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Anticoagulation régionale des circuits extracorporels par le citrate

Regional anticoagulation in extracorporeal circuits by citrate

  • Article Original / Original Article
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Réanimation

Résumé

L’anticoagulation au citrate des circuits d’épuration en réanimation est une alternative à l’anticoagulation systémique, notamment dans la prise en charge de l’insuffisance rénale aiguë. Dans le circuit extracorporel, la chélation du calcium sanguin par le citrate assure une anticoagulation régionale permettant de dissocier l’anticoagulation du circuit de celle du patient. Comparée aux héparines, l’anticoagulation au citrate augmente la durée de vie des filtres, diminue le nombre de transfusion et les accidents hémorragiques. Un protocole de correction de l’hypocalcémie induite chez le patient limite les accidents métaboliques. Métabolisé en bicarbonate par le foie, le citrate non filtré peut exposer le patient à l’alcalose ou à l’acidose en cas de défaillance hépatique. Le réglage des débits d’épuration extrarénale avec cette technique nécessite un apprentissage qui a été simplifié par la mise à disposition de générateurs d’épuration extrarénale dédiés à l’anticoagulation régionale au citrate.

Abstract

Regional citrate anticoagulation is a safe alternative to systemic anticoagulation during extracorporeal therapy in critically ill patients. Citrate is administrated in the extracorporeal circuit and chelates the calcium required in the coagulation cascade. Citrate provides safe regional anticoagulation without changes in the patient’s coagulation status. Compared to heparin, the benefits of regional citrate anticoagulation include less bleeding, less need for transfusion and longer circuit lifetime. However, citrate leads to hypocalcaemia that has to be corrected by calcium infusion. In the liver, non-filtered citrate is metabolized in bicarbonate and alkalosis may occur; its prevention is based on specific dialysis or dilution solutions. Acidosis may occur in case of liver failure. Use of dedicated devices based on written guidelines is the key-point to guarantee the procedure safety.

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  1. Service de réanimation polyvalente, hôpital Docteur Duchenne, centre hospitalier de Boulogne sur Mer, BP 609, F-62321, Boulogne sur Mer cedex, France

    P. Ducq & E. Delaporte

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Ducq, P., Delaporte, E. Anticoagulation régionale des circuits extracorporels par le citrate. Réanimation 23, 618–628 (2014). https://doi.org/10.1007/s13546-014-0927-4

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