枸橼酸抗凝在连续性静脉—静脉血液滤过中的应用

目的 :研究枸橼酸置换液用于解决高危出血倾向急性肾衰患者行连续性静脉 静脉血液滤过 (CVVH)的抗凝问题。　 方法 :选择高危出血倾向急性肾衰患者 1 0例 ,行CVVH治疗 ,随机分为A、B两组 ,A组患者置换液输入速度 2 0 0 0ml/h ,血流量 2 0 0ml/min ;B组患者置换液输入速度 4 0 0 0ml/h ,血流量 2 50ml/min。两组患者所用枸橼酸置换液不含钙及镁离子 ,枸橼酸根浓度分别为 1 3 3mmol/L和 7mmol/L ,同时通过外周静脉补充钙 (A组 :4mmol/h ,B组 :5 5mmol/h)及镁离子 (A组 :1 3mmol/h ,B组 :2 4mmol/h)。监测患者治疗前后及治疗中全血活化凝血时间 (WBACT)、血清总钙、离子钙水平及酸碱变化 ,滤器使用时间 ,治疗中不良反应。　 结果 :1 0例患者共行CVVH治疗 37次 ,总治疗时间 334 3h。治疗前后及治疗中血清总钙、离子钙没有大幅度变化 ,置换液输入前WBACT无明显变化 ,置换液输入后WBACT明显延长 ,A组比B组更明显 (P =0 0 1 )。治疗后患者碱剩余 (BE)及pH无大幅度上升 ,无碱中毒出现。平均滤器使用时间达 [42 99± 9 1 2 (30 5～ 67 6) ]h。无出血并发症 ,无严重不良反应。　 结论 :枸橼酸置换液在CVVH治疗过程中可取得良好局部抗凝效果 ,对患者全身凝血状态无明显影响 ,不加重全身出血倾向 ,无明显副作用     

重症患者局部枸橼酸抗凝行连续性静脉-静脉血液滤过离子钙浓度的探讨

目的:观察连续性静脉-静脉血液滤过(CVVH)局部枸橼酸抗凝(RCA)参数设置及滤器后钙离子([iCa2+]post-filter)水平与滤器寿命的关系.方法:回顾2016年6月1日至2017年7月31日期间鼓楼医院重症医学科RCA的CVVH患者.设定血流速度和枸橼酸钠速度不变(血流量180 ml/min,4％枸橼酸钠...     

在严重出血倾向重危患者应用枸橼酸抗凝进行连续性静脉-静脉血液滤过治疗

目的：采用枸橼酸抗凝的连续性静脉－静脉血液滤过（CVVH）治疗伴出血倾向的重危患者，观察不同临床情况下枸橼酸抗凝的疗效及安全性。方法：40例伴有出血倾向患者行CVVH治疗，采用枸橼酸抗凝。其中10例患者伴有明显肝功能损害，10例患者伴有低氧血症，其余20例患者不伴有以上两种情况。监测治疗中动脉血气，血清离子钙水平及全血活化凝血时间（WBACT）变化。结果：所有患者CVVH治疗中滤器前WBACT与治疗前相比无显著差异，而滤器后WBACT则显著延长（P＜0．05）。有肝功能损害患者治疗前存在明显代谢性酸中毒，治疗中逐步纠正；持续低氧血症患者CVVH治疗中酸中毒进行性加重；而不伴上述两种情况的患者治疗前无明显代谢性酸中毒，治疗中酸碱状况变化不明显。除伴低氧血症患者治疗中滤器前血清离子钙出现进行性下降外，其余患者治疗中部保持在正常范围。结论：存在肝功能异常患者行CVVH治疗时应用枸橼酸抗凝并无明显低钙血症或酸中毒等代谢并发症，而存在低氧血症患者应用枸橼酸抗凝则可能出现进行性加重酸中毒及低离子钙血症。     

