Case submitted by: Dr. Neil Agarwal
Case Published: June 2020

History of Present Illness (HPI)

A 67 year-old man with a past medical history of hypertension, alcohol abuse, obesity, and chronic obstructive pulmonary disease (COPD) presents to the Emergency Department with shortness of breath.

He is noted to be in acute hypoxic respiratory failure and is emergently intubated. Empiric antibiotic therapy is initiated. Norepinephrine is started due to persistent hypotension despite 3 liters of Ringer’s Lactate boluses. He is transferred to the ICU for further management.

In the intensive care unit, Nephrology is consulted for worsening kidney function. His urine output has decreased to less than 5 ml/hour for the past 6 hours. He develops worsening hyperkalemia. The decision is made to start kidney replacement therapy.

You start the patient on continuous veno-venous hemofiltration (CVVH) with regional citrate anticoagulation (RCA) added to the replacement fluid. His initial prescription is as follows:

Blood flow rate 250 ml/min
Pre-filter replacement fluid 2 L/hour
No net ultrafiltration (UF)

The next morning you are notified by the nurse that the circuit clotted twice overnight.

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