本文關(guān)鍵詞：對比兩種抗凝方式在危重患者行腎臟替代治療時的安全性及有效性　出處：《延安大學(xué)》2016年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 連續(xù)性腎臟替代治療 持續(xù)性靜-靜脈血液濾過 枸櫞酸 肝素 抗凝

【摘要】：目的:連續(xù)性腎臟替代治療(Continuous Renal Replacement Therapy,CRRT)技術(shù)在臨床中的應(yīng)用日益增多,尤其是重癥監(jiān)護(hù)室,現(xiàn)已成為重癥監(jiān)護(hù)室中必備搶救技術(shù);而腎臟替代治療能否順利實施,依賴于體外循環(huán)管路的抗凝效果,抗凝效果同時也是患者病情能否得到及時、有效控制以及醫(yī)療工作能否有條不紊進(jìn)行的關(guān)鍵。本研究旨在比較兩種不同抗凝方式在危重患者行腎臟替代治療時的安全性及有效性,為臨床醫(yī)師制定相對優(yōu)化的抗凝方案提供一定的理論依據(jù)。方法:對延安大學(xué)附屬醫(yī)院東關(guān)心腦血管病區(qū)重癥監(jiān)護(hù)室行CRRT的患者進(jìn)行研究,根據(jù)抗凝方案分為肝素組、枸櫞酸組。根據(jù)納入、排除標(biāo)準(zhǔn),篩選出肝素組20例、枸櫞酸組20例。入選患者行該治療時均選擇8G 20cm雙腔血濾管,經(jīng)股靜脈置入,用含1.25萬單位肝素的生理鹽水沖洗體外管路及濾器后,連接PRISMA FLEX血濾機(jī)與血濾管的引血端,并開始引血,將預(yù)充液排出體外后將管路另一端連接到回血端,設(shè)置初始血流速為100-200ml/min,采用前稀釋50%、后稀釋50%,置換液均采用延安大學(xué)附屬醫(yī)院東關(guān)分院重癥醫(yī)學(xué)科常規(guī)配方。肝素組(A組):首次劑量30IU/Kg,隨后以10IU/Kg/h持續(xù)泵注,根據(jù)患者凝血指標(biāo)調(diào)整用量。枸櫞酸組(B組):研究中枸櫞酸均采用4%枸櫞酸鈉抗凝劑(200ml:8.0g)。初始4%枸櫞酸鈉泵速(ml/h)設(shè)置為血流速度的1.2倍,10%葡萄糖酸鈣泵速為4%枸櫞酸鈉泵速的7.3%,根據(jù)濾器后離子鈣濃度及時調(diào)整枸櫞酸泵入速度,根據(jù)體內(nèi)離子鈣濃度調(diào)整10%葡萄糖酸鈣泵入速度。分別觀察CRRT前后的血常規(guī):白細(xì)胞(WBC)、血紅蛋白(HB)、血小板計數(shù)(PLT),腎功能:血尿素氮(BNU)、血肌酐(SCr),血清電解質(zhì):鈉(Na)、鉀(K)、氯(Cl)、鈣(Ca),凝血功能:活化部分凝血活酶時間(APTT)、凝血酶原時間(PT),血?dú)夥治?p H值、碳酸氫鹽(HCO3-)、堿剩余(BE)、血乳酸濃度(Lac),代謝方面指標(biāo)及濾器壽命,綜合評價兩種抗凝方案的有效性及安全性。結(jié)果:該研究共納入40例患者,其中肝素組(A組)20例、枸櫞酸組(B組)20例,兩組患者治療前的性別、年齡、體重、APACHEⅡ評分差異無顯著性(P0.05);對治療前A、B兩組的血常規(guī)(WBC、HB、PLT)、凝血功能(APTT、PT)、腎功能(BNU、SCr)、血清電解質(zhì)(Na、K、Cl、Ca)進(jìn)行組間比較,差異均無統(tǒng)計學(xué)意義(P0.05)。A組中WBC、HB、PLT在治療后較治療前下降(P0.05),B組中WBC、PLT在治療后較治療前下降(P0.05);A組活化部分凝血活酶時間(APTT)在治療后較治療前延長(P0.05),而對B組治療前后APTT進(jìn)行統(tǒng)計學(xué)分析,無統(tǒng)計學(xué)差異(P0.05);兩組患者治療后血肌酐(SCr)及血尿素氮(BUN)均較前下降(P0.05),對治療前后下降值進(jìn)行組間比較,兩組患者治療前后血尿素氮下降值有統(tǒng)計學(xué)差異(P0.05),而兩組患者治療前后血肌酐下降值之間比較無統(tǒng)計學(xué)差異(P0.05);兩組患者的血清電解質(zhì)(Na、K、Cl、Ca)在治療前后組內(nèi)比較有統(tǒng)計學(xué)意義(P0.05),B組在治療各時間點(diǎn)的濾器前離子鈣和濾器后離子鈣分別進(jìn)行組內(nèi)比較差異無統(tǒng)計學(xué)意義(P0.05),分別對治療后6h、12h時的濾器前后離子鈣進(jìn)行組間比較,有統(tǒng)計學(xué)差異(P0.05);對兩組血?dú)庵笜?biāo)(p H值、HCO3-、BE、Lac)治療前后分別進(jìn)行組內(nèi)比較,差異有統(tǒng)計學(xué)意義(P0.05);濾器使用壽命用均數(shù)±標(biāo)準(zhǔn)差表示,肝素組為13.9±4.69h,枸櫞酸組為30.2±7.90h,枸櫞酸組濾器壽命長于肝素組,組間比較P=0.047(P0.05),差異有統(tǒng)計學(xué)意義。結(jié)論:1.枸櫞酸組的濾器壽命明顯長于肝素組,枸櫞酸抗凝效果優(yōu)于肝素;2.枸櫞酸對活化部分凝血活酶時間無影響,雖兩組出血并發(fā)癥無統(tǒng)計學(xué)意義,但可認(rèn)為枸櫞酸組在安全性上更有優(yōu)勢;3.枸櫞酸組對腎功能的影響優(yōu)于肝素組。
