Intensive Care Med (2014) 40:912–913 DOI 10.1007/s00134-014-3292-x
Jean-Franc¸ois Soubirou Morgane Commereuc Tomek Kofman Adrien Constan Irma Bourgeon-Ghittori Fre´de´rique Schortgen
Should we use anticoagulant lock for short-term haemodialysis catheter in the ICU? Accepted: 3 April 2014 Published online: 16 April 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014
Dear Editor, Haemodialysis catheter anticoagulant lock is commonly used in the ICU [1]. Prevention of infection and thrombosis are the two reasons justifying this practice. The maintenance of haemodialysis catheter in acute kidney injury (AKI) is, however, easier than in chronic patients because of its short-term use. Spillage of lock solution in systemic circulation is always observed and may lead to bleeding complications. Although this risk has been well described with the management of long-term haemodialysis catheter, it is underestimated by intensivists.
LETTER
Recently, three patients managed with short-term haemodialysis catheter (stHDC) were admitted to our unit for life-threatening haemorrhages related to heparin lock (5,000 UI/ml). Heparin leak occurred despite a careful installation performed by trained nurses using a volume corresponding to the indicated volume on each port lumen. All cases were documented by detectable anticoagulant activity with overdosage in two patients. To assess the efficacy of saline lock solution in maintaining stHDC patency, we conducted a prospective cohort study including 100 consecutive double lumen stHDC inserted in 75 ICU patients managed with intermittent haemodialysis (IHD). At the end of each IHD session, the two lumens of stHDC were flushed with 20 ml of isotonic saline solution and clamped under pressure. Catheter removal was advised in case of suspected infection or catheter dysfunction defined by the need for line reversal and/or by the inability to maintain blood flow above 200 ml/ min and/or by partial (poor flow on aspiration and flush) or total (unable to aspirate or push) occlusion [2–4]. Catheter tip culture was indicated in parallel with peripheral blood culture when catheter-related bloodstream infection (CRBSI) was suspected. The study was approved by the Ethics
Committee of the French Society of Intensive Care Medicine. Median SAPS II score was 65 (52–82) points, 79 % of patients required mechanical ventilation and 60 % vasopressors. Fifty-five per cent had a platelet count below 100,000/ mm3 and/or a prothrombin ratio of less than 50 %. The total of catheterization days was 596 with a median of 5 (3–8) days per catheter (min 1– max 21). The number of IHD delivered per catheter was 3 (1–5) with a median duration of 4.0 (3.5–4.5) h per session. Interdialytic interval was 1.25 (1.00–1.67) days. Thirty-six percent of IHD were anticoagulantfree. Line reversal occurred in 5 % of IHD. Thirteen and three stHDC were removed because of dysfunction and of suspected infection, respectively. Our results did not differ from those reported using heparin [3, 5] or citrate [2, 4] lock (Table 1). Anticoagulant lock related bleeding should be considered in patients managed with stHDC and can be easily confirmed by elevated anti-Xa activity or prolonged aPTT. The benefit/risk ratio of such practice needs to be carefully evaluated in patients managed for AKI who are already predisposed to bleeding. The need for short-term RRT applied on a daily basis limits the risk of intraluminal stasis of blood and both the risk of catheter thrombosis and infection.
