不同抗凝技术在连续性静脉-静脉血液滤过中的应用评价

目的 对连续性静脉-静脉血液滤过治疗过程中不同抗凝技术进行评价。方法 选择危重患者48例行连续性静脉-静脉血液滤过（CVVH）治疗，其中出血倾向12例，设为A组，采用局部枸橼酸钠抗凝法；活动性出血者17例，设为B组，采用无肝素抗凝技术；其余患者19例。设为C组，采用低分子肝素钙抗凝。3组置换液速度均为3000ml／h，持续时间12h／d，碳酸氢盐置换液前稀释方式输入。计算溶质下降率，治疗前后检测电解质、酸碱指标、凝血指标；记录心率、平均动脉压、跨膜压及滤器寿命。结果 3组治疗后血尿素氮、肌酐均显著下降，但组间比较溶质下降率差异无显著性（P〉0．05）；电解质、酸碱指标在治疗后均趋于稳定。A、B组各凝血指标在治疗后无显著改变，C组部分凝血活酶时间显著延长（P〈0．05）。整个治疗过程中，3组患者心率、平均动脉压均较稳定。跨膜压明显升高的时间点：A组〉C组〉B组。滤器平均寿命：A组〉C组〉B组（P〈0.05）。结论 CVVH中3种抗凝技术各有优缺点，只有个体化地选择抗凝技术，才能使CVVH更安全有效地应用于危重患者的治疗。     

连续性静脉-静脉血液滤过中采取局部枸橼酸抗凝的价值分析

目的探讨连续性静脉-静脉血液滤过中采取局部枸橼酸抗凝的价值。方法将2011年9月至2015年12月接受治疗的78例行连续性静静脉血液滤过（CVVH）患者纳入本研究。按照入院顺序抽签后随机分为实验组和对照组。观察患者治疗前后血清游离钠、血钠、碳酸氢根浓度、血肌酐、尿素氮水平、治疗时间、实际超滤量以及治疗安全性。结果两组治疗前后血清游离钠、血钠、碳酸氢根浓度比较差异未见统计学意义（P〉0.05）,实验组治疗后血肌酐、尿素氮水平均低于治疗前和对照组,差异有统计学意义（P〈0.05）,对照组治疗后血肌酐、尿素氮水平均低于治疗前,差异有统计学意义（P〈0.05）。实验组治疗时间、实际超滤量均高于对照组,差异有统计学意义（P〈0.05）。实验组治疗安全性高于对照组,差异有统计学意义（χ~2=4.446,P〈0.05）。结论 CVVH过程中,采取局部枸橼酸抗凝,对于患者血清游离钠、血钠、碳酸氢根浓度无明显影响,可改善血肌酐、尿素氮水平,延长治疗时间,增加实际超滤量,安全性较高。     

连续性静脉血液透析滤过在危重病患者中的应用

危重病患者常发生循环衰竭、体液超负荷、肺功能衰竭、脑水肿、肝功能衰竭、急性肾功能衰竭、严重感染等情况，且常处感染性休克于高代谢高分解状态，治疗困难，死亡率高。近年来连续性肾脏替代(CRRT)治疗广泛的应用，     

局部枸橼酸抗凝在连续性静脉-静脉血液滤过中的临床应用分析

分析在连续性静脉-静脉血液滤过之中应用局部枸橼酸抗凝的临床效果。本院将选取从2016年3月~2017年3月需予以连续性静脉-静脉血液滤过患者46例作为分析的主要对象,依照不同枸橼酸的输入方法进行分组,所有患者予以局部枸橼酸抗凝。观察组将枸橼酸盐与置换液分开输入,对照组将枸橼酸盐加入置换液中实现输入,对2种输入方法影响抗凝的效果加以分析,并对其安全性进行评价。观察组滤器使用的时间明显比对照组长,且静脉壶凝血产生比对照组少。统计学分析后,2组间具有统计学意义(P0.05)。而在安全性方面,观察组和对照组对肝功能、凝血功能的影响不明显(P0.05),无统计学意义。对采取连续性静脉-静脉血液滤过的临床患者中,局部枸橼酸抗凝采取枸橼酸盐与置换液分开输入,具有较好的临床效果,不会产生显著副作用,可以进行推广。     

