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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Critically ill patients often develop acute renal failure and&#44; on many occasions&#44; need continuous extrarenal treatment&#46; One of the main disadvantages of the technique is the coagulation of the filters&#44; which reduces the effectiveness of the therapy&#44; increases costs and prolongs the patient&#191;s recovery&#46; The continuous nature of the technique&#44; therefore&#44; requires an anticoagulation system to guarantee its effectiveness&#44; optimise the survival of the circuit and reduce blood loss due to filter coagulation&#46;<span class="elsevierStyleSup">1</span> However&#44; this will increase the risk of haemorrhage already run by these patients&#46; Furthermore&#44; turbulent blood flow and interaction of the membrane with platelets could induce platelet dysfunction&#44; which increases the risk of haemorrhage&#46;<span class="elsevierStyleSup">2</span> The objective is to keep the filter&#44; the extracorporeal lines and the catheters free of clots&#44; avoiding a systemic anticoagulation that favours haemorrhage complications&#46; The need for anticoagulants will depend on technical factors&#44; such as the applied blood flow or the type of the filter membrane&#44; as well as on patient-related factors&#44; namely the hepatic function and the number of platelets&#46; It is important to understand the intrinsic mechanisms involved in the premature coagulation of the filter&#191;s circuit to optimise anticoagulation and keep the filter from coagulating for the longest amount of time possible&#46; Many studies have been carried out&#44; one by Tank et al&#44;<span class="elsevierStyleSup">3</span> which shows that continuous extrarenal treatment in critically ill patients at a high risk of haemorrhage can be performed without anticoagulation&#44; which minimises the risk of haemorrhage and it is linked with an acceptable filter lifetime&#46;</p><p class="elsevierStylePara">The objective of our study is to examine the lifetime of the filters used in techniques of continuous renal treatment&#44; with or without anticoagulation&#44; for critically ill patients with or without coagulopathy&#46; For this reason&#44; a prospective&#44; cohort study was carried out in a polyvalent intensive care unit of a third-level hospital for a period of four months&#46; Patients at a high risk of haemorrhage were included&#44; i&#46;e&#46; those who suffered from active bleeding or had an episode of major bleeding during the last 48 hours&#44; the 24 hours post operation or those who had a Quick index of &#60; 50&#37; and&#47;or aPTT of &#62; 60 seconds and&#47;or a platelet count of &#60; 60&#44;000&#47;ml&#46; The Prisma system was used on all the patients with predilution replacement&#44; which was present in patients with renal failure &#40;acute or chronic&#41; and haemodynamic instability&#44; requiring liquids management and controlling electrolytes or the acid-base equilibrium&#46; The mean time &#40;mt&#41;&#44; counted in hours&#44; of the filters and their standard deviation were analysed as statistical data by comparing the average values by means of the Fisher test&#46;</p><p class="elsevierStylePara">Twelve patients took part in the study&#44; 8 men &#40;66&#37;&#41; and 4 women &#40;33&#37;&#41;&#44; with APACHE II and SAPS scorings of 17 and 35&#44; respectively&#44; when admitted to hospital&#46; Forty-eight filters were analysed&#44; of which 28 &#40;58&#46;3&#37;&#41; corresponded to patients at a high risk of haemorrhage&#44; with an mt of 21&#46;8 &#177; 4&#46;09 hours&#46; Heparin was administered intravenously in 12 filters &#40;25&#37;&#41; at an anticoagulant dose&#44; with a filter mt of 17 &#177; 6&#46;5 hours&#46; Finally&#44; in the 8 filters &#40;16&#46;6&#37;&#41; corresponding to the patients without any risk of haemorrhage&#44; who were only administered subcutaneously a prophylactic dose of heparin against deep vein thrombosis&#44; the mt was 16 &#177; 4&#46;2 hours&#46;</p><p class="elsevierStylePara">When comparing the average lifetime of the filters in patients without any risk of haemorrhage&#44; there are no significant differences between those who were administered heparin intravenously at an anticoagulant dose and those who only received prophylactic heparin subcutaneously &#40;p &#61; 0&#46;70&#41;&#46; As expected&#44; the mt of the filters in patients with coagulopathy is significantly greater than those administered intravenous heparin &#40;p &#60; 0&#46;05&#41; or those who received the prophylaxis dose &#40;p &#60; 0&#46;01&#41;&#46;</p><p class="elsevierStylePara">The ideal anticoagulant would prevent coagulation of the filters without causing haemorrhage&#44; would have a short halflife with an action limited to the extracorporeal circuit and easy monitoring&#44; secondary