Continuous renal replacement treatment and the 'bleeding patient'.

Area of Science:

• Nephrology
• Intensive Care Medicine
• Critical Care

Background:

• End-stage renal failure (ESRF) patients on maintenance hemodialysis present unique challenges for anticoagulation during critical illness.
• Intra-abdominal bleeding necessitates anticoagulation management in critically ill patients, often complicated by renal impairment.

Observation:

• Continuous veno-venous haemodiafiltration (CVVHDF) was initiated for a patient with ESRF and suspected intra-abdominal bleeding.
• Regional citrate anticoagulation (RCA) using the modified Alabama Protocol was employed to maintain extracorporeal circuit patency and avoid systemic anticoagulation.

Findings:

• The modified Alabama Protocol for RCA successfully facilitated CVVHDF, enabling treatment continuity and preventing bleeding complications.
• Protocol violations led to significant metabolic derangements, including hypocalcemia and metabolic acidosis, highlighting the importance of strict adherence and monitoring.
• Correction of protocol deviations resulted in successful treatment and satisfactory biochemical control without increased bleeding risk.

Implications:

• Regional citrate anticoagulation is a viable and safe anticoagulation strategy for CVVHDF in ESRF patients with intra-abdominal bleeding when the protocol is strictly followed.
• Robust workforce training and vigilant patient monitoring are paramount for safe and effective implementation of RCA, particularly in complex critical care settings.
• This case underscores the critical need for precision in managing electrolyte balance and acid-base status during RCA to prevent adverse events.