简化局部枸橼酸抗凝在连续性静-静脉血液滤过中的应用

目的 探讨简化局部枸橼酸抗凝(RCA)在连续性静-静脉血液滤过(CVVH)中应用的安全性与有效性.方法 14例患者用简化RCA方法行CVVH治疗,将枸橼酸钠置换液以2 000 ml/h或3 000 ml/h的速度前稀释输入,10%葡萄糖酸钙和25%硫酸镁从外周静脉泵入或滤器静脉端输入;分别于治疗前及治疗后4、8、12 h测定患者血清电解质、血气分析、凝血功能,并观察患者病情变化,测定治疗后滤器容积.结果 14例患者共进行CVVH治疗34例次,治疗时间4～36 h,平均(16.0±7.5)h;30例次未更换滤器完成治疗,治疗后滤器容积(97.19±2.75)ml,均大于原有容积的80%;滤器使用寿命平均(14.79±5.98)h.治疗12 h时患者滤器动脉端采血检测凝血酶原时间(PT)较治疗前明显缩短[(12.2±1.2)s比(14.0±3.3)s],且滤器动脉端血浆总钙明显升高[(2.46±0.30)mmol/L比(2.07±0.36)mmol/L,均P<0.05];而滤器动脉端采血检测活化部分凝血活酶时间(APTT)、凝血酶时间(TT)及Ca2+、Mg2+浓度和pH值、剩余碱(BE)均无明显变化.1例低氧血症患者因严重并发症停止治疗;均未出现高钠血症、碱中毒、出血并发症.结论 将拘橼酸钠加人置换液中的简化RCA方法可以安全用于置换液速度>2 000 ml/h的CVVH;并可避免RCA导致的高钠血症、碱中毒等并发症.     

局部枸橼酸钠抗凝的连续性静脉-静脉血液滤过治疗中患者补钙速度的研究

目的探讨超滤液中钙的清除率,并明确在采用局部枸橼酸钠抗凝的连续性静脉-静脉血液滤过（CVVH）治疗期间,其是否可以作为患者补钙速度的参考指标。 方法55例需要连续性肾脏替代治疗（CRRT）的高危出血风险患者,均接受CVVH治疗模式,拟采取局部枸橼酸钠抗凝（4%枸橼酸钠200 ml/h）。第一阶段采用完全后稀释方式输入,检测血总钙及超滤液总钙浓度,观察超滤液中钙的清除率。第二阶段将正常组和低钙组患者均随机分为全后稀释组、前后1:1稀释组、全前稀释组。在CVVH期间,根据第一阶段实验得出的钙清除比例等量补充钙剂。常规每4 h监测体内血离子钙及滤器后离子钙浓度,并在上机前、上机后6 h和12 h分别检测患者血总钙、超滤液总钙及血离子钙的浓度。 结果（1）治疗时间：每例次平均治疗时间（21.2±5.6）h,无一例患者因体外回路凝血而终止CVVH治疗;（2）第一阶段15例患者超滤液总钙浓度与血总钙浓度比例为85%,其中正常组钙清除率为84.5%,低钙组钙清除率为85.5%,正常组和低钙组的钙清除率与总体钙清除率3组间无统计学差异（F=0.8484,P>0.05）;（3）第二阶段正常组30例患者理论计算所得超滤液钙浓度与实际检测所得超滤液钙浓度比较,全后稀释组、前后1:1稀释组、全前稀释组结果均无统计学差异（t=0.1637,1.103,0.04;P均>0.05）,第二阶段低钙组10例患者理论计算所得超滤液钙浓度与实际检测所得超滤液钙浓度比较,全后稀释组、前后1:1稀释组、全前稀释组结果均无统计学差异（t=0.1968,2.402,0.1818;P均>0.05）;（4）第二阶段正常组30例患者CVVH模式治疗前、治疗后6 h和12 h的体内血总钙浓度比较和血离子钙浓度比较,结果均无统计学差异（F=2.5690,2.8930;P均>0.05）,第二阶段低钙组10例患者CVVH模式治疗前、治疗后6 h和12 h的体内血总钙浓度比较和血离子钙浓度比较,结果均无统计学差异（F=0.7124,1.080;P均>0.05）;（5）CVVH模式治疗期间,正常组30例患者没有血钙异常发生,低钙组10例患者没有出现低钙血症的临床表现且治疗期间体内血离子钙水平正常。 结论在采取局部枸橼酸钠抗凝的CVVH治疗期间,可以根据患者血总钙浓度以及置换液前后补充方式的不同,计算出理论上患者的血钙清除率,并将其作为CVVH治疗时补钙速度的参考依据。     

