This is the third instalment in a four part series on continuous renal replacement therapy. (See part 1 and part 2). In this video, Dr Yogesh Apte outlines the fundamentals of anticoagulation in CRRT.
Successful CRRT depends on a good volume of blood flow from the patient, through the extracorporeal circuit and back into the patient. A significant component of this is anticoagulation to prevent clotting of the circuit, in particular the filter. The different anticoagulant agents affect variable components of the coagulation cascade.
As outlined in this video, the options for anticoagulation include systemic anticoagulation or regional anticoagulation. In few, particular circumstances, CRRT may be attempted without anticoagulation; however these patients are often coagulopathic to begin with. In this presentation Dr Apte will outline the pros and cons of the different methods of anticoagulation and how commonly used agents affect the coagulation cascade.
Options for systemic anticoagulation include heparin, low molecular weight heparin and direct thrombin inhibitors. Heparin is the most commonly used anticoagulant as it effectively reduces clotting of the circuit. It does however increase the risk of bleeding and has the additional risk of HITS.
Regional anticoagulants include heparin-protamine, citrate calcium and prostacyclin. Citrate is the most commonly used of these, can be used when patients have increased risk of bleeding and is recommended by the KDIGO guidelines as the anticoagulant of choice. It does however have a risk of systemic metabolic alkalosis and hypocalcemia.
There are benefits and risks of each form of anticoagulant and the choice of agent/method used should be based on patient factors as well as local guidelines.