本文選題：肝素　切入點(diǎn)：抗凝　出處：《河北醫(yī)科大學(xué)》2015年碩士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的:肝素是目前全球血液凈化治療的主要抗凝劑,傳統(tǒng)應(yīng)用部分凝血酶原時(shí)間(Application of partial thromboplastin time,APTT)監(jiān)測(cè)凝血功能調(diào)整肝素用量,但患者出血風(fēng)險(xiǎn)和濾器壽命的改善并不理想�？焖傺◤椓D(Rapid thromboelastograph,r TEG)是從凝血因子、血小板、纖溶系統(tǒng)功能方面,動(dòng)態(tài)監(jiān)測(cè)全血凝血狀態(tài)的一種檢驗(yàn)方法。本研究應(yīng)用常規(guī)APTT聯(lián)合快速血栓彈力圖評(píng)估連續(xù)腎替代治療患者肝素抗凝的效果,指導(dǎo)調(diào)整肝素劑量,以改善濾器凝血,降低患者出血風(fēng)險(xiǎn)。方法:本研究選取滄州市中心醫(yī)院重癥醫(yī)學(xué)科在2014年3月---2014年12月收治的應(yīng)用連續(xù)腎替代治療(continuous renal replacement therapy,CRRT)治療的患者,排除應(yīng)用抗凝劑、活動(dòng)性出血、肝素抗凝禁忌、肝功能衰竭患者,共選取病例40例,隨機(jī)分為2組,實(shí)驗(yàn)組20例應(yīng)用APTT聯(lián)合r TEG肝素酶對(duì)比試驗(yàn)?zāi)蜃蛹せ顣r(shí)間(active time,ACT)時(shí)間縮短率(ACT%)監(jiān)測(cè)抗凝效果調(diào)整肝素劑量,對(duì)照組20例應(yīng)用APTT監(jiān)測(cè)抗凝調(diào)整肝素劑量。兩組患者性別、年齡、體重、治療前血小板、APTT、水平均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。兩組均采用CVVH模式,前稀釋,置換液量2000ml/h,血流速150ml/min。實(shí)驗(yàn)組治療過(guò)程中監(jiān)測(cè)r TEG肝素酶對(duì)比實(shí)驗(yàn),了解肝素抗凝效果調(diào)整肝素劑量及凝血過(guò)程中影響凝血的因素,為抗凝作出指導(dǎo)。對(duì)照組依照常規(guī)應(yīng)用APTT調(diào)整肝素劑量。兩組均記錄第一個(gè)濾器使用時(shí)間,出血情況。患者皮膚新出現(xiàn)淤血、鼻腔粘膜出血、牙齦出血、消化道出血,呼吸道出血,采血部位充分壓迫止血后仍出現(xiàn)明顯瘀斑為出血傾向。治療過(guò)程中監(jiān)測(cè)跨膜壓達(dá)到300、報(bào)濾器凝血或靜脈小壺可見(jiàn)明顯凝血塊,終止治療。比較兩組間濾器使用時(shí)間、肝素用量及出血發(fā)生率。結(jié)果:實(shí)驗(yàn)組濾器時(shí)間23.4±3.92h比對(duì)照組18.5±3.23h延長(zhǎng)有統(tǒng)計(jì)學(xué)意義(P0.05)。肝素用量實(shí)驗(yàn)組17697.5±3255.02U,對(duì)照組17700.0±4781.96U無(wú)統(tǒng)計(jì)學(xué)差異(P=0.99)。實(shí)驗(yàn)組發(fā)生出血傾向2例,對(duì)照組5例,出血發(fā)生率分別為4.27/1000h和15.97/1000h。結(jié)論:血栓彈力圖以圖形的方式動(dòng)態(tài)檢測(cè)血塊形成的全過(guò)程,分析全血粘彈性特點(diǎn),同時(shí)體現(xiàn)了更多的個(gè)體化細(xì)胞成分及其相互作用的定性分析,能更全面的反映凝血全過(guò)程。因此應(yīng)用血栓彈力圖監(jiān)測(cè)連續(xù)腎替代治療患者的凝血狀態(tài),可準(zhǔn)確反應(yīng)患者的凝血功能,在影響濾器凝血因素方面提供APTT不能體現(xiàn)的血小板功能。肝素酶對(duì)比實(shí)驗(yàn),能提供更好的肝素抗凝效果指導(dǎo),準(zhǔn)確調(diào)整肝素劑量,延長(zhǎng)濾器使用時(shí)間,減輕醫(yī)療人員工作負(fù)擔(dān),增強(qiáng)治療效果,減少出血并發(fā)癥,減少由此帶來(lái)的風(fēng)險(xiǎn)。血栓彈力圖是一種實(shí)用、有效的監(jiān)測(cè)手段,可作為連續(xù)腎替代治療抗凝監(jiān)測(cè)和指導(dǎo)的良好指標(biāo)。
[Abstract]:Objective: heparin is the main anticoagulant in global blood purification therapy. The traditional application of partial prothrombin time (Application of partial thromboplastin time APTT) is used to monitor the blood coagulation function and adjust the dosage of heparin. But the risk of bleeding and the improvement of filter life were not ideal. Rapid thromboelastography and TEG were based on coagulation factors, platelets and fibrinolytic system function. In this study, routine APTT combined with rapid thromboelastography was used to evaluate the anticoagulant effect of heparin in patients with continuous renal replacement therapy, and to guide the adjustment of heparin dose to improve the coagulation of filter. Methods: patients treated with continuous renal replacement therapy (CRRT) from March 2014 to December 2014 were selected to exclude the use of anticoagulant and active bleeding. 