体外局部枸橼酸抗凝在改良床旁血液滤过中的应用

目的:观察体外局部枸橼酸抗凝(RCA)技术在改良床旁血液滤过中的应用效果。方法:实验分为枸橼酸抗凝组(RCA组)和肝素抗凝组(UH组)。RCA组7例,行改良床旁血液滤过30例次,UH组7例,行改良床旁血液滤过32例次。监测活化部分凝血活酶时间(APTT),观察体外循环凝血情况;监测血清Ca2+、尿素氮、肌酐、碳酸氢根等指标。结果:与UH组比较,RCA组体外抗凝效果明显,疗效不受影响;RCA组治疗后APTT较治疗前无明显延长,与UH组比较差异显著(P0.01);2组在体外循环凝血观察无差异。结论:体外局部RCA治疗效果肯定,安全性良好,适合有出血或高危出血倾向患者行床旁血液滤过时抗凝。     

无肝素抗凝技术在连续性静脉-静脉血液滤过中的应用

目的对连续性静脉-静脉血液滤过治疗过程中无肝素抗凝技术进行综合评价。方法2005年1月至4月对四川大学华西医院的42例危重患者行连续性静脉-静脉血液滤过(CVVH)治疗,其中高危出血患者19例采用无肝素技术抗凝,设为观察组;23例采用低分子肝素抗凝,设为对照组(其中3例因故改用无肝素抗凝)。两组置换液速度均为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。结果两组治疗后血尿素氮、肌酐均显著下降,但组间比较溶质下降率差异并无显著性意义(P>0.05),对照组活化部分凝血时间(APTT)显著延长(P<0.05)。观察组跨膜压在7h明显升高,而对照组在9h明显升高;观察组滤器的平均寿命短于对照组(P<0.05)。结论CVVH中应用无肝素抗凝技术同样高效、稳定、安全,对于高危出血患者,是保障CVVH治疗持续进行的重要措施。     

脓毒症与血液灌流联合连续性静脉-静脉血液滤过治疗的研究进展

脓毒症是全球危重症的主要致死原因之一,目前面临着提高抢救成功率、缩短ICU住院时间、降低病死率、减少相关住院费用的巨大挑战。如能通过早期干预和阻断脓毒症患者的一系列炎症级联反应,可以提高脓毒症患者的抢救成功率,缩短ICU住院时间,降低病死率等,对患者和社会均具有重要的社会效益和经济效益。目前研究发现血液灌流联合连续性静脉-静脉血液滤过治疗可能通过更好地清除炎性介质、调节细胞免疫、改善内环境等机制为脓毒症的治疗带来新的希望。该文就其相关研究概况进行综述。     

连续性静脉-静脉血液滤过在重症胰腺炎治疗中的价值

目的 观察在传统治疗重症急性胰腺炎(SAP)的同时行连续性静脉-静脉血液滤过(CVVH)的疗效。方法 53例SAP患者在接受传统治疗的同时行CVVH,每次至少持续24h。监测CVVH前后病情及血清淀粉酶、脂肪酶的变化,行动脉血气分析和APACHlE Ⅱ评分,测血中内毒素水平。结果 CVVH治疗后患者心动过速、呼吸窘迫、腹痛、腹胀等症状明显缓解,APACHEⅡ评分明显降低,淀粉酶、脂肪酶、尿素氮、肌酐明显降低,酸中毒、低氧血症纠正。CVVH治疗6h后,血中内毒素水平下降,24h后又恢复至治疗前的水平。53例患者中38例痊愈出院,存活率为71．7％。结论 在传统治疗SAP的同时行CVVH,能提高抢救的成功率,降低病死率。     

