More on Anticoagulation for Continuous Hemofiltration

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Abstract
Hsu et al. (Sept. 4 issue)1 describe a method of regional anticoagulation for continuous venovenous hemofiltration that involves the infusion of a citrate-containing replacement fluid. For over a year we have used a similar technique, in which a replacement fluid containing 15 mmol of disodium citrate per liter is infused at a fixed rate of 2 liters per hour, volume control is achieved by variable ultrafiltration, and the blood-flow rate is set at 60 to 150 ml per minute. This approach achieves metabolic control equivalent to that with lactate-based solutions. Correction of acidosis, however, can be insufficient in cases of severe shock because low hepatic perfusion may compromise the conversion of citrate into bicarbonate. In patients with acidosis due to impaired organ perfusion, we use a solution containing both citrate and bicarbonate (15 mmol of disodium citrate per liter and 10 mmol of sodium bicarbonate per liter).