40 cases of heparin anticoagulant contraindication and hepatic failure were randomly divided into two groups. The anticoagulant effect and heparin dose were monitored by APTT combined with r TEG heparinase contrast test in 20 patients in the experimental group, and 20 patients in the control group were monitored by the anticoagulant effect and heparin dose. The sex and age of the patients in the two groups were compared with those in the control group, and the control group was used to monitor the anticoagulant effect and the dose of heparin in the control group. Body weight, platelet count before treatment were not statistically significant (P 0.05). Both groups were treated with CVVH model, pre-dilution, replacement fluid volume of 2000ml / h, and blood flow velocity of 150ml / min. The contrast experiment of r TEG heparinase was performed in the experimental group during the course of treatment. To understand the anticoagulant effect of heparin in adjusting heparin dose and the factors affecting coagulation during coagulation, and to provide guidance for anticoagulation. The control group was treated with conventional APTT to adjust the dose of heparin. The first filter time was recorded in both groups. Bleeding. New bleeding in the skin, nasal mucosal bleeding, gingival bleeding, gastrointestinal bleeding, respiratory bleeding, The bleeding tendency was still obvious after the full compression of the blood collection site. During the treatment, the transmembrane pressure reached 300, and the filter coagulation or venous jug could be seen, and the treatment was terminated. The time of using the filter between the two groups was compared. Results: the filter time of the experimental group was 23.4 鹵3.92h longer than that of the control group (18.5 鹵3.23h). The dosage of heparin was 17697.5 鹵3255.02U in the experimental group and 17700.0 鹵4781.96U in the control group. The incidence of hemorrhage was 4.27 / 1000 h and 15.97% / 1000 h respectively. Conclusion: thromboelastogram can dynamically detect the whole process of blood clot formation, analyze the characteristics of whole blood viscoelasticity, and reflect the qualitative analysis of more individual cell components and their interactions. Thromboelastogram can be used to monitor the coagulation state of patients with continuous renal replacement therapy, and can accurately reflect the coagulation function of the patients. In the aspect of influencing the coagulation factors of filter, we can provide platelet function that APTT can not reflect. The contrast experiment of heparinase can provide better guidance on anticoagulant effect of heparin, adjust the dose of heparin accurately, prolong the use time of filter, and lighten the work burden of medical personnel. Thromboelastography is a practical and effective monitoring method and can be used as a good index for monitoring and guiding anticoagulant therapy of continuous renal replacement therapy.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R459.7

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 施輝;;低分子肝素鈣在58例維持血透患者透析抗凝過(guò)程中的應(yīng)用[J];中國(guó)醫(yī)藥指南;2016年15期

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本文編號(hào)：1562372