局部枸橼酸抗凝在血液灌流联合连续性肾脏替代治疗危重症患者高危出血中的应用

The application of Regional Citrate anticoagulation in hemoperfusion combined with continuous renal replacement treatment for severe patients with high risk of hemorrhage

目的:探讨应用局部枸橼酸抗凝(Regional Citrate anticoagulation,RCA)在血液灌流(hemoperfusion,HP)联合连续性肾脏替代治疗(continuous renal replacement,CRRT)危重症高危出血患者中的应用效果及安全性。方法:选择危重症高危出血患者45例,采用4%RCA行HP串联CRRT方案,观察RCA治疗前、治疗2 h、4 h、6 h、12 h后外周血各指标变化,包括:血红蛋白(Hb)、血小板计数(PLT)、血浆凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)、游离钙(iCa 2+)、钠离子(Na+)、总钙(tCa 2+)、碳酸氢根(HCO)、尿素氮(BUN)、肌酐(Cr)。观察RCA治疗前、治疗2 h、4 h、6 h、12 h后体内外周血及滤器后(串联血液灌流器后)的血气分析指标变化,包括iCa 2+、pH值、HCO。观察患者治疗过程中出血发生率及原有出血加重情况,体外循环凝血情况,透析器、灌流器和静脉壶凝血情况。结果:45例患者血液净化治疗,共162例次,均能顺利完成治疗,未发生严重出血或原有出血加重。RCA对比治疗前,治疗2 h、4 h、6 h、12 h滤器后PT、APTT均延长于体内外周血;治疗2 h、4 h、6 h、12 h滤器后i Ca 2+水平均低于体内外周血,差异有统计学意义(P<0.05)。治疗前、治疗2 h、4 h、6 h、12 h体内外周血Hb、PLT、PT、APTT、i Ca 2+、tCa 2+、Na+比较,差异无统计学意义(P>0.05)。治疗前、治疗BUN、Cr、PH值、HCO比较,差异有统计学意义(P<0.05)。结论:枸橼酸抗凝对全身凝血功能影响小,不增加出血风险,密切监测下对患者体内代谢无不良影响,在HP联合CRRT治疗危重症高危出血患者中应用安全、有效。

Objective To evaluate the efficacy and safety of Regional Citrate Anti-coagulation(RCA)in hemoperfusion(HP)combined with continuous renal replacement therapy(CRRT)in treating patients at high risk of hemorrhage.Method 45 patients at high risk of hemorrhage were chosen.They were treated with 4 percent HP combined with CRRT.To observe changes of peripheral blood biochemical indicators before and 2 h,4 h,6 h,12 h after RCA,including Hb,PLT,PT,APTT,iCa 2+,Na+,tCa 2+,HCO,BUN and Cr.To observe changes of blood gas analysis indexes,including iCa 2+,pH level and HCO before and after treatment 2 h,4 h,6 h,12 h in peripheral blood and after filters(combined with hemoperfusion)before and 2 h,4 h,6 h,12 h after RCA.The incidence of bleeding and the aggravation of the original bleeding,the coagulation of cardiopulmonary bypass,the coagulation of dialyzer,perfusion device and venous kettle were observed.Results All the 45 patients underwent 162 sessions of HP were all successfully performed.There was no serious bleeding or the original bleeding aggravation.Compared with before and 2 h,4 h,6 h,12 h treatment after RCA,the post dialyzer PT and APTT were prolonged in peripheral blood.After treatment,the iCa 2+levels at 2,4,6,12 hours were lower than in vivo peripheral blood.The difference was statistically significant(P<0.05).Compared with before and 2 h,4 h,6 h,12 h treatment,there was no significant difference in patients′Hb,PLT,PT,APTT,iCa 2+and Na+(P>0.05).But the differences among patients′BUN,Cr,pH level and HCO was statistically significant(P<0.05).Conclusion Citrate anticoagulation has little effect on systemic coagulation function.It won′t increase the risk of bleeding.And in the case of close monitoring,it has no adverse effect on metabolism.It is safe and effective to use HP combined CRRT high risk bleeding in patients.