无肝素抗凝连续性血液净化治疗对脓毒症患者凝血功能的影响

目的 观察无肝素抗凝连续性血液净化治疗对脓毒症患者凝血功能的影响.方法 对27例脓毒症患者行49例次无肝素抗凝连续性血液净化治疗,在治疗前、治疗后及治疗后第3天观察患者急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ评分)及凝血功能相关参数的变化.结果 治疗后凝血酶原时间、活化部分凝血活酶时间均较治疗前延长(P＜0.05),纤维蛋白原下降;连续性血液净化治疗后第3天,APACHEⅡ评分下降,凝血酶原时间、活化部分凝血活酶时间仍延长,与常规治疗组比较差异有统计学意义(P＜0.05).结论 连续性血液净化是治疗严重脓毒症的有效措施之一,能改善患者凝血紊乱状态,其机制可能与多种因素有关.

Abstract：

Objective To evaluate the effect of continuous blood purification(CBP) without anticoagulation on the function of coagulation in the patients with severe sepsis. Methods 49 times CBP without anticoagulation were used in 27 patients with severe sepsis. APACHE Ⅱ score and some parameters of coagulation function in pre-CBP,post-CBP and the 3rd day after CBP were studied and compared. Results TT,APTT were longer in post-CBP and on the 3rd day after CBP than in pre-CBP ( P ＜ 0.05), Fg decreased significantly compared with control group. APACHE Ⅱ after CBP lowered obviously compared with pre-CBP (P＜0.01).Conclusion CBP is one of effective methods for the patients with severe sepsis, and can improve the coagulation function of these patients.     

控制连续性血液净化患者医院感染的规范化管理

目的 探讨规范化管理措施在控制连续性血液净化(CBP)患者医院感染中的作用.方法 对27例行CBP治疗的患者实施规范化管理,即保持环境洁净、加强患者的基础护理、预防血管通路感染、改进操作程序、合理应用抗生素以及加强质量控制.结果 27例中治愈10例,后期转为常规血液透析治疗15例,死亡2例;发生医院感染4例,发生率为14.8%,较上年同期的28.0%明显降低.结论 规范化管理可有效控制CBP患者医院感染的发生.     

连续性血液净化的护理体会

多脏器功能障碍综合征(MODS)是严重创伤、严重感染、外科大手术、病理产科等原发病发生后,同时或序贯出现两个或两个以上系统器官的功能不全或衰竭的临床综合征.继往报道其死亡率高达62.5%～85.0%[1].为了提高MODS的抢救成功率,本院自2002年1月～2004年8月对31例MODS患者应用连续性血液净化治疗(CBP),取得了较满意的疗效,现将护理体会报道如下.     

连续性血液净化治疗多脏器功能障碍综合征

多脏器功能障碍综合征(MODS)是严重创伤、严重感染、外科大手术、病理产科等原发病发生后,同时或序贯出现两个或两个以上系统器官的功能不全或衰竭的临床综合征,病死率较高.我院近年来采用连续性血液净化(CBP)抢救此类患者11例,现报告如下.     

连续性血液净化治疗多脏器功能障碍综合征的护理

多脏器功能障碍综合征(MODS)是严重创伤、严重感染、外科大手术、病理产科等原发病发生后,同时或序贯出现两个或两个以上系统器官的功能不全或衰竭的临床综合征,死亡率高,继往报道的占62.5%～85%[1].本院自2002年2月～2003年8月对重症监护病房收治的11例MODS患者应用连续性血液净化(CBP)治疗,疗效较满意,现将护理体会报道如下.     

