局部枸橼酸抗凝在血液灌流联合连续性肾脏替代治疗中的应用观察

Observation on the use of regional citric acid anticoagulation in hemoperfusion combined with continuous renal replacement therapy

目的探究局部枸橼酸抗凝应用于血液灌流联合连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)中的安全性及疗效。方法回顾性纳入四川大学华西医院2021年1月-2022年3月行连续性静脉-静脉血液透析滤过串联血液灌流患者。所有患者血管通路均采用颈内静脉/股静脉留置双腔导管,使用Prismaflex V8.0 CRRT机器及体外循环管路ST150及一次性使用血液灌流器HA380进行治疗,4%枸橼酸钠以180~200 mL/h速度由动脉端泵入,血泵速率130~150 mL/min,透析液∶置换液剂量=1∶1,CRRT治疗剂量为20~35 mL/(kg·h),置换液采用后稀释的方法补入,血液灌流治疗时间为8~10 h。观察血液灌流治疗完成率、体外循环寿命、出凝血事件发生率以及治疗前后降钙素原、C反应蛋白、白细胞介素-6等的变化。结果共纳入75例患者的143例次治疗,其中119例次顺利完成,血液灌流治疗完成率83.2%。血液灌流器平均寿命为(8.5±1.5)h。治疗中出凝血事件发生率为18.9%(27/143),其中13例次发生CRRT体外循环管路凝血,11例次发生血液灌流器凝血,3例次出现消化道出血。93例次治疗的滤器后离子钙水平维持在0.25~0.35 mmol/L,外周钙水平维持在1.0~1.1 mmol/L。与治疗0 h相比,治疗后72 h患者降钙素原显著下降(P=0.014),白细胞介素-6及C反应蛋白差异无统计学意义(P>0.05)。所有患者在治疗中均未发生过敏反应。结论在CRRT联合血液灌流治疗中,使用枸橼酸抗凝能获得良好的体外循环寿命、炎症介质清除能力、较低的出血风险。

Objective To explore the safety and efficacy of regional citrate anticoagulation in hemoperfusion combined with continuous renal replacement therapy(CRRT).Methods Patients who underwent continuous venovenous hemodiafiltration tandem hemoperfusion between January 2021 and March 2022 in West China Hospital of Sichuan University were retrospectively enrolled.All patients received double-lumen catheter indwelling through internal jugular vein or femoral vein for vascular access,and were treated with Prismaflex V8.0 CRRT machine,extracorporeal circulation line ST150,and disposable hemoperperfusion device HA380.Four percent sodium citrate was pumped from the arterial end at the rate of 180-200 mL/h.The blood pump rate was 130-150 mL/min,the ratio of dialysis fluid to the dose of replacement fluid was 1∶1,the amount of CRRT treatment agent was 20-35 mL/(kg·h),replacement fluid was added by post-dilution method,and the treatment time of hemoperfusion was 8-10 h.The dialysis treatment completion rate,the cardiopulmonary bypass life,the incidence of coagulation events,and the levels of procalcitonin,C-reactive protein,interleukin-6,etc.were observed.Results A total of 143 cases of treatment were completed in 75 patients,among them,119 cases were successfully completed and the completion rate of hemoperfusion treatment was 83.2%.The average life of hemoperfusion devices was(8.5±1.5)h.Bleeding or blood clotting occurred in 18.9%of the treatment(27/143),13 cases had CRRT extracorporeal circulation coagulation,11 cases had hemoperfusion device coagulation,and 3 cases had gastrointestinal bleeding.The ionic calcium levels after the filter of 93 cases of treatment were maintained around0.25-0.35 mmol/L,and the peripheral calcium levels were maintained around 1.0-1.1 mmol/L.Compared with that at 0 h,the procalcitonin decreased significantly 72 h after hemoperfusion treatment(P=0.014),while there was no significant change in interleukin-6 or C-reactive protein after 72 h treatment(P0.05).None of the patients experienced anaphylaxis during treatment.Conclusion In CRRT combined with hemoperfusion,the use of regional citrate anticoagulation results in good cardiopulmonary bypass life,inflammatory mediators clearance,and a lower risk of bleeding.