Table 1 Incidence of haemodialysis catheter dysfunctions and infections reported in acute haemodialysis according to the lock solution used References
No catheters
Catheterization duration (days)
Parienti [1, 3]
690
5
Souweine [5] Skofic [4] Hermite [2]
130 534 58 77 100
7 12 12 6 5
Our study
Lock solution
Heparin (66 % of catheters) Heparin Citrate Citrate Saline Saline
HD catheter dysfunction
Line reversal (% of IRRT)
CRBSI/1,000 catheter days
Jugular = 2.3 Femoral = 1.5 0 1.6 24 30 0
Catheter loss
Events/1,000 catheter days
11 %
NA
9
NA 12 % NA NA 13 %
NA 20 26 127 22
NA NA NA NA 5
HD haemodialysis, NA not available, IRRT intermittent renal replacement therapy, CRBSI catheter-related bloodstream infection
913
2. Hermite L, Quenot JP, Nadji A, Barbar SD, Charles PE, Hamet M, Jacquiot N, Ghiringhelli F, Freysz M (2012) Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial. Intensive Care Med 38:279–285 3. Parienti JJ, Megarbane B, Fischer MO, Lautrette A, Gazui N, Marin N, Hanouz JL, Ramakers M, Daubin C, Mira JP, Charbonneau P, du Cheyron D (2010) References Catheter dysfunction and dialysis performance according to vascular 1. Parienti JJ, Thirion M, Megarbane B, access among 736 critically ill adults Souweine B, Ouchikhe A, Polito A, Forel requiring renal replacement therapy: a JM, Marque S, Misset B, Airapetian N, randomized controlled study. Crit Care Daurel C, Mira JP, Ramakers M, du Med 38:1118–1125 Cheyron D, Le Coutour X, Daubin C, 4. Skofic N, Buturovic-Ponikvar J, Kovac J, Charbonneau P (2008) Femoral vs Premru V, Knap B, Marn Pernat A, jugular venous catheterization and risk of Kersnic B, Gubensek J, Ponikvar R nosocomial events in adults requiring (2009) Hemodialysis catheters with acute renal replacement therapy: a citrate locking in critically ill patients randomized controlled trial. JAMA with acute kidney injury treated with 299:2413–2422 intermittent online hemofiltration or hemodialysis. Ther Apher Dial 13:327–333
A 4 % citrate solution is an alternative anticoagulant lock. In the absence of adequate evaluations in AKI patients, antithrombotic and antiseptic locks might be justified in centres having a particularly high incidence of CRBSI only [2].
5. Souweine B, Liotier J, Heng AE, Isnard M, Ackoundou-N’Guessan C, Deteix P, Traore O (2006) Catheter colonization in acute renal failure patients: comparison of central venous and dialysis catheters. Am J Kidney Dis 47:879–887 J.-F. Soubirou ()) M. Commereuc A. Constan I. Bourgeon-Ghittori F. Schortgen APHP-Service de re´animation me´dicale, CHU Henri Mondor, 94000 Cre´teil, France e-mail: [email protected] Tel.: ?33-1-49812389 Fax: ?33-1-42079943 F. Schortgen e-mail: [email protected] T. Kofman APHP-Service de ne´phrologie, CHU Henri Mondor, 94000 Cre´teil, France F. Schortgen INSERM Unite´ 955, Universite´ Paris Est Cre´teil, Cre´teil, France
Jean-Franc¸ois Soubirou Morgane Commereuc Tomek Kofman Adrien Constan Irma Bourgeon-Ghittori Fre´de´rique Schortgen
Should we use anticoagulant lock for short-term haemodialysis catheter in the ICU? Accepted: 3 April 2014 Published online: 16 April 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014
Dear Editor, Haemodialysis catheter anticoagulant lock is commonly used in the ICU [1]. Prevention of infection and thrombosis are the two reasons justifying this practice. The maintenance of haemodialysis catheter in acute kidney injury (AKI) is, however, easier than in chronic patients because of its short-term use. Spillage of lock solution in systemic circulation is always observed and may lead to bleeding complications. Although this risk has been well described with the management of long-term haemodialysis catheter, it is underestimated by intensivists.
LETTER
Recently, three patients managed with short-term haemodialysis catheter (stHDC) were admitted to our unit for life-threatening haemorrhages related to heparin lock (5,000 UI/ml). Heparin leak occurred despite a careful installation performed by trained nurses using a volume corresponding to the indicated volume on each port lumen. All cases were documented by detectable anticoagulant activity with overdosage in two patients. To assess the efficacy of saline lock solution in maintaining stHDC patency, we conducted a prospective cohort study including 100 consecutive double lumen stHDC inserted in 75 ICU patients managed with intermittent haemodialysis (IHD). At the end of each IHD session, the two lumens of stHDC were flushed with 20 ml of isotonic saline solution and clamped under pressure. Catheter removal was advised in case of suspected infection or catheter dysfunction defined by the need for line reversal and/or by the inability to maintain blood flow above 200 ml/ min and/or by partial (poor flow on aspiration and flush) or total (unable to aspirate or push) occlusion [2–4]. Catheter tip culture was indicated in parallel with peripheral blood culture when catheter-related bloodstream infection (CRBSI) was suspected. The study was approved by the Ethics
Committee of the French Society of Intensive Care Medicine. Median SAPS II score was 65 (52–82) points, 79 % of patients required mechanical ventilation and 60 % vasopressors. Fifty-five per cent had a platelet count below 100,000/ mm3 and/or a prothrombin ratio of less than 50 %. The total of catheterization days was 596 with a median of 5 (3–8) days per catheter (min 1– max 21). The number of IHD delivered per catheter was 3 (1–5) with a median duration of 4.0 (3.5–4.5) h per session. Interdialytic interval was 1.25 (1.00–1.67) days. Thirty-six percent of IHD were anticoagulantfree. Line reversal occurred in 5 % of IHD. Thirteen and three stHDC were removed because of dysfunction and of suspected infection, respectively. Our results did not differ from those reported using heparin [3, 5] or citrate [2, 4] lock (Table 1). Anticoagulant lock related bleeding should be considered in patients managed with stHDC and can be easily confirmed by elevated anti-Xa activity or prolonged aPTT. The benefit/risk ratio of such practice needs to be carefully evaluated in patients managed for AKI who are already predisposed to bleeding. The need for short-term RRT applied on a daily basis limits the risk of intraluminal stasis of blood and both the risk of catheter thrombosis and infection.