低分子肝素抗凝、枸橼酸抗凝和无抗凝剂技术在危重病患者实施连续性静脉-静脉血液滤过中的应用

连续性静脉-静脉血液滤过(CVVH)是血液净化治疗中的新技术,以其血流动力学稳定、溶质清除率高、可清除炎性介质和强大的稳定内环境的功能,在危重病患者的抢救中起着极其重要的作用。鉴于危重病患者的出血倾向、抗凝方式的选择及其效果至     

连续性静静脉血液透析滤过在儿童心脏术后急性肾衰竭中的应用

目的探讨连续性静静脉血液透析滤过（CVVHDF）对儿童心脏术后急性肾衰竭（ARF）的治疗效果。方法2004年7月至2008年7月应用PrismaTM机器行CVVHDF治疗11例心脏术后并发ARF患儿。结果11例患者开始CVVHDF治疗时的平均年龄是30.6个月（6个月～12.4岁）,平均体重是15Kg（9.4～30.8Kg）,肾脏替代治疗平均持续时间是62h（10～212h）。术后共8例（72.7%）患者死亡,其中4例在CVVHDF治疗期间死亡,均死于多器官功能障碍综合征（MODS）,并且肾功能未恢复;另外4例中2例死于心力衰竭,1例死于呼吸衰竭,1例死于蛛网膜下腔出血。治疗24h后存活患者血尿素氮（BUN）和肌酐（Scr）均明显降低（P〈0.05）,共7例（63.6%）患儿肾功能恢复。治疗48h后患者平均动脉压（MAP）明显上升,心率（HR）及中心静脉压（CVP）下降（P值均〈0.05）。结论CVVHDF是治疗心内直视术后合并ARF患儿的有效手段,可以改善患者肾功能,稳定血流动力学,但患儿预后仍主要取决于原发病及术后心力衰竭严重程度。     

连续性静脉静脉血液透析滤过在心脏术后多器官功能障碍综合征中的应用

1999年 3月～ 2 0 0 0年 2月 ,我们采用ＣＲＲＴ技术中的一种连续性静脉静脉血液透析滤过 (ｃｏｎｔｉｎｕｏｕｓｖｅｎｏｖｅｎｏｕｓｈｅｍｏｄｉａｆｉｌｔｒａｔｉｏｎ ,ＣＶＶＨＤＦ)用于救治 4例心脏术后并发多脏器功能障碍综合征(ＭＯＤＳ)患者 ,现报道如下。对象和方法1.一般资料 :4例体外循环心脏直视手术后患者 ,ＣＶＶＨＤＦ前血清肌酐均 >32 0 μｍｏｌ/Ｌ ,均需要机械通气治疗 ,并以多巴胺 8～ 10 μｇ·ｋｇ 1·ｍｉｎ 1维持血压 ,3例患者同时还需要离心泵左心转流和主动脉内球囊反搏辅助循环支持。2 .ＭＯＤＳ的诊断标准 :4…     

