连续性血液净化枸橼酸体外抗凝技术在高危出血患者中的应用

Application of continuous blood purification with citrate anti-coagulant in patients at high risk of bleeding

目的研究枸橼酸体外抗凝技术行连续性血液净化(continuous blood purification,CBP)的抗凝效果,解决高危出血倾向患者需行CBP时抗凝难的问题。方法32例高危出血倾向患者随机分为A、B两组,每组16例。均行CBP治疗,均采用枸橼酸抗凝剂为碱基的置换液。A组患者置换液输注速度为2 000 mL/h,血流量200 mL/min,枸橼酸浓度为13.3 mmol/L;B组置换液输注速度为4 000 mL/h,血流量250 mL/min,枸橼酸浓度为7 mmol/L。通过外周静脉补充钙剂。监测患者每日治疗前及结束时全血活化凝血时间(WBACT)、血气分析、血清离子钙及总钙水平。结果32例患者共行CBP治疗112次,总治疗时间1 238.3 h;置换液输入前WBACT与治疗前差异不显著,输入置换液后两组滤器后WBACT(s)较滤器前在2、4、6 h各时间点的延长均有显著性差异(P<0.01);治疗后患者碱剩余(BE)及pH无大幅度上升,无碱中毒出现;治疗前后血清总钙、离子钙水平无显著变化;不加重全身出血倾向,无其他严重不良反应。结论枸橼酸体外抗凝技术能解决高危出血倾向患者行CBP时抗凝难题。

Objective To evaluate the efficiency of continuous blood purification （CPB） with citrate anticoagulant in patients at high risk of bleeding. Methods 32 patients with high risk for bleeding were treated with citrate-based pre-dilution. They were randomly divided into group A （16 cases） and B （16 cases）. Blood flow rate was 200 mL/min in group A, and 250 mL/min in group B. Replacement solution was infused at 2 000 mL/hr with citrate 13.3 mmol/L in group A and 4 000 mL/hr with citrate 7 mmol/L in group B. Calcium gluconate was infused with a separate line. Calcium infusion rate was adjusted according to serum ionized calcium. Serum total calcium, ionized calcium, whole blood activated clotting time （WBACT） and acid-base changes were monitored pre and postCPB. Complaints of the patients during treatment and each filter were recorded. Results 32 patients had undergone CPB 112 times. The total treatment time was 1 238.3 h. The levels of WBACT of pre-filter altered little during CPB. The levels of WBACT of post-filter were significantly prolonged compared with pre-filter at 2 h, 4 h, 6 h in group A and B, respectively. Total serum calcium and ionized calcium showed subtle changes during and postCPB compared with that during pre-CPB. No metabolic alkalosis was found post-CPB. No bleeding episodes and serious side effects were found in the whole duration of 1 238.3 hours of CPB. Conclusion Citrate-based replacement solution at high and low infusion rates during CPB can obtain effective anticoagulation for patients with high risk of bleeding.