连续性静脉-静脉血液滤过联合血液灌流治疗SIRS疗效观察

目的观察连续性静脉-静脉血液滤过（CVVH）联合血液灌流（HP）治疗全身性炎症反应综合征（SIRS）的疗效。方法将20例SIRS患者随机分为两组,治疗组予CVVH联合HP,对照组单独予CVVH。结果与治疗前比较,两组治疗后体温、心率、白细胞计数及血浆内毒素、细胞因子均明显下降（P〈0．05）,治疗组下降更明显（P〈0．05）。结论CVVH联合HP治疗SIR安全有效。     

连续性静脉-静脉血液滤过在体外循环术后急性肾衰竭中的应用

急性肾衰竭是体外循环术(cardiopul monarybypass,CPB)后严重并发症之一,单纯药物治疗预后较差[1]。2004年1月～2006年12月,我们采用连续性静脉—静脉血液滤过(CVVH)治疗CPB后急性肾衰竭患者6例,效果良好,现报道如下。资料与方法一般资料本组共6例(男5,女1),年龄56～74岁。风湿性心瓣膜病行二尖瓣置换术2例,冠心病冠状动脉搭桥术3例,原位双肺移植术1例。术前肾功能均正常。BUN<2.1mmol/L,Scr<142μmol/L,体外循环时间120～240min。全组于CVVH前均使用速尿5～10mg/kg,但每小时尿量<0.5ml/kg。术后所有患者BUN16～88mmol/L,平均30.8…     

连续性静脉-静脉血液滤过术在毛细血管渗漏综合征治疗中的应用

将60例毛细血管渗漏综合征（CLS）患者随机分为观察组及对照组各30例。两组均予综合治疗,观察组在此基础上行连续性静脉一静脉血液滤过（CVVH）术,监测两组治疗前后中心静脉压（CVP）、平均动脉压（MAP）、每小时尿量及血浆血栓调节蛋白（TM）和血管性血友病因子（VWF）水平变化,比较治疗后5d多脏器功能障碍综合征（NODS）发生率。结果观察组治疗后48hMAP及每小时尿量明显高于对照组（P均〈0．05）;治疗后3d血浆TM、VWF明显低于对照组（P均〈0．05）;治疗后5d脏器衰竭数目及MODS发生率明显低于对照组（P均〈0．05）。认为CVVH可有效改善毛细血管渗漏,使患者顺利度过危险期。     

Continuous arteriovenous hemodialysis and continuous venovenous hemofiltration in burn patients with acute renal failure

Acute renal failure (ARF) is a very common condition that may occur in patients with major burn injuries. The majority of burn patients with ARF have a high mortality rate, ranging from 73% to 100%. There are several ways to treat ARF in burn patients, including peritoneal dialysis (PD), intermittent hemodialysis, and continuous renal replacement therapy (CRRT). CRRT is generally used in patients in whom intermittent hemodialysis has failed to control hypovolemia, as well as in patients who cannot tolerate intermittent hemodialysis. Additionally, PD is not suitable for patients with burns within the abdominal area. For these reasons, most patients with unstable hemodynamic conditions receive CRRT. In this study (conducted in our burn unit between 1997 and 2004), six burn patients received CRRT: three received continuous arteriovenous hemodialysis (CAVHD) and the other three received continuous venovenous hemofiltration (CVVH). The patients were all males, with a mean age of 49.8 years (range, 27-80 years), and a mean burnt surface area of 65.1% (range, 30-95%). Four patients died due to multiple organ failure, and two patients recovered from severe ARF. CRRT has been proven safe and useful for burn patients with ARF. According to this study, we conclude that CVVH is an appropriate tool for treating ARF, with a lower incidence of vascular complications than CAVHD.     