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目的 观察连续性高流量血液滤过(HVHF)治疗严重感染伴有多器官功能障碍综合征(MODS)的临床疗效及安全性.方法 2005-2007年中国医科大学附属第一医院收治的20例确诊为产重感染伴有MODS的病人,平均APPACHEⅡ评分为23.8±8.3,平均SOFA评分为10.6±4.0,在常规治疗的基础上应用HVHF治疗至少3d,血流速度250mL/min,超滤量4L/h,置换液以前稀释方式输入,普通肝素抗凝,每24h更换滤器1次.比较治疗前后病人生命体征、血清尿素氮、肌酐、胆红素、动脉血乳酸、血小板、氧合指数及APPACHEⅡ评分和SOFA评分的变化,并监测治疗过程中的并发症.结果 20例病人在HVHF治疗后生命体征迅速稳定,体温、心率、呼吸频率降低,平均动脉压上升,血清尿素氮、肌酐水平下降,动脉血乳酸降低,血小板计数升高,氧合指数改善,APPACHEⅡ评分及SOFA评分降低,与治疗前相比差异具有统计学意义(P＜0.05),血清胆红素水平在治疗后来见明显改善.治疗过程中病人未见严重的离子及酸碱紊乱及其他并发症的发生.结论 连续性HVHF治疗能够降低严重感染伴有MODs病人的全身炎性反应,改善器官功能水平,未见严重并发症的发生,安全有效.     

Nursing care of children suffering from severe hemolytic uremic syndrome treated with plasma exchange and continuous blood purification

目的 探讨血浆置换(PE)联合连续性血液净化(CBP)治疗小儿重症溶血性尿毒症综合征的疗效及护理方法.方法 对11例重症溶血性尿毒症综合征患儿进行PE联合CBP治疗53例次,平均4.7(3～7)次/例.治疗前准确进行护理评估;治疗中密切监护,建立及维护好血管通路,积极防治并发症.结果 8例好转或治愈,2例死亡,1例放弃治疗出院失访.结论 PE联合CBP治疗小儿重症溶血性尿毒症综合征疗效好,密切观察病情及合理的护理措施能保证治疗的安全及有效.     

连续性血液净化治疗在多脏器功能障碍综合征患者中的应用

目的：探讨连续性血液净化(CBP)治疗在多脏器功能障碍综合征(MODS)惠中的疗效。方法：9例伴急性肾衰竭(ARF)的MOD6患，共进行43例次的连续性血液净化治疗，以连续性静脉一静脉血液滤过(CVVH)和连续性静脉—静脉血液透析(CVVHD)为主，根据病情需要加做血浆置换(PE)或血液灌流(HP)。连续性血液净化治疗期间随时监测血压、心率、中心静脉压等生命体征，根据需要检测肾功能、电解质、动脉血气、肝功能等。结果：9例患在连续性血液净化治疗期间，生命体征稳定，血尿素氮、肌酐、血钾等的清除较满意，脱水量均可迭预期目标。连续性血液净化治疗未发生严重副作用。9例患经治疗后2例治愈，1例好转出院，自动出院2例，死亡4例。结论：连续性血液净化是较好的治疗多脏器功能障碍综合征的血液净化方法，在多脏器功能障碍综合征患的抢救中取得了一定的疗效。     

高危出血倾向患者床旁持续血液净化抗凝方法探讨及护理

目的探讨高危出血倾向患者行床旁持续血液净化（CBP）治疗的最佳抗凝方法及护理对策。方法将30例并存高危出血倾向需行CBP的急慢性肾衰竭患者随机分为A、B、C三组，A组9例采用传统的无肝素生理盐水；中洗法抗凝；B组8例采用低分子肝素抗凝法；C组13例在B组的基础上．每6～8小时以肝素盐水冲洗浸泡管路及滤器抗凝。结果3组均未诱发或加重出血，病死率组间比较，差异无显著性意义（P〉0．05）。体外循环凝血情况、24h更换滤器、治疗时间三组比较，差异有显著性意义（均P〈0．01）；两两比较，除B、C组血滤器凝血程度及A、B组更换滤器外。其余各项组间比较，差异有显著性意义（P〈0．01，P〈0．0125，P〈0．05）。结论采用低分子肝素抗凝同时．每6～8小时以肝素盐水冲洗浸泡管路及滤器抗凝是高危出血倾向患者行床旁CBP最佳的抗凝方法。     