effects would not exist and it would provide an effective antagonist&#46; None of the currently available anticoagulants can satisfy all these prerequisites&#46; The most commonly used method to prevent coagulation of the system is the continuous administration of heparin in the proximal line of the extracorporeal circuit&#46; Patients at risk have been recommended heparins of a low molecular weight&#44; prostacyclins&#44; regional heparinisation with protein neutralisation&#44; recontrolgional anticoagulation with citrate&#44; prostacyclins and the infusion of predilution saline solution&#46;</p><p class="elsevierStylePara">To conclude&#44; the replacement administered before the filter dilutes the filter&#191;s blood reduces haemoconcentration and improves rheological conditions&#46; Its use is suitable when the platelet count is &#60; 60&#44;000&#47;ml&#44; the APTT is &#62; 60 seconds or twice the control value&#44; the INR is &#62; 2 or when there is spontaneous haemorrhage or a disseminated intravascular coagulopathy&#46; Recent studies show that critically ill patients at a high risk of haemorrhage&#44; and undergoing these continuous therapies&#44; can be treated without anticoagulation of the circuit&#44; thus without altering the circuit&#191;s halflife&#46;<span class="elsevierStyleSup">4&#44;5</span> In our study&#44; in which we used predilution replacement&#44; we can confirm that the filters of the patients without any risk of haemorrhage have the same halflife whether or not they anticoagulate&#46; 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Continuous extrarenal treatment without anticoagulation therapy
Depuración extrarrenal continua sin anticoagulación
Luciano Santana Cabreraa, M.. Sánchez Palaciosa, A.. Ramírez Rodrígueza, A.. Villanueva Ortiza
a Hospital Universitario Insular de Gran Canaria, Gran Canaria, Islas Canarias, España,
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the extracorporeal lines and the catheters free of clots&#44; avoiding a systemic anticoagulation that favours haemorrhage complications&#46; The need for anticoagulants will depend on technical factors&#44; such as the applied blood flow or the type of the filter membrane&#44; as well as on patient-related factors&#44; namely the hepatic function and the number of platelets&#46; It is important to understand the intrinsic mechanisms involved in the premature coagulation of the filter&#191;s circuit to optimise anticoagulation and keep the filter from coagulating for the longest amount of time possible&#46; Many studies have been carried out&#44; one by Tank et al&#44;<span class="elsevierStyleSup">3</span> which shows that continuous extrarenal treatment in critically ill patients at a high risk of haemorrhage can be performed without anticoagulation&#44; which minimises the risk of haemorrhage and it is linked with an acceptable filter lifetime&#46;</p><p class="elsevierStylePara">The objective of our study is to examine the lifetime of the filters used in techniques of continuous renal treatment&#44; with or without anticoagulation&#44; for critically ill patients with or without coagulopathy&#46; For this reason&#44; a prospective&#44; cohort study was carried out in a polyvalent intensive care unit of a third-level hospital for a period of four months&#46; Patients at a high risk of haemorrhage were included&#44; i&#46;e&#46; those who suffered from active bleeding or had an episode of major bleeding during the last 48 hours&#44; the 24 hours post operation or those who had a Quick index of &#60; 50&#37; and&#47;or aPTT of &#62; 60 seconds and&#47;or a platelet count of &#60; 60&#44;000&#47;ml&#46; The Prisma system was used on all the patients with predilution replacement&#44; which was present in patients with renal failure &#40;acute or chronic&#41; and haemodynamic instability&#44; requiring liquids management and controlling electrolytes or the acid-base equilibrium&#46; The mean time &#40;mt&#41;&#44; counted in hours&#44; of the filters and their standard deviation were analysed as statistical data by comparing the average values by means of the Fisher test&#46;</p><p class="elsevierStylePara">Twelve patients took part in the study&#44; 8 men &#40;66&#37;&#41; and 4 women &#40;33&#37;&#41;&#44; with APACHE II and SAPS scorings of 17 and 35&#44; respectively&#44; when admitted to hospital&#46; Forty-eight filters were analysed&#44; of which 28 &#40;58&#46;3&#37;&#41; corresponded to patients at a high risk of haemorrhage&#44; with an mt of 21&#46;8 &#177; 4&#46;09 hours&#46; Heparin was administered intravenously in 12 filters &#40;25&#37;&#41; at an anticoagulant dose&#44; with a filter mt of 17 &#177; 6&#46;5 hours&#46; Finally&#44; in the 8 filters &#40;16&#46;6&#37;&#41; corresponding to the patients without any risk of haemorrhage&#44; who were only administered subcutaneously a prophylactic dose of heparin