Q: 57 year old male with End Stage Renal Disease (ESRD) is in ICU with septic shock and now on Continuous Renal Replacement Therapy (CRRT). Patient's catheter has frequent problem with clotting despite changing it twice to different sites and use of citrate solution. Patient previously has history of GI bleed per chart. What approach can be taken for use of heparin for CRRT in patients with possible risk of bleeding?



Answer:  One approach which was described 35 years ago but still applicable and has been used with success in such scenarios - is giving boluses of 500 units of heparin every 30 minutes to keep the activated clotting time more than 150 but less than 200 seconds. Heparin can be used in low dose with continuous infusion keeping tight parameter of ACT as per above. 



Reference: 

Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: regional versus low-dose heparin. Kidney Int 1979; 16:513.