高危出血倾向患者床旁持续血液净化抗凝方法探讨及护理

目的 探讨高危出血倾向患者行床旁持续血液净化(CBP)治疗的最佳抗凝方法及护理对策.方法 将30例并存高危出血倾向需行CBP的急慢性肾衰竭患者随机分为A、B、C三组,A组9例采用传统的无肝素生理盐水冲洗法抗凝;B组8例采用低分子肝素抗凝法;C组13例在B组的基础上,每6～8小时以肝素盐水冲洗浸泡管路及滤器抗凝.结果 3组均未诱发或加重出血,病死率组间比较,差异无显著性意义(P＞0.05).体外循环凝血情况、24 h更换滤器、治疗时间三组比较,差异有显著性意义(均P＜0.01);两两比较,除B、C组血滤器凝血程度及A、B组更换滤器外,其余各项组间比较,差异有显著性意义(P＜0.01,P＜0.0125,P＜0.05).结论 采用低分子肝素抗凝同时,每6～8小时以肝素盐水冲洗浸泡管路及滤器抗凝是高危出血倾向患者行床旁CBP最佳的抗凝方法.     

腹腔镜完全腹膜外疝修补术和平片修补术治疗长期使用抗凝药物的腹股沟疝患者的对比研究

目的比较腹腔镜完全腹膜外疝修补术（laparoscopic totally extra-peritoneal,TEP）和局部浸润麻醉下平片修补术治疗长期使用抗凝药物腹股沟疝患者的临床效果。 方法回顾分析2017年4月至2018年4月,中山大学附属第八医院行TEP和平片修补术治疗长期使用抗凝药物的腹股沟疝52例患者的临床资料,按照术式不同分为2组。TEP组25例,平片修补术组27例,随访3～12个月。比较2组手术时间、术后重大心脑血管并发症、术后引流量、血肿或浆液肿、腹股沟神经异常或慢性疼痛、术后复发、术后感染等方面的差异。 结果2组均无重大心脑血管并发症患者,均无复发及感染患者。TEP组和平片修补术组手术时间分别为（55.2±10.3）min和（32.4±4.3）min,血肿或浆液肿发生率分别为7例（28%）和1例（3.7%）,引流量分别为（40.8±8.6）ml和（36.6±5.2）ml,差异有统计学意义（P<0.05）;腹股沟神经异常或慢性疼痛发生率分别为2例（8%）和2例（7.4%）,差异无统计学意义（P>0.05）。 结论对老年腹股沟疝患者,长期应用抗凝药物不是手术禁忌证,做好围手术期处理,选择合适的麻醉和手术方式是治疗成功的关键。     

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??Value of early goal-directed therapy for treatment of surgical patients with severe sepsis DAI Hai-wen, ZHANG Zhao-cai, YAN Jing, et al. Department of Intensive Care Unit, Zhejiang Hospital, Hangzhou 310013, China Corresponding author: YAN Jing, E-mail: zjicu@vip.163.com Abstract Objective To investigate the effect of early goal-directed therapy (EGDT) on surgical patient with severe sepsis. Methods One hundred and seventy-seven surgical patients with severe sepsis admitted between August 2004 and June 2007 at 7 hospitals of Grade III Level A in Zhejiang Province were randomized to conventional treatment group (n=90) and EGDT group (n=87), the former was underwent fluid resuscitation goaled by central venous pressure (CVP), mean artery blood pressure (MBP) or systolic blood pressure (SBP) and urinary output, and the latter was guiding by CVP, MBP or SBP and UO plus central venous oxygen saturation (ScvO2)??The patients were achieved the goals by treating with fluid, transfusions and cardiac stimulants in a period of 6 hours after enrollment. The difference of 28-day survival (primary endpoint), the length of stay in ICU, mechanical ventilation time, antibiotics utilization time, complication of newly infection and clinical scores (secondary endpoints) between the 2 groups was compared. Results In comparison with conventional group, the 28-day survival of EGDT group was increased by 18% (79.3% vs 61.1%, P=0.023), the APACHE II score and MODS score were significantly improved after 6h of EGDT fluid resuscitation (APACHE II: 21.7±5.9 vs 15.4±4.3, P=0.008; MODS: 8.4±3.3 vs 5.1±2.9, P=0.017), there is no difference in other parameters for secondary endpoint (all P>0.05). Conclusion EGDT improved 28-day survival and clinical scores and had beneficial effects on outcomes in surgical patients with severe sepsis.     

