A new citrate anticoagulation protocol in extracorporeal treatment
treatment for
septic shock patients with Coupled Plasma Filtration Adsorption (CPFA)
Authors: Marco Pozzato MD1, Fiorenza Ferrari MD2, Pasqualina Cecere MD1, Paola Mesiano MD1, Antonella Vallero MD1,
Sergio Livigni MD2 and Francesco Quarello MD1
Hospital: 1Nephrology & Dialysis Unit and 2ICU, S. Giovanni Bosco Hospital, Turin, Italy
OBJECTIVES
METHODS
From 2001 to 2011 we treated in our centre
94 patients in septic shock with CPFA.
CPFA, combining a unselective plasma
adsorption
on
hydrophobic
resin
(MediaSorb) with a continuous slow
hemofiltration proved to be an effective
treatment of septic shock patients with or
without acute kidney injury (AKI),
improving the hemodynamic, the blood
chemistry data and the survival.
In ICU most patients are at risk of bleeding
due to recent surgery or the presence of
abnormal coagulation context, particularly
in septic shock patients.
Aim of this study was to elaborate and
evaluate a citrate anticoagulation protocol.
Kg
Predilution
ml/h
Postdilution
ml/h
Calcium Chloride
ml/h
50
2250
100
4
55
2250
150
4
60
2250
200
4
65
2250
250
3
70
2250
300
3
75
2250
350
From 01/12/2009 to 31/12/2011 we treated with CPFA 11 consecutive mechanical
ventilated patients, 6 males and 5 females (mean age 59.5 ± 12.6 years), with septic shock
and multiorgan dysfunction (MODS 2.0 ± 0.9) and 4 of 11 with AKI; days spent in intensive
care unit 30 ± 19.9. We observed all the inclusion criteria of Compact study
(ClinicalTrials.gov-Protocol Registration Receipt 2006-05-31). We treated all patients with
CPFA-CVVH pre-post dilution, prescribed Qb 150 ml/min, plasma filtration 30 ml/min (18%)
using on predilution citrate bag (Na+ 136 mmol/L, Citrate 10 mmol/L, Citric acid 2 mmol/L),
on postdilution with infusion bag (Na+ 139 mmol/L, K+ 1.5 mmol/L, Ca++ 2 mmol/L, HCO335 mmol/L, glucose 5.55 mmol/L) and following the next table (Table 1). All biochemical
data were collected and analyzed at the beginning of treatment to monitor the performance
of different parameters.
RESULTS
2,5
2
1, 5
1
3
80
2250
400
3
85
2250
450
3
0,5
0
90
2250
500
2
95
2250
550
2
2250
600
2
100
A
B
C
D
E
E
F
G
H
I
L
M
Patient
Table 2. Average Ca++/iCa++ for each patient to
verify the non-toxicity of citrate at the end of
CPFA cycle
Table 1. Protocol scheme citrate-calcium chloride infusion
80
Patients Survival
70
60
100%
50
72,7%
80%
63,6%
40
PT %
PTT sec
60%
30
40%
20
20%
10
0%
After 28
After 90
0
A
B
C
D
E
E
F
G
H
I
L
M
Patient
Days
Table 4. Elevated survival at 28 and 90 days
related to clinical status of patients
We performed 73 treatments accounting for 733 hours, mean
duration 8.4 ± 1.0 hrs, mean plasma volume of 12.20 ± 2.8 L, Qb
143 ± 12 ml/min, Qp 24.6 ± 3.8 ml/min, a treated plasma dose/kg
body weight of 1 ± 0.37 L/Kg. Mean CaCl2 10% infusion of 4.5 ±
1.3 ml/h, with a citratemia, evaluated as total Ca++/iCa++ ratio,
always < 2.5 (1.92 ± 0.14) (Table 2), also in 4 patients with liver
dysfunction (mean 2 ± 0.20); the average of the systemic ionized
calcium was found to be always within the physiological range
(iCa++ 1.1 ± 0.1 mmol/L).
Finally we analyzed blood chemistry data that pointed out a mean
bicarbonatemia of 25.3 ± 4.8 mmol/L and a mean pH of 7.42 ±
0.05; also we evaluated the coagulation status of the patient with
the means of the PT (57.5 ± 13.2) and PTT (50 ± 10.7 sec)
(Table 3).
Table 3. Average PT and PTT for each patient:
lack of significant changes in buoyancy of the
coagulation
CONCLUSIONS
The protocol in use in our centre allowed us to obtain an elevated dose of plasma/Kg
patient with a circuit life longer that other anticoagulation methods.
We observed an elevated survival at 28 and 90 days related to clinical status of patients
(72.7% and 63.6%, respectively; Table 4).
We observed that the convective dose was less important, because during the treatment
the MediaSorb was enough effective in the cytokines removal. Nevertheless, we
guarantee in each treatment a minimal convective dose of 20 ml/Kg/h.
REFERENCES:
1. Monchi M, et al. Citrate vs. heparin for anticoagulation in continuous venovenous
hemofiltration: a prospective randomized study. Int. Care Med. 2004; 30: 260-65.
2. Formica M, et al. Treatment of septic shock with the use of CPFA (associated plasma
filtration and adsorption): impact on hemodynamics monitored with PICCO. G Ital.
Nefrol. 2003; 20: 258-63.
3. Mariano F, et al. Regional citrate anticoagulation in ill patients treated with plasma
filtration and adsorpion. Blood Purif. 2004; 22: 313-9.
4. Cubattoli L, et al. Citrate anticoagulation during CVVH in high risk bleeding patients.
Int. J Artif. Organs. 2007; 30: 244-45.
5. Pozzato M, at al. Safety and efficacy of citrate anticoagulation in septic shock
patients treated with with Coupled Plasma Filtration Adsorption (CPFA). Am Soc
Nephrol 9-13 November 2011, Abstract book.