against deep vein thrombosis&#44; the mt was 16 &#177; 4&#46;2 hours&#46;</p><p class="elsevierStylePara">When comparing the average lifetime of the filters in patients without any risk of haemorrhage&#44; there are no significant differences between those who were administered heparin intravenously at an anticoagulant dose and those who only received prophylactic heparin subcutaneously &#40;p &#61; 0&#46;70&#41;&#46; As expected&#44; the mt of the filters in patients with coagulopathy is significantly greater than those administered intravenous heparin &#40;p &#60; 0&#46;05&#41; or those who received the prophylaxis dose &#40;p &#60; 0&#46;01&#41;&#46;</p><p class="elsevierStylePara">The ideal anticoagulant would prevent coagulation of the filters without causing haemorrhage&#44; would have a short halflife with an action limited to the extracorporeal circuit and easy monitoring&#44; secondary effects would not exist and it would provide an effective antagonist&#46; None of the currently available anticoagulants can satisfy all these prerequisites&#46; The most commonly used method to prevent coagulation of the system is the continuous administration of heparin in the proximal line of the extracorporeal circuit&#46; Patients at risk have been recommended heparins of a low molecular weight&#44; prostacyclins&#44; regional heparinisation with protein neutralisation&#44; recontrolgional anticoagulation with citrate&#44; prostacyclins and the infusion of predilution saline solution&#46;</p><p class="elsevierStylePara">To conclude&#44; the replacement administered before the filter dilutes the filter&#191;s blood reduces haemoconcentration and improves rheological conditions&#46; Its use is suitable when the platelet count is &#60; 60&#44;000&#47;ml&#44; the APTT is &#62; 60 seconds or twice the control value&#44; the INR is &#62; 2 or when there is spontaneous haemorrhage or a disseminated intravascular coagulopathy&#46; Recent studies show that critically ill patients at a high risk of haemorrhage&#44; and undergoing these continuous therapies&#44; can be treated without anticoagulation of the circuit&#44; thus without altering the circuit&#191;s halflife&#46;<span class="elsevierStyleSup">4&#44;5</span> In our study&#44; in which we used predilution replacement&#44; we can confirm that the filters of the patients without any risk of haemorrhage have the same halflife whether or not they anticoagulate&#46; 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Article information
ISSN: 20132514
Original language: English
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2024 March 32 17 49
2024 February 33 26 59
2024 January 23 24 47
2023 December 24 21 45
2023 November 22 31 53
2023 October 27 17 44
2023 September 21 29 50
2023 August 27 27 54
2023 July 28 29 57
2023 June 31 18 49
2023 May 30 29 59
2023 April 22 13 35
2023 March 21 23 44
2023 February 29 18 47
2023 January 21 27 48
2022 December 30 32 62
2022 November 37 22 59
2022 October 29 34 63
2022 September 32 29 61
2022 August 36 41 77
2022 July 24 40 64
2022 June 27 30 57
2022 May 23 32 55
2022 April 29 35 64
2022 March 31 35 66
2022 February 34 33 67
2022 January 24 27 51
2021 December 35 42 77
2021 November 25 36 61
2021 October 35 36 71
2021 September 27 35 62
2021 August 19 29 48
2021 July 29 29 58
2021 June 15 16 31
2021 May 23 22 45
2021 April 31 20 51
2021 March 18 14 32
2021 February 14 9 23
2021 January 27 18 45
2020 December 11 9 20
2020 November 25 10 35
2020 October 11 6 17
2020 September 22 4 26
2020 August 20 8 28
2020 July 19 7 26
2020 June 21 9 30
2020 May 17 10 27
2020 April 22 16 38
2020 March 15 12 27
2020 February 24 17 41
2020 January 24 15 39
2019 December 17 13 30
2019 November 23 18 41
2019 October 14 13 27
2019 September 22 11 33
2019 August 14 9 23
2019 July 17 22 39
2019 June 17 13 30
2019 May 14 11 25
2019 April 21 37 58
2019 March 17 15 32
2019 February 17 15 32
2019 January 14 15 29
2018 December 43 35 78
2018 November 53 10 63
2018 October 40 12 52
2018 September 49 19 68
2018 August 28 11 39
2018 July 37 16 53
2018 June 30 12 42
2018 May 35 16 51
2018 April 38 4 42
2018 March 27 7 34
2018 February 26 5 31
2018 January 16 5 21
2017 December 35 9 44
2017 November 12 3 15
2017 October 26 5 31
2017 September 20 13 33
2017 August 21 6 27
2017 July 23 7 30
2017 June 16 4 20
2017 May 21 9 30
2017 April 19 5 24
2017 March 13 12 25
2017 February 17 5 22
2017 January 14 4 18
2016 December 46 5 51
2016 November 62 5 67
2016 October 74 7 81
2016 September 115 4 119
2016 August 172 4 176
2016 July 124 0 124
2016 June 87 0 87
2016 May 92 0 92
2016 April 78 0 78
2016 March 65 0 65
2016 February 77 0 77
2016 January 100 0 100
2015 December 105 0 105
2015 November 75 0 75
2015 October 65 0 65
2015 September 92 0 92
2015 August 57 0 57
2015 July 53 0 53
2015 June 36 0 36
2015 May 34 0 34
2015 April 5 0 5
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