一种“二阶段补钙模型”在RCA-CVVH中的临床应用

Clinical application of the two-stage calcium supplement model in continuous venous-venous hemofiltration under regional citrate anticoagulation(RCA-CVVH)

目的基于"二阶段补钙模型"建立补钙方程并加以临床实践,以更加简便、有效的推广枸橼酸抗凝技术。方法选取上海交通大学医学院附属第九人民医院行肾脏替代治疗的患者共50人、共进行有效局部枸橼酸抗凝下连续静脉静脉血液滤过(continuous venous-venous hemofiltration under regional citrate anticoagulation,RCA-CVVH)计156例次,其中连续静脉静脉血液滤过(continuous venous-venous hemofiltration,CVVH)采用前稀释模式、低碱无钙置换液,置换液速度4L/h,治疗时间6~8h。循环管路动脉端输注血液保存液-a(anticoagulant citrate dextrose solution-a,ACDa),枸橼酸以4~4.5mmol/L血浆流量速度输入;静脉端补充5%氯化钙,补钙速率利用"二阶段补钙模型"计算得出。在CVVH治疗过程中观察滤器凝血程度,并且每2~3h用i Stat生化仪监测动脉端、滤器前的游离钙水平,留取动脉端1ml血液检测总钙水平,并计算得出动脉端总钙/离子钙水平。结果在156例CVVH中,RCA抗凝有效占总次数的96.79%(151/156),抗凝效果理想;90.4%的管路滤器前离子钙浓度在0.2~0.4mmol/L,均在目标范围内;90.5%的管路动脉端离子钙监测结果均在1.0~1.2mmol/L;97.14%的体内总钙与离子钙比值结果<2.5,无枸橼酸蓄积倾向;熟练应用"二阶段补钙方程"可明显减少离子钙监测频率,减少人力、物力、财力。结论二阶段补钙模型有效性、安全、简便,具有良好的临床实用性。

Objective： To promote the local citrate anticoagulation simplely and effectively,we established equation and practiced in clinical based on the ＂two-stage calcium supplement model＂. Methods： There were 156 cases with effective continuous venous-venous hemofiltration under regional citrate anticoagulation （RCA-CVVH） in a total 50 patients selected. The continuous venous-venous hemofiltration （CVVH） mode was pre-dilution with the low-base calcium-free replacement solution which speed was 4L/h.The treatments lasted 6-8 hours. The anticoagulant citrate dextrose solution-a（ACD-a） was infused at arterial end, and the citrate was fed with 4 ~ 4.5 mmol / L plasma flow. The venous end was supplemented with 5% calcium chloride, and the calcium rate was calculated with the ＂two-stage calcium supplement model＂ . The degree of coagulation was observed during CVVH treatment. The mean calcium level was measured by the iState biochemical analyzer every 2-3 hours. The total calcium level was measured at the arterial end and the total calcium / ion calcium level was calculated. Results： In 156 cases of CVVH, the efficiency of anticoagulation with RCA accounted for 96.79%（151/156）,and the anticoagulation effect was ideal.90.4% of the concentration of ionized calcium in ore-filter were 0.2-0.4mmol / L,which were within the target range.90.5% of the concentration of ionized calcium in arterial port were 1.0-1.2mmol / L. 97.14% of the ratio of total calcium and ionized calcium were less than 2.5 in vivo with no citrate accumulation tendency. Skilled application of ＂two-stage calcium supplement equation＂ can significantly reduce the frequency of ion-calcium monitoring,and reduce the manpower, material and financial resources. Conclusions： The two-stage calcium supplement model is effective, safe and simple,and it has good clinical Practicality.