【摘要】：目的:連續(xù)性腎臟替代治療(continuous renal replacement therapy CRRT)是危重癥患者治療領(lǐng)域的重大進(jìn)步,它能夠清除炎癥介質(zhì)、維持內(nèi)環(huán)境穩(wěn)定、替代腎臟功能。但安全有效的抗凝是CRRT順利進(jìn)行的重要保證,本研究旨在對(duì)低分子肝素和局部枸櫞酸兩種抗凝方法進(jìn)行比較研究,以期為CRRT的抗凝治療提供更好的依據(jù)和方案。方法:將行CRRT治療的危重癥患者隨機(jī)分組為低分子肝素組(A組)和局部枸櫞酸組(B組),均選擇連續(xù)性靜脈-靜脈血液濾過(CVVH)模式,血管通路采用經(jīng)股靜脈置入12F16cm雙腔中心靜脈導(dǎo)管。CRRT應(yīng)用PRISMA FLEX血濾機(jī)(GAMBRO)和AN69濾器(M100膜面積0.9m2),置換液3000ml/h,前置換75%,后置換25%,血流速度100-150ml/min。血液濾過開始前用含肝素鈉1.25萬(wàn)單位的生理鹽水2L預(yù)沖濾器及管路,開始引血時(shí)將含肝素鈉的預(yù)沖液排出。低分子肝素組(A組):低分子肝素負(fù)荷量40IU/kg,隨后持續(xù)泵入劑量4IU/kg/h。枸櫞酸組(B組):初始枸櫞酸鈉泵速(ml/h)設(shè)置為血流速度的1.2-1.5倍,10%葡萄糖酸鈣泵速為8.8-11.1ml/h(枸櫞酸泵速的6.1%),根據(jù)濾器后離子鈣調(diào)整枸櫞酸用量,根據(jù)體內(nèi)離子鈣調(diào)整葡萄糖酸鈣用量。監(jiān)測(cè)濾器使用壽命、CRRT治療前后的血液學(xué)指標(biāo)、凝血功能指標(biāo)、肝腎功能及代謝方面指標(biāo),并評(píng)價(jià)抗凝的有效性及安全性。結(jié)果:本研究共納入67例患者,A組34例,B組33例,在CRRT治療前A、B兩組患者之間的年齡、體重、APACHEⅡ評(píng)分及肌酐清除率無明顯統(tǒng)計(jì)學(xué)意義(P0.05)。在CRRT治療前分別對(duì)兩組的白細(xì)胞(WBC)、血紅蛋白(HGB)、血小板(PLT)、凝血功能、腎功能及肝功能進(jìn)行組間比較,均無明顯統(tǒng)計(jì)學(xué)差異(P0.05)。A組中HGB在治療后較治療前有下降(P0.05),活化部分凝血活酶時(shí)間(APTT)在治療后較前延長(zhǎng)(P0.05),B組治療前后HGB及APTT無顯著變化(P0.05),但兩組患者的PLT均較治療前有下降(P0.05)。兩組患者治療后血肌酐及血尿素氮均較前下降(P0.05),組間比較無明顯統(tǒng)計(jì)學(xué)差異(P0.05)。兩組患者在治療各時(shí)間點(diǎn)離子指標(biāo)的組內(nèi)及組間比較無明顯統(tǒng)計(jì)學(xué)意義(P0.05),但血?dú)庵笜?biāo)比較有明顯差異(P0.05)。濾器使用壽命用(均數(shù)±標(biāo)準(zhǔn)差)表示,低分子肝素抗凝組為33.76±13.56h,局部枸櫞酸抗凝組為41.36±20.85h,枸櫞酸組濾器壽命長(zhǎng)于低分子肝素組,兩組間比較P值為0.081(P0.05),無明顯統(tǒng)計(jì)學(xué)差異。結(jié)論:1局部枸櫞酸抗凝組的濾器壽命長(zhǎng)于低分子肝素抗凝組,但統(tǒng)計(jì)學(xué)比較得出無統(tǒng)計(jì)學(xué)意義,所以可能仍需要大樣本量及多中心的研究分析。2在兩種抗凝方式下血液濾過均能有效清除血肌酐及血尿素氮。
[Abstract]:Objective: continuous renal replacement therapy (continuous renal replacement therapy CRRT) is an important progress in the field of critically ill patients. It can remove inflammatory mediators, maintain the stability of the internal environment, and replace renal function. However, safe and effective anticoagulation is an important guarantee for the smooth progress of CRRT. The purpose of this study is to compare the two anticoagulant methods of low molecular weight heparin and local citric acid in order to provide a better basis and scheme for the anticoagulant therapy of CRRT. Methods: the critically ill patients who were treated with CRRT were randomly divided into low molecular weight heparin group (group A) and local citrate group (group B). Continuous veno-venous hemofiltration (CVVH) was selected. The vascular pathway was treated with 12F16cm double central vena cava catheter. CRRT was used to apply Presta FLEX blood filter (gambro) and AN69 filter (M100 membrane area 0.9m2), the replacement fluid was 3000ml / h, the anterior replacement was 75cm, the posterior replacement was 2525ml / min, and the blood flow velocity was 100-150 ml / min. The preflushing fluid containing heparin sodium 12500 units of normal saline 2L preflushing filter and pipeline was used before the beginning of hemofiltration, and the preflushing solution containing heparin sodium was discharged when the blood was drawn. Low molecular weight heparin group (group A): low molecular heparin loading of 40 IUU / kg, and then continuously pumped into the dose of 4 IU / kg / h. In the citrate group (group B), the initial sodium citrate pump velocity (ml/h) was set to 1.2-1.5 times of the velocity of blood flow. The velocity of calcium gluconate pump was 1.2-1.5 times that of the velocity of citric acid pump. The rate of calcium gluconate was adjusted according to the ion calcium behind the filter and the dosage of calcium gluconate was adjusted according to the ion calcium in vivo. The blood parameters, coagulation function, liver and kidney function and metabolism were monitored before and after CRRT treatment, and the efficacy and safety of anticoagulant were evaluated. Results: there were 33 patients in group B and 34 patients in group A in this study. There was no significant difference in age, weight, Apache 鈪，

本文編號(hào)：2128292