Clinical Case Scenario
A 59‑year‑old female with acute gallstone pancreatitis develops infected necrotic peripancreatic collection and septic shock requiring noradrenaline. She is oligo‑anuric with pre‑renal AKI and is initiated on CRRT with regional citrate anticoagulation (RCA). After 16 hours, she becomes hypotensive, requires addition of vasopressin infusion, however, the filter clots twice, and ABG shows metabolic acidosis with rising lactate.
Key Lab Findings:
- WBC: 17,500 /µL
- Platelets: 400,000 /µL
- Urea: 35 mmol/L, Creatinine: 247 µmol/L
- Na⁺: 139 mmol/L, K⁺: 5.8 mmol/L
- pH: 7.1, HCO₃⁻: 16 mmol/L, Lactate: 5.0 mmol/L
- Bilirubin: 3.2 mg/dL, INR: 1.4, AST/ALT: 82/48
CRRT Settings:
- Qb: 200 mL/min
- Citrate: 4% TSC @ 280 mL/hr
- Dialysate: 2.0 L/hr (Ca‑free)
- Replacement: 0.9 L/hr (Ca‑free)
- Calcium infusion: 10% CaCl₂ @ 4 mL/hr
- Systemic iCa²⁺: 0.92 mmol/L, Total Ca: 2.26 mmol/L, Ca/iCa ratio: 2.45
- Post‑filter iCa²⁺: 0.47 mmol/L (target 0.25–0.35 mmol/L)
Which of the following is NOT a useful next intervention?