[Abstract]:Objective: continuous renal replacement therapy (Continuous Renal Replacement Therapy, CRRT) the clinical application is increasing, especially in ICU, ICU has become necessary rescue techniques; renal replacement therapy and the smooth implementation of the anticoagulant effect depends on the extracorporeal circulation pipeline, patients can also anticoagulant effect timely, effective control of key and medical work can be carried out. Everything in good order and well arranged the purpose of this study was to compare two different methods of anticoagulation efficacy and safety in critically ill patients undergoing renal replacement therapy, provide a theoretical basis for clinicians to develop relatively optimal anticoagulation. Methods: the study of cardiovascular intensive care ward of Affiliated Hospital of Yan'an University, Dongguan for CRRT patients, according to anticoagulation is divided into heparin group, citrate group. According to the inclusion and exclusion criteria. Quasi, screened the heparin group 20 cases, 20 cases were citrate group. 8G 20cm double cavity filter for the treatment of patients with blood, through the femoral vein implantation in vitro, flushing piping and filters with saline containing 12 thousand and 500 units of heparin, blood lead connected PRISMA FLEX filter and filter the blood of blood and start, blood lead to priming fluid excreted after the pipeline is connected to the other end to end blood, set the initial blood flow rate was 100-200ml/min, the dilution of 50%, after the replacement liquid was diluted to 50% with conventional medicine in the Dongguan branch of Affiliated Hospital of Yan'an University formula. The heparin group (A group): the first dose of 30IU/Kg, then with 10IU/Kg/h continuous infusion, according to blood coagulation indexes in patients with. Adjust the amount of citric acid group (B group): the study of citrate were used 4% Sodium Citrate Injection for Transfusion (200ml:8.0g). The initial 4% sodium citrate pump speed (ml/h) set to 1.2 times the flow velocity, 10% calcium gluconate pump 閫熶負(fù)4%鏋告┘閰擱挔娉甸，

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