重症患者局部枸橼酸抗凝行连续性静脉-静脉血液滤过离子钙浓度的探讨

Post-filter ionic calcium concentration during continuous venous-venous hemofiltration under regional citrate anti-coagulation in critical patients

目的:观察连续性静脉-静脉血液滤过(CVVH)局部枸橼酸抗凝(RCA)参数设置及滤器后钙离子([iCa^(2+)]_(post-filter))水平与滤器寿命的关系.方法:回顾2016年6月1日至2017年7月31日期间鼓楼医院重症医学科RCA的CVVH患者.设定血流速度和枸橼酸钠速度不变(血流量180 ml/min,4%枸橼酸钠220 ml/h),观察血滤期间内环境情况、滤器寿命.按[iCa^(2+)]_(post-filter)分为C1组(≤0.45 mmol/L)、C2组(0.45 mmol/L<[Ca^(2+)]_(post-filter)≤0.55 mmol/L)、C3组([iCa^(2+)]_(post-filter)>0.55 mmol/L),观察各组滤器寿命(h)和滤器48h存活率.按滤器寿命分为T1组(t≤24h)、T2组(24h<t≤48h)、T3组(t>48h),比较各组[iCa^(2+)]post-filter水平.分析[iCa^(2+)]_(post-filter)与滤器寿命是否存在相关性.结果:共纳入56例患者114例次CVVH.(1)滤器平均寿命46.27±18.82h,平均[iCa^(2+)]po-filter0.52±0.08 mmol/L,体内钙离子1.01±0.19 mmol/L;(2)所有患者CVVH期间未出现明显出血、代谢紊乱等并发症;(3)不同[iCa^(2+)]_(post-filter)组滤器寿命分别是C1组:41.93±17.26h,C2组:47.75±19.91h,C3组:46.45±17.99h,三者之间无统计学意义;48h滤器"存活率"分别是33.33%、43.86%、47.22%,三组之间无统计学差异.(4)T1组、T2组、T3组的[iCa^(2+)]_(post-filter)分别是:0.49±0.07 mmol/L、0.51±0.08 mmol/L、0.53±0.07 mmol/L,三组之间无统计学差异.(5)[iCa^(2+)]_(post-filter)与滤器寿命进行相关性分析,发现两者无相关性.结论:枸橼酸与血流速度设定为合适的固定比例时,可适当放宽[iCa^(2+)]post-filter的目标范围,对滤器使用寿命影响较小,且安全性较好.

Objective:To study parameters setting and the relationship between post-filter ionized calcium concentrations([iCa^(2+)]_(post-filter))and lifespans of filters during continuous venous-venous hemofiltration under regional citrate anticoagulation(RCA-CVVH).Methodology:Patients treated with RCA-CVVH from June 1st 2016 to July 31st 2017,were enrolled in the study.Blood flow velocity and sodium citrate velocity were set unchanged(blood flow:180ml/min,4%sodium citrate:220 ml/h).The internal environment and lifespans of filters were observed during hemofiltration.According to different values of[iCa^(2+)]_(post-filter),the data was divided into three groups:Group C_(1)[iCa^(2+)]_(post-filter)≤0.45 mmol/L),Group C_(2)(0.45[iCa^(2+)]_(post-filter)≤0.55 mmol/L),Group C_(3)([iCa^(2+)]_(post-filter)>0.55mmol/L).The lifespans of filters and surviving rates in 48th hour were compared.According to different lifespans of filters,the data was divided into three groups:Group T1(t≤24h),Group T2(24h<t≤48h),Group T3(t>48h).[Ca^(2+)]post filter of three groups were compared.The relation of[iCa^(2+)]_(post-filter)and lifespans of filters were analyzed.Results:Totally 56 patients and 114 times of CVVH in the same setting were enrolled.(1)The mean lifespan was 46.27±18.82h,and the mean[iCa^(2+)]_(post-filter)was 0.52±0.08mmol/L,the mean systemic iron calcium was 1.01±0.19mmol/L.(2)There were no bleeding,metabolism disarrangements during RCA-CVVH.(3)The lifespans of Group C1,C2 and C3 were 41.93±17.26h,47.75±19.91h and 46.45±17.99h individually,and there was no statistical difference among the three groups(F=0.73,P>0.05).The 48h“surviving rates“were 33.33%,43.86%,47.22%.Differences were not signifcant(χ2=1.08,P>0.05).(4)[iCa^(2+)]_(post-filter)in group T1,T2 and T2,were 0.49±0.07、0.51±0.08、0.53±0.07mmo/L(F=1.86,P>0.05).There was no statistical difference among the three groups.(5)The r-value for the correlation between[iCa^(2+)]_(post-filter)and lifespans of filters was 0.13(P>0.05).Conclusion:To maintain a fixed ratio of sodium citrate and blood flow during RCA-CVVH,target of[iCa^(2+)]_(post-filter)could be extended,thus not only treatment is safe and efficient,the difficulty of adjusting the treatment parameters could be avoided partly,but also lifespans of filters are not influenced,and risk of metabolic disorders is reduced.