危重症患者持续静脉静脉血液滤过局部枸橼酸抗凝与全身普通肝素抗凝的比较研究

Comparative studies with regional citrate anticoagulation and systemic heparin anticoagulation for continuous venovenous hemofiltration in sever patients

目的危重症患者进行连续静脉静脉血液滤过(CVVH)时使用局部枸橼酸抗凝和全身普通肝素抗凝有效性和安全性比较。方法回顾性分析2007年8月至2008年2月北京协和医院内科重症监护病房因急性肾功能衰竭接受CVVH治疗的24例危重症患者共行52次CVVH,按抗凝方式分为局部枸橼酸抗凝组(A组,30次)和全身肝素抗凝组(B组,22次)。比较两组滤器寿命,血滤停止的原因以及与两种抗凝方式相关的代谢异常和出血并发症的发生率。结果 A组滤器寿命明显长于B组[57.0(36.0～71.3)h对18.3(7.9～35.5)h,P<0.01]。Kaplan-Meier生存曲线显示,两组滤器寿命差异有统计学意义(P<0.01)。因凝血导致血滤终止的比例B组为90.9%(20/22),显著高于A组40.0%(12/30)(P=0.001)。危及生命的出血事件和严重的酸碱失衡或电解质紊乱在两组均未发生。结论与全身普通肝素抗凝相比,内科危重症患者进行CVVH时采用局部枸橼酸抗凝,滤器寿命明显延长,并且不增加代谢异常和严重出血事件的风险。

Objective To compare the efficacy and safety of regional citrate anticoagulation with systemic heparin in continuous venovenous hemofiltration （ CVVH ） for medical intensive care unit （ MICU ） patients. Methods Data of patients with acute renal failure admitted into a medical ICU between August 2007 and February 2008 in Peking Union Medical College Hospita was retrospectively analyzed. CVVH runs were grouped into regional citrate and systemic heparin anticoagulation. Hemofilter operational life span, incidence of major bleedings and metabolic disorder were compared between citrate and heparin anticoagulation groups. Results A total of 52 CVVH runs were analyzed ,30 with regional citrate antieoagulation and 22 with systemic heparin. Overall hemofliter operational life span with citrate was significantly longer than heparin [ 57 （36 - 71.3 ）h vs 18.3 （7.9 -35.5 ）h, P 〈0. 001 ]. Kaplan-Meier analysis revealed significant survival difference between the two groups. Spontaneous filter circuit discontinuation due to clotting occurred more commonly in heparin group than regional citrate group （90. 9% vs 40. 0% , P = 0. 001 ）. Neither major bleeding nor metabolic disorder complications were recorded in both groups. Conclusion Regional citrate anticoagulation is superior to systemic heparin for the hemofilter survival without increasing the risk of metabolic disturbance or major bleeding events in critically ill patients treated with CVVH.