小剂量低分子肝素在高出血风险多器官功能障碍综合征患者血液滤过治疗中的应用

The application of low-dose low molecular weight heparin during CVVH in the patients with multiple organ dysfunction syndrome and high risk of bleeding

目的探讨小剂量低分子肝素和普通肝素抗凝对高出血风险多器官功能障碍综合征（MODS）患者连续性静脉-静脉血液滤过（CVVH）疗效的影响及安全性。方法选择我院ICU 2011年1月~2015年6月具有高出血风险MODS行CVVH治疗的患者60例进行回顾性分析。依据CVVH治疗过程中抗凝方案不同分为两组：低分子肝素抗凝组（LMWH组）和普通肝素抗凝组（SH组）。观察入选患者治疗前、治疗后24h APACHEⅡ评分、血肌酐、尿素氮、血小板计数、APTT,计算乳酸清除率的变化,并记录两组患者滤器寿命、出血并发症发生情况、ICU住院时间和28d死亡率。结果两组患者治疗后24h APACHEⅡ评分、血肌酐、尿素氮、乳酸清除率均较治疗前明显好转（P〈0.05）,两组治疗后比较差异无统计学意义（P〉0.05）;两组治疗后24h PLT较治疗前下降,APTT较治疗前延长（P〈0.05）,两组治疗后24h PLT比较差异无统计学意义（P〉0.05）,SH组治疗后24h APTT延长较LMWH组明显（P〈0.05）。SH组出现2例皮肤粘膜出血,LMWH组出现1例皮肤粘膜出血,均无严重大出血情况发生。两组滤器使用寿命、ICU住院时间和28d死亡率差异无统计学意义（P〉0.05）。结论低分子肝素和普通肝素抗凝对高出血风险MODS患者CVVH疗效无明显差异,小剂量应用相对安全,但低分子肝素抗凝对凝血功能影响相对较小,出血风险减少。

Objective To investigate the efficacy and safety of low-dose low molecular weight heparin and standard heparin anticoagulation on the treatment of continuous veno-venous hemofiltration （CVVH） in patients with high risk of bleeding and multiple organ dysfunction syndrome （MODS）. Methods Sixty patients with high risk of bleeding and MODS treated with CVVH in our hospital from Jan 2011 to Jun 2015 were divided into low molecular weight heparin group （LMWH group） and standard heparin group （SH group）. APACHE Ⅱ score, serum creatinine, blood urea nitrogen, blood platelet count, APTT and lactate clearance rate in two groups were observed before treatment and 24h after treatment. Filter lifespan, bleeding complica- tions, the length of ICU stay and 28d mortality were observed. Results There was significant difference in levels of A- PACHE Ⅱ score, serum creatinine, blood urea nitrogen, PLT, APTT, lactate clearance rate at 24h after treatment compared with pre-treatment in both groups （P〈0.05）. Levels of APTT in SH group were significantly longer at 24h after treatment than that in LMWH group （P〈0.05）. Bleeding in skin and mucosa was observed in 2 cases in SH group and 1 case in LMWH group without other severe bleeding complications. There was no significant difference in filter lifespan, the length of ICU stay and 28d mortality between two groups （P〉0.05）. Conclusion There is no significant difference in the efficacy of low molecular weight heparin and standard heparin anticoagulation on the treatment of CVVH in patients with MODS and high risk of bleeding. Low- dose application is relatively safe, but low molecular weight heparin has relatively small effect on blood coagulation and reduce the risk of bleeding.