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Standardized protocols have been well established for both heparin and regional citrate anticoagulation in children receiving dialysis. The ppCRRT Registry Group has shown that heparin- and citrate-based anticoagulation protocols have been shown to confer equitable filter survival in pediatric CRRT, and the use of either is clearly supported over the use of no anticoagulation schemes.636 The main advantage of citrate anticoagulation was the prevention of systemic pharmacological anticoagulation of the patient, which can be an issue in patients with multiorgan failure and sepsis. Calcium is a requisite cofactor in both the intrinsic and extrinsic coagulation cascades. Citrate functions by binding free calcium, thereby inhibiting coagulation in both the intrinsic and extrinsic coagulation pathways. The most frequently studied pediatric citrate protocol636-638 uses Anticoagulant Dextrose solution A (ACD-A, Baxter Healthcare, USA), prescribed based on the blood flow rate:
ACD rate (ml/h) = blood pump rate (ml/min x min/h) x 1.5
ACD-A is infused via a stopcock at the catheter-CRRT circuit connection leading to the CRRT machine. Since our prescribed blood pump flow is 200 ml/min, the resulting ACD-A rate would be 300 ml/h. The second aspect of the citrate protocol provides prevention of citrate-induced systemic hypocalcemia by providing a calcium chloride continuous infusion (8 g calcium chloride per liter normal saline) to the patient via a central line. The calcium chloride rate is also based on the blood pump rate:
Calciumchloride (ml/h) = blood pump rate (ml/min x min/h) x 0.6
The goals of regional citrate anticoagulation are to maintain the circuit ionized calcium between 0.8 and 1.6 mg/dl (0.2 and 0.4 mmol/l), and the patient’s systemic ionized calcium in the normal physiologic range 4.4–5.2 mg/ dl (1.1–1.3mmol/l). The circuit ionized calcium concentration is managed by adjustment of the citrate rate, while the patient’s systemic ionized calcium concentration is managed by adjustment of the calcium chloride rate.
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