Choice of replacement solution and anticoagulant in continuous venovenous hemofiltration

BACKGROUND: Several types of replacement fluid and methods of anticoagulation have been employed for continuous renal replacement therapy, but there is no consensus on a preferred approach. We evaluated the indications for the selection of replacement fluid and anticoagulant among critically ill patients receiving continuous venovenous hemofiltration (CVVH) and assessed the effect of the selection on the efficacy of anticoagulation and complications. METHODS: We retrospectively studied 29 consecutive patients who received CVVH in the Medical Intensive Care Unit at Massachusetts General Hospital. There were 3 types of replacement solution available, an isotonic citrate solution which was also used for regional anticoagulation of the extracorporeal circuit, and bicarbonate and lactate solutions which were used with low-dose heparin or no anticoagulant. Blood flow rate was set at 120 ml/min when citrate replacement fluid was used and at 200 ml/min with bicarbonate or lactate. The replacement fluid was administered proximal to the hemofilter at a constant rate of 1,600 ml/h. RESULTS: There were 22 patients who received citrate replacement fluid which was mainly chosen for the purpose of anticoagulation in the setting of contraindications to heparin. 12 patients received bicarbonate, predominantly when citrate was considered contraindicated due to liver failure or high-anion gap metabolic acidosis, and 2 received lactate; 8 of these 14 patients were anticoagulated with heparin and 6 were managed without anticoagulation. There were 44 filters used in the patients receiving citrate with a median filter life of 42.0 (interquartile range 22.2 - 70.7) hours. Only 8 of the 44 filters were lost due to clotting. Heparin was used for anticoagulation of 17 filters and no anticoagulation was used in the case of 15 filters, resulting in a median filter life of 43.0 (13.5 - 75.0) and 12.0 (4.0 - 33.0) hours, respectively. Clinically significant bleeding occurred in 2 patients, 1 receiving citrate and another receiving heparin. No patient had evidence for citrate toxicity, metabolic alkalosis or hypernatremia. 14 (48.3%) patients survived. CONCLUSIONS: The use of regional citrate anticoagulation of the CVVH circuit appears advantageous in patients with increased risk of bleeding and bicarbonate-based replacement fluid seems desirable in patients with lactic acidosis due to shock and/or severe liver failure. Tailoring the type of replacement fluid and method of anticoagulation to the individual patient leads to long filter lives, excellent metabolic control and minimal complications.     

The Adequacy of Fragmin as a Single Bolus Dose with Reused Dialyzers

Abstract: Thirty-four hemodialysis patients were studied in a crossover fashion to compare the effectiveness of bolus-dose Fragmin (a low molecular weight heparin) with regular heparin usage in hemodialysis. For each anticoagulant, 3 dialyzes were studied for each patient; the first sessions involved a new dialyzer, and the subsequent sessions involved dialyzers reprocessed with peracetic acid. To assess the effectiveness of the anticoagulation regimens, the following were measured: the dialyzer fiber bundle volume and the instantaneous dialyzer clearances for urea (1 h into the second session). In addition, factor Xa levels were measured in 5 patients during the first and second sessions at 0 min, 30 min, and 4 h. Fiber bundle volumes were (in ml) 75.4 ± 8.8, 73.0 ± 8.9, and 73.5 ± 7.6 on first, second, and third uses with Fragmin (p = ns); and 77.8 ± 9.0, 73.4 ± 8.1, and 73.8 ± 8.1 with heparin (p < 0.001 second and third vs. first). Thus, there were no significant differences between Fragmin and heparin. Instantaneous dialyzer clearances were 165.8 ± 12.6ml/min with Fragmin and 163.8 ± 9.8 with heparin (p = ns). Factor Xa levels were 0 predialysis, 0.81 ± 0.17 U/ml at 30 min on first use, and 0.92 ± 0.09 U/ml on second use (p = ns); they were 0.51 ± 0.21 U/ml at 4 h on first use and 0.61 ± 0.16 U/ml on second use (p = ns). Thus, bolus-dose Fragmin provided similar results to constant infusion heparin and is not deleteriously influenced by reprocessing dialyzers with peracetic acid.     

Effects of argatroban as an anticoagulant for haemodialysis in patients with antithrombin III deficiency.

