枸橼酸抗凝在乳酸酸中毒患者连续性肾脏替代治疗中的应用价值

Application of anti-coagulation of citric acid in continuous renal replacement therapy for patients with lactic acidosis

目的研究局部枸橼酸抗凝与低分子肝素抗凝在乳酸酸中毒患者连续性肾脏替代治疗中的效果及安全性。方法收集2017年5月至2018年7月于南阳市中心医院行连续性肾脏替代治疗的55例乳酸酸中毒患者,其中枸橼酸组(观察组)42例,低分子肝素组13例(对照组)。比较两组患者治疗前后血小板计数(PLT)、活化部分凝血活酶时间(APTT)、血清钙(Ca^(2+))、pH、血清乳酸(Lac)、碳酸氢根(HCO_3^-)、碱剩余(BE)、离子钠(iNa^+)、离子钙(iCa^(2+))水平的变化,并比较两组患者的滤器使用寿命和凝血发生情况。结果观察组患者治疗后8 h时Lac下降幅度显著大于对照组(P<0.05);对照组患者治疗后APTT较治疗前时间延长,PLT值明显低于观察组,差异有统计学意义(P<0.05);两组间其余实验室指标比较,差异无统计学意义(P>0.05)。观察组体外循环凝血率显著低于低分子肝素组,滤器使用寿命明显长于对照组,差异均有统计学意义(P<0.05)。结论枸橼酸抗凝在乳酸酸中毒患者体内可以起到一定的酸碱缓冲作用,降低乳酸效果明显,纠正酸中毒,可提高患者生存率,并减少出血风险,延长滤器寿命。

Objective To study the effectiveness and safety of local citrate anticoagulation (RCA) and low molecular weight heparin anticoagulation in continuous renal replacement therapy (CRRT) for patients with lactic acidosis. Methods A total of 55 patients with lactic acidosis who were treated with CRRT in our hospital from 2015.05 to 2018.07 were enrolled,including 42 patients in the RCA group (observation group) and 13 patients in the low molecular weight heparin group (control group).The changes of platelet (PLT),activated partial thromboplastin time (APTT),serum calcium (Ca 2+),pH values,serum lactic acid (Lac),bicarbonate ion (HCO3-),base excess (BE),sodium ion (iNa +) and calcium ion (iCa 2+) before and after CRRT were compared between the two groups.Comparison of filter service life and coagulation incidence between the two groups was also performed. Results At 8h after treatment,the decrease of Lac in the observation group was significantly greater than that in the control group ( P <0.05).The APTT after treatment in the control group was prolonged compared with that before treatment ,and the PLT value was significantly lower than that in the observation group with statistical significance of difference ( P <0.05).The difference of other indices between the two groups were not statistically significant ( P >0.05).The coagulation rate of in vitro circulation in the observation group was significantly lower than that in the low-heparin group,and the filter life was significantly lon ger than that in the control group with statistical significance of difference ( P <0.05). Conclusions This study indicates that citrate anticoagulation can play a role in acid-base buffering in patients with lactic acidosis,reduce the level of lactic acid significantly,mitigate bleeding risk and prolong the filter life.