改良无肝素抗凝方法对高危出血倾向患者连续性静静脉血液滤过治疗的影响

目的探讨改良无肝素抗凝方法对高危出血倾向患者连续性静静脉血液滤过（CVVH）治疗的影响。方法选取36例具有高危出血倾向行无肝素CVVH治疗的患者,共治疗128例次,随机分为观察组及对照组各64例次。对照组采用传统无肝素抗凝治疗,观察组采用改良式无肝素抗凝法治疗,比较2组有效治疗时间、生理盐水冲洗量、净超滤量、滤器和静脉壶凝血及治疗后出血并发症情况。结果2组有效治疗时间、生理盐水冲洗量及净超滤量比较差异均有统计学意义。2组滤器和静脉壶凝血情况比较,差异均有统计学意义。2组无一例诱发或加重出血。结论改良式无肝素抗凝法是高危出血倾向患者CVVH治疗的一种行之有效的血液净化方法,不但能起到安全有效的抗凝效果,还可延长有效治疗时间,减少生理盐水冲洗量,增加净超滤量,降低滤器和静脉壶凝血发生率,减轻护理工作量,节约成本,科学有效的护理配合是治疗成功的保证。     

Pharmacokinetic modeling and dosage adaptation of biapenem in Japanese patients during continuous venovenous hemodiafiltration

The present study examined the pharmacokinetics of biapenem during continuous venovenous hemodiafiltration (CVVHDF) and assessed the pharmacodynamic exposure, based on a pharmacokinetic model, to consider biapenem dosage adaptation in CVVHDF. Biapenem (300 mg) was administered by 2-h infusion to seven critically ill patients receiving CVVHDF. The flow rates were 60 ml/min for blood, 800 ml/h for filtrate, and 600 ml/h for dialysate. The drug concentrations in plasma and filtratedialysate were determined by high-performance liquid chromatography and analyzed pharmacokinetically. The sieving coefficient was 0.92 ± 0.06 (mean ± SD). The simulation curves, using a multicompartment model, were well fitted to the measurements in plasma and filtrate-dialysate. The clearance by CVVHDF and the clearance by non-CVVHDF routes were 1.29 ± 0.08 and 6.14 ± 1.89 l/h, respectively. The multicompartment model was used to assess the pharmacodynamic exposure (time above the minimum inhibitory concentration of 4 μg/ml) in plasma. When the total daily dose was 600 mg, the duration of time was greater at 300 mg every 12 h than at 600 mg every 24 h. The minimum dosages needed to achieve more than 30% of the dosing interval at filtrate-dialysate flow rates of 1.4, 2.8, and 5.6 l/h were 300 mg every 12 h, 600 mg every 12 h, and 600 mg every 12 h, respectively. These results suggested that low doses or increased dosing intervals should be avoided in patients receiving this renal replacement technique. Information on pharmacodynamic exposure obtained from this model may help us to determine the appropriate biapenem dosage for CVVHDF. Moreover, our pharmacokinetic model may be useful for further pharmacokinetic studies of biapenem.     

Augmented teicoplanin clearance through probable adsorption onto a polymethyl methacrylate (PMMA) hemofilter during continuous venovenous hemodiafiltration

Teicoplanin, a glycopeptide antibiotic against Gram-positive bacteria, is used during continuous venovenous hemodiafiltration (CVVHDF), though adsorption onto a hemofilter has been observed in an in-vitro study. We report a case of extensive augmentation of teicoplanin clearance by a polymethyl methacrylate (PMMA) hemofilter. A 74-year-old man (body weight 53 kg) was performed CVVHDF with the PMMA hemofilter. The effluent flow rate maintained at 600–650 mL/h. The measured teicoplanin clearance was 31.0 mL/min, and the clearance was reduced to 11.1 mL/min over the next 6.5 hours. In conclusion, we should closely monitor teicoplanin dosing during CVVHDF using a PMMA membrane hemofilter.     

