连续静脉-静脉血液滤过时局部枸橼酸钠抗凝初始剂量的探讨

Discussion on the initial dose of regional sodium citrate as anticoagulant when undergoing continuous veno-venous hemofiltration

目的初步探讨连续静脉-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)时局部枸橼酸钠抗凝的初始剂量.方法前瞻性分析我院重症医学科2017年2月至2019年1月行CVVH时给予局部枸橼酸钠抗凝的126例患者的临床资料,按照枸橼酸钠的初始剂量将纳入的患者随机分为高剂量组和低剂量组,高剂量组63例,低剂量组63例.对比两组患者在治疗30 min、2h和4h时滤器前压、滤压降、跨膜压,治疗2h和4h时滤器后Ca2+浓度和枸橼酸钠输注速率,同时比较两组患者在治疗前和治疗24h后血小板计数(PLT)、活化部分凝血酶原时间(KPTT)、电解质(Na+、Ca2+、HCO3-)浓度及治疗24h内出凝血相关不良事件情况.结果两组患者在治疗30 min、2h时滤器前压、滤压降和跨膜压比较差异无统计学意义(P>0.05),在治疗4h时两组患者滤器前压比较差异无统计学意义(P>0.05),但滤压降和跨膜压比较差异有统计学意义(P<0.05);按照CVVH前患者是否存在钙离子升高(Ca2+>1.2 mmol/L),分别将两组患者CVVH治疗4h时的跨膜压和滤压降数据进行亚组分析,高钙患者两组跨膜压和滤压降比较差异有统计学意义(P<0.05),而非高钙患者两组跨膜压和滤压降比较差异无统计学意义(P>0.05);两组患者在治疗2h和4h时滤器后Ca2浓度和枸橼酸钠输注速率比较差异有统计学意义(P<0.05);两组患者在治疗前及治疗24 h后PLT、KPTT及动脉血气Na+、HCO3-、Ca2+浓度比较差异无统计学意义(P>0.05);两组患者治疗24h内均无出血事件发生,管路/滤器血栓发生率比较差异有统计学意义(P<0.05).结论在CVVH过程中按照高剂量方案给予枸橼酸钠抗凝更有利于控制血液净化的压力参数,降低体外循环中血栓的发生率.

Objective To discuss the initial dose of regional sodium citrate as anticoagulant when undergoing continuous veno-venous hemofiltration(CVVH).Methods The clinical data of 126 patients who received sodium citrate anticoagulation when undergoing CVVH in the ICU department of our hospital from February 2017 to January 2019 was analyzed prospectively.According to the initial dose of sodium citrate,the patients were divided into high-dose group(63 cases)and low-dose group(63 cases).The prefilter pressure,filter pressure drop and transmembrane pressure were compared between the two groups at 30 min,2 h and 4 h after the treatment.Concentration of Ca^2++after the filter and velocity of sodium citrate were compared at 2 h and 4 h after the treatment.Meanwhile,we compared platelet count,kaolin partial thromboplastin time(KPTT),electrolyte concentration(Na+,Ca^2+and HC03~)before the treatment and 24 h after the treatment,and coagulation-related adverse event within 24 hours between the two groups.Results There were no statistically significant differences between the two groups in prefilter pressure,filter pressure drop and transmembrane pressure at 30 min and 2 h after the treatment.At 4 h after the treatment,there was no statistically significant difference in the pre-filter pressure between the two groups(P>0.05),but the pressure drop and transmembrane pressure level were significantly different,there were statistical differences(P<0.05).According to the presence or absence of elevated concentration of Ca2^+(Ca+>1.2 mmol/L)in the patients before CVVH,subgroup analysis was performed on the data of transmemhrane pressure and filtration pressure drop of the patients in ihe two groups at 4 h after CVVH treatment.The results of subgroup analysis showed that there were significant differences in transmembrane pressure and filtration pressure drop between the two groups of the patients with high concentration of Ca^2+(P<0.05),while no significant difference between the two groups of the patients without high concentration of Ca^2+(P>0.05).There were significant differences in concentration of Ca2^+after the filter and velocity of sodium citrate at 2 h and 4 h after the treatment between the two groups(P<0.05).There were no statistically significant differences in PLT,KPTF,concentrations of Na+,HC03~,and Ca2+between the two groups before the treatment and 24 h after the treatment(P>0.05).No bleeding events occurred in the two groups within 24 h,but the incidence of pipeline/filter thrombosis was significantly lower in the high-dose group than in the low-dose group(P<0.05).Conclusion In the process of CVVH,high-dose scheme of sodium citrate anticoagulation is more beneficial to control the pressure parameters of blood purification and can reduce the incidence of thrombosis in extracorporeal circulation.