Table 1 Incidence of haemodialysis catheter dysfunctions and infections reported in acute haemodialysis according to the lock solution used References
No catheters
Catheterization duration (days)
Parienti [1, 3]
690
5
Souweine [5] Skofic [4] Hermite [2]
130 534 58 77 100
7 12 12 6 5
Our study
Lock solution
Heparin (66 % of catheters) Heparin Citrate Citrate Saline Saline
HD catheter dysfunction
Line reversal (% of IRRT)
CRBSI/1,000 catheter days
Jugular = 2.3 Femoral = 1.5 0 1.6 24 30 0
Catheter loss
Events/1,000 catheter days
11 %
NA
9
NA 12 % NA NA 13 %
NA 20 26 127 22
NA NA NA NA 5
HD haemodialysis, NA not available, IRRT intermittent renal replacement therapy, CRBSI catheter-related bloodstream infection
913
2. Hermite L, Quenot JP, Nadji A, Barbar SD, Charles PE, Hamet M, Jacquiot N, Ghiringhelli F, Freysz M (2012) Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial. Intensive Care Med 38:279–285 3. Parienti JJ, Megarbane B, Fischer MO, Lautrette A, Gazui N, Marin N, Hanouz JL, Ramakers M, Daubin C, Mira JP, Charbonneau P, du Cheyron D (2010) References Catheter dysfunction and dialysis performance according to vascular 1. Parienti JJ, Thirion M, Megarbane B, access among 736 critically ill adults Souweine B, Ouchikhe A, Polito A, Forel requiring renal replacement therapy: a JM, Marque S, Misset B, Airapetian N, randomized controlled study. Crit Care Daurel C, Mira JP, Ramakers M, du Med 38:1118–1125 Cheyron D, Le Coutour X, Daubin C, 4. Skofic N, Buturovic-Ponikvar J, Kovac J, Charbonneau P (2008) Femoral vs Premru V, Knap B, Marn Pernat A, jugular venous catheterization and risk of Kersnic B, Gubensek J, Ponikvar R nosocomial events in adults requiring (2009) Hemodialysis catheters with acute renal replacement therapy: a citrate locking in critically ill patients randomized controlled trial. JAMA with acute kidney injury treated with 299:2413–2422 intermittent online hemofiltration or hemodialysis. Ther Apher Dial 13:327–333
A 4 % citrate solution is an alternative anticoagulant lock. In the absence of adequate evaluations in AKI patients, antithrombotic and antiseptic locks might be justified in centres having a particularly high incidence of CRBSI only [2].
5. Souweine B, Liotier J, Heng AE, Isnard M, Ackoundou-N’Guessan C, Deteix P, Traore O (2006) Catheter colonization in acute renal failure patients: comparison of central venous and dialysis catheters. Am J Kidney Dis 47:879–887 J.-F. Soubirou ()) M. Commereuc A. Constan I. Bourgeon-Ghittori F. Schortgen APHP-Service de re´animation me´dicale, CHU Henri Mondor, 94000 Cre´teil, France e-mail: [email protected] Tel.: ?33-1-49812389 Fax: ?33-1-42079943 F. Schortgen e-mail: [email protected] T. Kofman APHP-Service de ne´phrologie, CHU Henri Mondor, 94000 Cre´teil, France F. Schortgen INSERM Unite´ 955, Universite´ Paris Est Cre´teil, Cre´teil, France