A novel citrate anticoagulation regimen for continuous venovenous hemodiafiltration

OBJECTIVE: Validation of a novel citrate anticoagulation regimen for continuous venovenous hemodiafiltration (CVVHDF). DESIGN AND SETTING: Prospective cohort trial in medicosurgical intensive care units of two university-affiliated teaching institutions. PATIENTS: Participants were patients at high risk for bleeding, with renal failure requiring CVVHDF without heparin. Fourteen patients completed the study. INTERVENTION: A convection-based citrate anticoagulation CVVHDF regimen using an isotonic replacement fluid containing citrate administered in predilution. A neutralizing solution of calcium chloride and magnesium sulfate was infused at the end of the circuit. Blood flow rate was set and kept at 125 ml/min, and the flow rate of the replacement fluid was initiated at 1250 ml/h and adjusted thereafter according to the monitoring of blood activated coagulation time (ACT), with a target between 180 to 220 s. MEASUREMENTS AND RESULTS: The average filter time-life was 44 h. Thrombosis of the proximal portion of the circuit (which was not anticoagulated) was the main reason for technique failure. A mean urea clearance of 21 ml/min was obtained. Electrolytes and acid-base balance were both well maintained. Six percent (16/287) of Ca(i) readings less than 0.3 mmol/l were associated with very high ACT levels (>300 s). CONCLUSIONS: This regimen is shown to be safe, efficacious, and convenient. Citrate anticoagulation should be monitored using postfilter ACT and/or ionized calcium with respective targets of 200-250 s or 0.3-0.4 mmol/l.     

Incidence and outcome of metabolic disarrangements consistent with citrate accumulation in critically ill patients undergoing continuous venovenous hemodialysis with regional citrate anticoagulation

Background

Systemic citrate accumulation is a complication of regional citrate anticoagulation (RCA) during continuous renal replacement therapy (CRRT). Our objective was to determine the incidence of clinical signs consistent with citrate accumulation in a large and representative cohort of intensive care unit patients undergoing RCA-CRRT.

Methods

Patients treated with RCA-CRRT during 2008-2010 were retrospectively analyzed. Decreased systemic ionized calcium (iCa), increased demand for calcium substitution, elevated total calcium to iCa ratio, and metabolic acidosis were evaluated as indicators for citrate accumulation.

Results

In the 3-year period, 1070 patients were treated with RCA–continuous venovenous hemodialysis. Metabolic signs of citrate accumulation occurred in 32 patients (2.99%, 64.5±14.0 years, 65.6% male, Acute Physiology and Chronic Health Evaluation score 34.2±9.7): systemic iCa decreased to 1.01±0.10 mmol/L with a simultaneous increase of the calcium substitution rate to 129%±26%, and the mean total calcium to iCa ratio increased to 2.51±0.54. All 32 patients had therapy-resistant shock with severe lactic acidosis (pH 7.20±0.11, lactate 136±61 mg/dL), indicating severe intracellular hypoxia. None of the patients survived.

Conclusions

The incidence of disarrangements consistent with citrate accumulation in patients undergoing RCA–continuous venovenous hemodialysis was low, taking place exclusively in patients with severe lactic acidosis due to multiorgan failure. This suggests that the appearance of citrate accumulation is secondary to a severe failure of cellular respiration.     

CVVHDF在老年患者多器官功能衰竭中的应用

目的观察连续性静脉-静脉血液透析滤过（CVVHDF）用于老年多器官功能衰竭（multi-ple organ failure in the elderly,MOFE）患者的临床疗效。方法15例MOFE患者,年龄63～87（72．9±5．6）岁。观察CVVHDF治疗前后患者SIRS指标（体温、心率、呼吸、动脉血二氧化碳分压及外周血白细胞总数）的改变,监测其肾功能、电介质、动脉血气、中心静脉压的变化。结果CVVHDF治疗后患者SIRS反应明显减轻,血管活性药物逐渐减量,13例机械通气患者6例成功撤离呼吸机,3例心跳呼吸骤停患者2例神志转清。血清尿素氮、肌酐、血钾较治疗前显著降低,低氧血症、酸中毒、心衰得到纠正,治疗前、后比较差异有显著性（P〈0．05）。结论CVVHDF治疗MOFE患者,可明显抑制患者SIRS反应,全面改善心肺脑肾功能,是MOFE患者重要的治疗手段之一。     

