The Use of Regional Citrate Anticoagulation Continuous Venovenous Hemofiltration in Extracorporeal Membrane Oxygenation

Abstract

Patients on extracorporeal membrane oxygenation (ECMO) frequently requires continuous renal replacement therapy (CRRT). Additional anticoagulation for the CRRT circuit is usually not employed, but this may increases the risk of clot embolization, which shortens oxygenator lifespan and increases patient's risk. We report our experience on the use of regional citrate anticoagulation continuous venovenous hemofiltration (RCA-CVVH) connected to an ECMO circuit, which could be useful during low heparin or heparin-free ECMO situations. Regional citrate anticoagulation continuous venovenous hemofiltration was performed using AK200US machine with a blood flow of 150 ml/min, Acid Citrate Dextrose Solution prefilter infusion at 240 ml/hr, ultrafiltration rate of 2,040 ml/hr, and postdilutional online generated replacement fluid infused as appropriate. The circuit was aimed to run for 30 hrs. From May 2009 to May 2013, 63 patients received ECMO and 29 received RCA-CVVH. The median total CVVH time was 131 hrs (interquartile range [IQR]: 61-224 hrs), and hemofilter life was 27.2 hrs (IQR: 25.7-28.5 hrs). No hemofilter or oxygenator was changed because of clotting. Their hospital mortality was 27.6%. There were eight patients, who were judged to be too sick for anticoagulation, received predilution CRRT during the same period. Their hospital mortality was 75%. In conclusion, online postdilutional RCA-CVVH connected to an ECMO circuit is a feasible, safe, and effective CRRT technique.

A New Approach Combining Venoarterial Extracorporeal Membrane Oxygenation and CRRT for Adults: A Retrospective Study

“…Returning CRRT blood between the centrifugal pump and oxygenator is complex, as the highest pressure is found in this region. Research (13) has shown that pressure before the preoxygenator ranges from 150 to 320 mmHg. However, depending on the ECMO blood flow rate and return cannula size, the range of pressure before the preoxygenator could be larger.…”

Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference

“…The administration of heparin may depend on patient factors (e.g., risk of bleeding), circuit set-up (e.g., connection to patient or to ECMO), and institutional protocols. 128,130,[135][136][137][138][139][140][141] It is possible to have RRT circuits without dedicated heparin in this setting, unless excessively frequent clotting is observed. Studies are needed to compare different anticoagulation strategies in this setting.…”

Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic

“…36 A combined anticoagulation strategy with RCA-CKRT deployed concurrently to heparinized extracorporeal membrane oxygenation has been described in critically ill patients, with good filter life and no increased bleeding events. 37 Figure 2. Citrate and continuous kidney replacement therapy (CKRT) fluid consumption under (A) standard conditions, with higher blood flow rate (Qb) and pre-blood pump (PBP) rate, versus (B) conditions designed to reduce consumption.…”