilter neutralization with protamine, aiming at normalizing the systemic aPTT. This procedure has been described in chronic dialysis and CRRT,572,573,624,627,628 but has not been studied with much scrutiny. It is cumbersome and difficult to titrate because heparin has a much longer half-life than protamine, inducing a risk of rebound. In addition, it exposes the patient to the side-effects of both heparin (mainly the risk of HIT) and protamine (mainly anaphylaxis, platelet dysfunction, hypotension, and pulmonary vasoconstriction with right ventricular failure)629 and is therefore not recommended.
Do you have an enquiry or suggestion? Get in touch with us through Twitter @QxMD, Facebook QxMD, or email contact@qxmd.com