普通肝素微量持续抗凝治疗进展性脑梗死的对照研究

目的 探讨普通肝素微量持续抗凝治疗急性进展性脑梗死的方法.方法 采用完全随机、平行对照的前瞻性研究方法,选择急性进展性脑梗死患者351例,按随机数字表法分为3组.A组119例采用普通肝素以18 U·kg-1·h-1持续24 h静脉泵入,并根据每8h活化部分凝血活酶时间(APTT)的变化调整剂量;B组115例采用普通肝素12 500 U以18U·kg-1·h-1静脉滴注,每日1次;C组117例采用低分子肝素钙5000U皮下注射,每日2次.14d后观察患者的神经功能缺损程度[用美国国立卫生研究院卒中量表(NIHSS)评分]和出血事件(颅内出血、皮下出血、牙龈出血、尿潜血和粪潜血),随访6个月观察复发率及日常生活质量[ Barthel 指数(B1)].结果 A组总有效率(95.80％)明显高于B组(85.22％)和C组(85.47％),复发率(1.68％)明显低于B组(8.70％)和C组(8.33％),差异均有统计学意义(P＜0.05或P＜0.01);B组与C组比较差异均无统计学意义(均P＞0.05).A组B1(89.27±8.56)明显高于B组(72.57±9.77)和C组(71.66±9.37),差异均有统计学意义(均P＜0.01);B组与C组差异无统计学意义(P＞0.05).A组患者出血事件发生率(5.88％)高于B组(3.48％)和C组(4.27％),但差异无统计学意义(均P＞0.05).结论 普通肝素微量持续静脉泵入可显著减轻进展性脑梗死患者的神经功能缺损程度,增加治愈好转率,降低复发率,提高患者的远期生活质量,出血风险并未增高.     

Anticoagulant regimens in acute continuous hemodiafiltration: a comparative study

Objective To compare and contrast different heparin regimens for extracorporeal circuit anticoagulation in patients receiving acute continuous hemodiafiltration (ACHD).Design Prospective controlled randomized comparisons of the following regimens: 1) Low dose (500 IU/h) prefilter heparin versus regional anticoagulation in patients on continuous arteriovenous hemodiafiltration (CAVHD) via A-V shunt. 2) Low dose pre-filter heparin versus no anticoagulation in patients receiving CAVHD via femoral cannulae. 3) Low dose pre-filter heparin versus regional anticoagulation in patients on continuous veno-venous hemodiafiltration (CVVHD). 4) An assessment of the consequences of the use of no anticoagulant in patients predicted to be at high risk of hemorrhagic complications on treatment with CVVHD.Setting University Teaching Hospital ICU.Patients 64 ICU patients with acute renal failure.Measurements and main results Haemofilter survival during shunt CAVHD was significantly prolonged by the use of regional anticoagulation compared to the use of low dose heparin (mean filter survival: 57.1 h versus 42.9 h;p<0.05). In CAVHD using femoral cannulae, no significant differences in haemofilter survival were found between anticoagulation with low dose heparin and the use of no anticoagulant (mean filter survival: 55 h versus 52.5 h; NS). During CVVHD, regional anticoagulation compared to low dose heparin produced a trend towards prolonged filter life which was, however, not statistically significant (mean filter survival: 40.5 h versus 31.4 h; NS). In patients assessed to be at high risk of bleeding, CVVHD without anticoagulation provided a mean filter survival of 40.9 h (95% CI 27-54.8 h).Conclusions Regional anticoagulation leads to longer filter survival than low dose heparin in shunt CAVHD. A regimen of no anticoagulation during femoral CAVHD leads to a filter life similar to that of low dose heparinization. During CVVHD, regional anticoagulation and low dose heparin are associated with similar filter survival times. In patients assessed to be at high risk of bleeding, treatment with CVVHD without anticoagulation results in adequate filter survival.     