BACKGROUND: In congenital or acquired antithrombin III-deficient patients undergoing haemodialysis, coagulation or residual blood in the blood circuit and dialyser is commonly observed under anticoagulation with heparin. Argatroban, a synthetic thrombin antagonist, directly inhibits thrombin activity in a manner that is different from that of heparin, thereby displaying an anticoagulating effect without the activation of antithrombin III. For this reason, the anticoagulating effect of argatroban in haemodialysis patients with antithrombin III deficiency was investigated. METHODS: A retrospective nationwide survey was conducted among patients with congenital or acquired antithrombin III deficiency who had undergone haemodialysis with argatroban as an anticoagulant from April 1996 to April 2000. Inclusion criteria were patients with antithrombin III activity <70% of normal, and patients in whom blood coagulation or residual blood in the extracorporeal circuit could not be prevented by the use of heparin during haemodialysis. RESULTS: Of 80 patients who underwent haemodialysis with argatroban, 59 met the inclusion criteria. Compared with the data before the administration of argatroban, significant improvements of residual blood in the dialyser and arterial and venous drip chambers were observed at the last administration of argatroban. A significant rise in antithrombin III activity was also observed. Among 80 safety analysis cases, no adverse events were reported in 66 patients (82.5%). As severe adverse events, one showed bleeding tendency and one had prolongation of prothrombin time. CONCLUSION: Argatroban was an effective and safe anticoagulant for haemodialysis in patients with congenital or acquired antithrombin III deficiency.     

Effect of Nafamostat Mesilate on Bradykinin Generation and Hemodynamics During LDL Apheresis

Abstract: Dextran-sulfate (DS) cellulose used for low-density lipoprotein (LDL) apheresis seems to be a weak activator of the contact phase of the intrinsic coagulation pathway because the surface of this substance has negative charges. Heparin, a commonly used anticoagulant, has no effect on this process whereas the process is inhibited by a newly developed anticoagulant, nafamostat mesilate (NM). The effects on bradykinin generation were compared between heparin and NM. Five patients with severe hypercholesterolemia were treated with LDL apheresis using either heparin or NM on a different day. During apheresis with heparin, factor XII, high molecular weight kininogen, and prekallikrein were markedly decreased by passing through the DS column. A distinct generation of bradykinin was observed by passing plasma through the DS column, and this led to the rise of bradykinin levels from 12 ± 5 (mean ± SE) to 72 ± 14 pg/ml after treatment of 1,000 ml of plasma. NM suppressed almost completely the rise of bradykinin levels. Although blood pressure was apt to decrease during apheresis with heparin, there was no significant difference in blood pressure between heparin and NM. Since an angiotensin-converting enzyme inhibitor may lead to a marked rise in blood levels of bradykinin by suppressing its degradation, the use of NM is recommended for apheresis in patients taking this drug.     

HIV/AIDS外科合并症的手术治疗

目的 探讨HIV/AIDS外科合并症的手术风险和价值.方法 对27例HIV感染者(其中男26例,女1例,年龄27～74岁)术前检测免疫功能,规范手术操作程序,精细操作减少手术损伤,对血友病患者术中持续输注VIll因子,常规应用抗生素预防感染,及时处理并发症.结果 一类切口8例,伤口全部一期愈合,二类切口6例,仅1例伤口感染,三类切口13例,其中3例伤口愈合时间超过30 d.术后死于重度脓毒症1例,其他患者康复或好转出院.结论 对HIV感染者采用适当的手术方式和治疗方法可以取得较好的疗效.     

Ancrod: a practical alternative to heparin

To rapidly start systemic anticoagulation there are few alternatives to heparin; those that may be used are often less effective and are impractical substitutes for various reasons. We report the cases of seven patients in whom anticoagulant therapy was begun with ancrod instead of heparin for one or more of the following reasons: (1) failure to achieve systemic anticoagulation in response to heparin (e.g., antithrombin III deficiency), (2) heparin-associated complications (e.g., thrombocytopenia, thrombosis, or both), and (3) combined anticoagulation and improved blood rheology considered to be potentially more beneficial than anticoagulation alone (e.g., massive thrombosis). In the cases reported, ancrod permitted systemic anticoagulation equal to that of heparin; this was achieved without bleeding complications. In contrast to streptokinase or urokinase, ancrod does not degrade preformed, fully cross-linked thrombin fibrin; consequently hemorrhagic complications are uncommon. Ancrod appears to be an appropriate alternative to heparin and may be preferable to it in certain circumstances.