局部枸橼酸抗凝在重症急性胰腺炎患者连续性肾脏替代治疗中的应用

Application of topical citrate acid anticoagulation in patients with severe acute pancreatitis after continuous renal replacement therapy

目的 观察肝素和枸橼酸在重症急性胰腺炎患者连续性肾脏替代治疗(continuous renal replacement therapy, CRRT)中抗凝疗效的差异,了解二者在CRRT治疗期间对过滤器使用寿命及患者住院时间、病死率的影响。方法 回顾性收集2018年1月—2022年7月在河北北方学院附属第一医院重症监护病房住院行CRRT的重症急性胰腺炎患者,按抗凝药物使用情况分为肝素抗凝组(对照组)和枸橼酸抗凝组(研究组),分析两组在CRRT期间导管堵塞、过滤器使用寿命、住院时间和90 d病死率等的差异。结果 最终纳入108例患者,其中研究组56例,对照组52例。CRRT治疗前,研究组液体出入量平衡值低于对照组(P<0.05)。108例患者共接受了217次CRRT治疗,治疗时长44~87 h,中位治疗时长63 h。在导管通畅方面,研究组堵塞程度低于对照组(P=0.003)。研究组过滤器使用寿命长于对照组[42.5 vs. 29.0 h;风险比=1.83,95%置信区间(1.23,2.73),P<0.001];两组90 d病死率差异无统计学意义(P>0.05)。研究组过滤器平均使用量少于对照组[(1.93±0.09) vs.(2.17±0.14)个,P<0.001],因过滤器CRRT停机时间短于对照组[120(0,720) vs. 300(0,890) min,P=0.029],而CRRT持续时间长于对照组[10.6(4.9,27.7) vs. 8.1(3.6,25.0) d,P=0.024],过滤器因特殊情况更换的风险低于对照组(46.4%vs.65.4%,P=0.048)。两组重症监护病房住院时间及总住院时间差异无统计学意义(P>0.05)。结论 CRRT治疗期间,无论肝素还是枸橼酸均可协助CRRT的治疗,而枸橼酸可能更有助于改善局部凝血及全身炎症反应。

Objective To investigate the difference of anticoagulant efficacy of heparin and citric acid during continuous renal replacement therapy(CRRT)in patients with severe acute pancreatitis,and analyze their effects of on filter life span,length of hospital stay and mortality.Methods Patients with severe acute pancreatitis in Intensive Care Unit of the First Affiliated Hospital of Hebei North University between January 2018 and July 2022 were retrospectively enrolled,and they were divided into heparin group(control group)and citric acid group(research group)according to anticoagulation methods.The differences of anticoagulant catheter blockage during CRRT,filter life span,length of hospital stay,and 90-day mortality between the two groups were analyzed.Results A total of 108 patients were enrolled,including 56 in the research group and 52 in the control group.In pre-CRRT treatment,the balance value of fluid intake and outflow in the research group was significantly lower than that in the control group(P<0.05).The 108 patients received 217 times of CRRT treatment totally,with a median length of treatment of 63 h(range 44-87 h).The severity of catheter blockage in the research group was lower than that in the control group(P=0.003).The filter life span was longer in the research group than that in the control group[42.5 vs.29.0 h;hazard ratio=1.83,95%confidence interval(1.23,2.73),P<0.001];in the comparison of 90-day mortality,there was no significant difference between the two groups(P>0.05).The mean use of filters in the research group was less than that in the control group(1.93±0.09 vs.2.17±0.14,P<0.001).The downtime of CRRT due to filter life in the research group was obviously shorter than that in the control group[120(0,720)vs.300(0,890)min,P=0.029],while the duration of CRRT in the research group was remarkably better than that in the control group[10.6(4.9,27.7)vs.8.1(3.6,25.0)d,P=0.024],and the risk of filter replacement due to special conditons in the research group was lower than that in the control group(46.4%vs.65.4%,P=0.048).There was no statistically significant difference in the length of intensive care unit hospitalization or total hospitalization between the two groups(P>0.05).Conclusion Both heparin and citric acid could assist the treatment of CRRT,while citric acid might be apt to improve local coagulation and systemic inflammatory response.