局部枸橼酸抗凝在重症患者连续性肾脏替代治疗中的应用

Application of Regional Citrate Anticoagulation in Critically Ⅲ Patients Receiving Continuous Renal Replacement Therapy

目的 探讨在连续性肾脏替代治疗（continuous renal replacement therapy,CRRT）过程中应用局部枸橼酸抗凝（regional citrate anticoagulation,RCA）对凝血功能及治疗效果的影响.方法 前瞻性观察我院2010年1月至2013年9月期间进行CRRT的重症患者21例,治疗时间为连续72 h及（或）日间间断治疗8～16 h,4％枸橼酸钠以180～200 ml/h由体外循环的动脉端泵入,血流量150 ml/min;通过监测血气分析中血钙水平,使体外循环局部游离血钙维持在0.25～0.35 mmol/L之间,达到局部抗凝效果,并以调整外源钙的补充,增加（或减少）枸橼酸输入、血流量或透析液量等,达到安全有效的抗凝效果.监测治疗前及治疗后24 h的血浆凝血酶原时间（prothrombin time,PT）,活化部分凝血酶时间（actived partial thrombolastin time,APTT）,国际标准化比值（International normalized ratio,INR）,血小板（platelet,PLT）,pH值,血钙,血肌酐（SCr）,尿素氮（BUN）,C反应蛋白（C-reaction protein,CRP）,丙氨酸氨基转移酶（alanine aminotransferase,ALT）的变化,观察体外循环凝血情况、滤器使用寿命及临床出血事件.结果 ①监测患者凝血指标PT、APTT、INR及PLT无明显变化,差异无统计学意义（P＞0.05）;②在进行CRRT治疗过程中平均滤器使用寿命为21.34 h;③治疗过程中未引起凝血功能紊乱,未增加患者活动性出血的风险;④治疗后监测患者血气分析和血生化指标中pH值、SCr、BUN、CRP、ALT明显好转,差异有统计学意义（P＜0.05）.结论 RCA在重症患者行CRRT过程中是较理想的抗凝方式,安全又有效,对患者凝血指标无影响,能明显延长滤器使用寿命,无临床出血事件发生,可改善患者预后.

Objective To investigates the effect of regional citrate anticoagulation （RCA） on blood coagulation in the process of continuous renal replacement therapy （CRRT）.Methods Twenty one critically ill patients admitted in our hospital from January 2010 to September 2013 were given CRRT.The treatment time was 72 h continuously and（or） intermittent treatment 8-16 h in the day.4％ sodium citrate was pumped in a speed of 180 200 ml/h by the artery end of extracorporeal circula tion.The blood flow was 150 ml/min.By monitoring the level of calcium ions in the blood gas analysis to maintain the local calcium ions of extracorporeal circulation at 0.25 0.355 mmol/L,local anticoagu lant effect was achieved.By adjusting calcium supplement,increasing （or decreasing） citrate input,blood flow or dialysis fluid volume,the safe and effective anticoagulant effect was obtained.Before and 24 h after treatment,the changes in plasma prothrombin time （PT）,activated partial thrombolastin time （APTT）,international normalized ratio （INR）,platelet （PLT）,pH,calcium ion concentration （Ca2＋）,SCr,BUN,C-reactive protein （CRP）,and alanine aminotransferase （ALT） were monitored.The blood coagulation in the extracorporeal circulation,the service life of the filter and clinical bleed ing events were observed.Results （1） Blood coagulation indexes （PT,APTT,INR and PLT） had no obvious changes （P＞0.05）.（2） Average service life of filter was 21.34 h in the process of the CRRT.（3） There were no clotting disorders and the increased risk of active bleeding in the process of treatment.（4） There was significant change in blood gas analysis and blood biochemical indexes （pH,SCr,BUN,CRP,and ALT） after treatment （P＜0.05）.Conclusions For critically ill patients,RCA was safe and effective treatment for anticoagulation in the process of CRRT.RCA had no significant influence on the coagulation indexes,could significantly extend the service life of the filter,and had no clinical bleeding events.