连续静脉-静脉血液滤过时局部枸橼酸钠抗凝初始剂量的探讨

目的初步探讨连续静脉-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)时局部枸橼酸钠抗凝的初始剂量.方法前瞻性分析我院重症医学科2017年2月至2019年1月行CVVH时给予局部枸橼酸钠抗凝的126例患者的临床资料,按照枸橼酸钠的初始剂量将纳入的患者随机分为高剂量组和低剂量组,高剂量组63例,低剂量组63例.对比两组患者在治疗30 min、2h和4h时滤器前压、滤压降、跨膜压,治疗2h和4h时滤器后Ca2+浓度和枸橼酸钠输注速率,同时比较两组患者在治疗前和治疗24h后血小板计数(PLT)、活化部分凝血酶原时间(KPTT)、电解质(Na+、Ca2+、HCO3-)浓度及治疗24h内出凝血相关不良事件情况.结果两组患者在治疗30 min、2h时滤器前压、滤压降和跨膜压比较差异无统计学意义(P>0.05),在治疗4h时两组患者滤器前压比较差异无统计学意义(P>0.05),但滤压降和跨膜压比较差异有统计学意义(P<0.05);按照CVVH前患者是否存在钙离子升高(Ca2+>1.2 mmol/L),分别将两组患者CVVH治疗4h时的跨膜压和滤压降数据进行亚组分析,高钙患者两组跨膜压和滤压降比较差异有统计学意义(P<0.05),而非高钙患者两组跨膜压和滤压降比较差异无统计学意义(P>0.05);两组患者在治疗2h和4h时滤器后Ca2浓度和枸橼酸钠输注速率比较差异有统计学意义(P<0.05);两组患者在治疗前及治疗24 h后PLT、KPTT及动脉血气Na+、HCO3-、Ca2+浓度比较差异无统计学意义(P>0.05);两组患者治疗24h内均无出血事件发生,管路/滤器血栓发生率比较差异有统计学意义(P<0.05).结论在CVVH过程中按照高剂量方案给予枸橼酸钠抗凝更有利于控制血液净化的压力参数,降低体外循环中血栓的发生率.     

Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study

Objective To compare the efficacy and safety of adjusted-dose unfractionated heparin with that of regional citrate anticoagulation in intensive care patients treated by continuous venovenous hemofiltration (CVVH).Design and setting Prospective, randomized, clinical trial in a 32-bed medical and surgical ICU in a university teaching hospital.Patients ICU patients with acute renal failure requiring continuous renal replacement therapy, without cirrhosis, severe coagulopathy, or known sensitivity to heparin.Interventions Before the first CVVH run patients were randomized to receive anticoagulation with heparin or trisodium citrate. Patients eligible for another CVVH run received the other study medication in a cross-over fashion until the fourth circuit.Measurements and results Forty-nine circuits (hemofilters) were analyzed: 23 with heparin and 26 with citrate. The median lifetime of hemofilters was 70 h (interquartile range 44–140) with citrate anticoagulation and 40 h (17–48) with heparin (p=0.0007). One major bleeding occurred during heparin anticoagulation and one metabolic alkalosis (pH=7.60) was noted with citrate after a protocol violation. Transfusion rates (units of red cells per day of CVVH) were, respectively, 0.2 (0.0–0.4) with citrate and 1.0 (0.0–2.0) with heparin (p=0.0008).Conclusions Regional citrate anticoagulation seems superior to heparin for the filter lifetime and transfusion requirements in ICU patients treated by continuous renal replacement therapy.