连续性肾脏替代治疗体外循环寿命的影响因素分析

Analysis of the influencing factors on circuit survival during continuous renal replacement therapy

目的研究连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)过程中体外循环压力变化及其它因素对体外循环寿命的影响。方法纳入重症监护室使用行Prismaflex机器治疗的成年患者,总计85名患者,251个滤器,共10322.2h。收集治疗中每分钟体外循环压力数据、治疗参数、实验室数据,分析对体外循环寿命的影响。结果轻度双腔导管出口功能不良事件(access outflow dysfunction,AOD)尚不影响寿命;中重度AOD事件在不同抗凝亚组中对寿命影响存在差异:发生中重度AOD事件明显缩短无抗凝组、枸橼酸组的寿命(t值分别为3.179,1.949;P值分别为0.002,0.054);而在低肝/肝素组未观测到影响(t=0.630,P=0.950)。通过体外循环寿命的多因素COX模型分析,提示中重度AOD事件是其危险因素(β=0.638,HR=1.893,95%CI:1.300~2.756,P=0.001),枸橼酸(β=-0.906,HR=0.404,95%CI:0.304~0.537,P<0.001)及CVVHDF(β=-0.722,HR=0.486,95%CI:0.335~0.704,P<0.001)是保护因素。结论研究提示使用枸橼酸,CVVHDF能有效延长体外循环。当使用枸橼酸、无抗凝时,若发生中重度AOD,应通过调整循环入口的功能状态来延长循环寿命而不是一味提高抗凝强度。

Objective To study the effects of continuous extracorporeal circuit pressure and other factors on extracorporeal circuit lifespan during continuous renal replacement therapy(CRRT).Methods Eightyfive patients with 251 episodes of CRRT and a total of 10,322.2h were recruited in the intensive care unit.We extracted the pressure/minute data of extracorporeal circuit from CRRT machine,treatment parameters,and laboratory data to investigate the effects on extracorporeal circuit lifespan.Results Mild access outflow dysfunction(AOD)event did not affect the circuit lifespan.ModeratEto-severe AOD events had different effects on extracorporeal circuit life using various anticoagulants;moderatEto-severe AOD events significantly shortened the circuit lifespan when no anticoagulant or citrate was used(t=3.179,P=0.002;t=1.949 P=0.054)but had no effect on the circuit lifespan when low molecular weight heparin(LMWH)or heparin was used(t=0.630,P=0.950).Cox analysis suggested that moderatEto-severe AOD event was a risk factor for extracorporeal circuit survival(β=0.638,HR=1.893,95%CI 1.300~2.756,P=0.001),while citrate(β=-0.906,HR=0.404,95%CI 0.304~0.537,P<0.001)and CVVHDF(β=-0.722,HR=0.486,95%CI 0.335~0.704,P<0.001)were the protective factors.Conclusions Using citrate as the anticoagulant and CVVHDF can prolong the lifespan of CRRT.Clinically,when moderatEto-severe AOD event occurred and citrate or no anticoagulant was used,we should adjust access outflow to extend the circuit lifespan rather than the increase of anticoagulant dose.