阿加曲班与普通肝素抗凝在连续性血液净化中的疗效比较

The curative effect comparison between argatroban and heparin anticoagulant in continuous blood purification treatment

目的 观察阿加曲班和普通肝素（UFH）在危重症患者连续性血液净化（CBP）治疗中的抗凝效果和安全性,为优化危重患者CBP治疗的抗凝模式提供理论基础.方法 选择天津医科大学总医院滨海医院2015年9月至2016年10月收治的需行CBP治疗的患者60例,按随机数字表法分为两组,每组30例.一组在CBP前采用阿加曲班抗凝,首剂量250μg/kg,追加剂量1μg·kg^-1·min^-1持续滤器前输注,CBP治疗结束前20-30 min停止追加;另一组在CBP前采用UFH抗凝,首剂量0.3-0.5 mg/kg,追加5-10 mg/h,治疗结束前30 min停用.观察两组治疗前后活化部分凝血活酶时间（APTT）的变化和两组管路、滤器凝血情况以及患者出血情况;并比较两组CBP治疗前后血小板计数（PLT）的差异.结果 两组治疗后3 h和治疗结束前APTT均较治疗前明显延长〔UFH组（s）：64.96±7.35、64.33±6.27比37.77±5.23;阿加曲班组（s）：70.19±6.18、72.03±6.39比40.10±5.11〕,阿加曲班组治疗结束后1 h APTT（s：39.6±5.06）基本恢复正常,而UFH组（s：64.17±6.59）仍明显高于治疗前.阿加曲班组和UFH组不同管路及滤器凝血评分及不同出血评分分级患者比例比较差异均无统计学意义（均P〉0.05）.两组治疗后PLT均较治疗前明显降低,但阿加曲班组PLT水平明显高于UFH组（×109/L：192.20±50.05比160.00±57.12,P〈0.05）.结论 阿加曲班在危重症患者CBP治疗中有着更好的抗凝效果,抗凝可控性优于UFH,血小板减少症发生率低,能减少患者的出血风险.

Objective To observe the anticoagulant efficacy and safety of argatroban and unfractionated heparin （UFH） in continuous blood purification （CBP） treatment and provide the theoretical basis for optimizing the anticoagulant mode of CBP treatment in critically ill patients. Methods Sixty patients treated with CBP in Binhai Hospital of General Hospital of Tianjin Medical University from September 2015 to October 2016 were enrolled, and they were divided into two groups by random number table method, each group 30 cases. Before CBP therapy, the patients in argatroban group were treated with argatroban for anti-coagulation, the first dose was 250 μg/kg, the additional dose was 1 μg＆#183;kg-1＆#183;min-1 continuously infused before sustained filtration, and 20-30 minutes before the end of the CBP treatment, the dose added was stopped; the patients in UFH group were treated with UFH before CBP treatment, the first dose was 0.3-0.5 mg/kg, the additional dose was 5-10 mg/h, and 30 minutes before the end of CBP treatment the dose added was stopped. The changes of activated partial thromboplastin time （APTT） were monitored, before and after the end of CBP treatment, the coagulation of blood in the CBP filter/circuit and bleeding tendency of patients in two groups were observed, and the differences in platelet （PLT） counts were compared between the two groups before and after CBP treatment. Results The APTT of the two groups were significantly longer at 3 hours after treatment and before the end of treatment than those before treatment [UFH group （s）： 64.96±7.35, 64.33±6.27 vs. 37.77±5.23; argatroban group （s）：70.19±6.18, 72.03±6.39 vs. 40.10±5.11], and at 1 hour after the end of treatment, APTT basically returned to baseline level in argatroban group （s： 39.6±5.06）, while in the UFH group APTT was still higher than that before treatment （s： 64.17±6.59）. There were no statistical significant differences in the blood coagulation score of the CBP filter/circuit and bleeding score and gradation of patients between the two groups （both P〉0.05）. After treatment the PLT levels of the two groups were significantly lower than those before treatment, but the level of PLT in the argatroban group was significantly higher than that in the UFH group （×10^9/L： 192.20±50.05 vs. 160.00±57.12, P〈0.05）. Conclusion In comparison, argatroban has a better anticoagulant effect in CBP treatment for critically ill patients, argatroban is superior to UFH in controllability, so that using the former one can lower the incidence of thrombocytopenia and risk of bleeding.