连续性静脉-静脉血液透析滤过治疗慢性肾功能衰竭合并肝性脑病(12例临床分析)

目的：观察连续性静脉血液透析滤过（CVVHDF）治疗慢性肾功能衰竭（CRF）合并肝性脑病的效果。方法：12例CRF合并肝性脑病患者应用Prisma TM机器行CVVHDF治疗，置换液流速800－1200ml/h，透析液流量700－1000ml/h，共治疗72－120h，治疗前及治疗72h后行Glasgow-Pittsburgh评分及Pugh-Child分级。结果：12例患者死亡2例，存活10例，其中1例肾功能恶化需维持性透析；治疗后11例患者清醒；治疗72h后血清总胆红素、间接胆红素、尿素氮、肌酐、尿酸及血氨较治疗前显著降低，高钾血症及低钠血症均得以纠正，Glasgow-Pittsburgh评分及Pugh-Child分级构成比与治疗前相比有显著改善；治疗后1例患者滤器I级凝血。结论：CVVHDF可稳定清除毒素并维持血液动力学稳定，可用于CRF合并肝性脑病患者的治疗。     

Cardiovascular risk in patients with chronic renal failure. Patients in renal replacement therapy

Dialysis patients constitute a high-risk subset of patients for developing cardiovascular disease, which accounts for nearly 50% of deaths. After stratification for age, race and gender, cardiovascular mortality is 10-20 times higher in dialysis patients than in the general population. Cardiovascular disease in this population cannot be fully explained by the high prevalence of classical cardiovascular risk factors (age, hypertension, diabetes, hyperlipidemia, smoking, etc.). Thus, the involvement of "new" cardiovascular risk factors (hyperhomocysteinemia, hyperfibrinogenemia, high lipoprotein (a) levels, oxidative stress, inflammation, etc.), and uremia-related factors (anemia, impaired calcium-phosphorus metabolism, hyperparathyroidism, accumulation of endogenous inhibitors of nitric oxide synthesis, etc.) has been also invoked to play a role in the increased cardiovascular risk in these patients. Endothelial dysfunction is the initial event in the development of atherosclerosis. Uremic patients exhibit an endothelial dysfunction, even before starting dialysis, which persists o is even aggravated under dialysis treatment. Uremic patients must be considered at high risk of developing cardiovascular disease. Thus cardiovascular risk factors in these patients should be managed early, aggressive and multifactorially in order to reduce their high cardiovascular morbidity and mortality.     

Intermittent venovenous haemodiafiltration in critically ill patients with acute renal failure

Various renal replacement therapies have been used for the treatment of acute renal failure in critically ill patients in the last decade. Due to the slower rate of solute and fluid removal, the continuous renal replacement therapies are generally better tolerated than conventional therapy. There is no consensus whether different treatment strategies effect the outcome of critically ill patients and no clear definition of adequacy of renal support in the severely ill patient. Despite their possible benefits, the continuous renal replacement therapies place major demands on the organisation and workload in the dialysis unit. Having taken this into consideration our unit has opted for a ten hours daytime intermittent venovenous haemodiafiltration technique as an alternative for patients in severe conditions of haemodynamic instability, the so-called "go slow" dialysis.     

局部枸橼酸抗凝在肝衰竭患者连续性肾脏替代治疗中的应用

体外抗凝是连续性肾脏替代治疗(CRRT)的一项关键技术,肝素曾是CRRT首选的抗凝剂,但由于出血风险高,临床使用受限。枸橼酸作为一种新型局部抗凝剂,近年来受到越来越多的关注和推荐,但对于肝衰竭患者的应用一直存在争议。通过阅读近年来国内外相关文献,就局部枸橼酸抗凝在肝衰竭患者中的代谢特点、监测方法及其在CRRT应用中的安全性进行综述。     

高浓度枸橼酸钠抗凝在高危出血倾向患者常规血液透析中的应用

目的 探讨高浓度枸橼酸钠在高危出血倾向患者常规血液透析中应用的安全性和可行性。方法 选择72例维持性血透患者用30％枸橼酸钠抗凝常规透析，观察患者透析充分性、凝血情况、不良反应和透析前后的血气、电解质浓度、血钙。与58例常规血液透析患者进行对比分析。结果 所有枸橼酸钠抗凝患者均能完成4小时一5小时的常规血液透析，透析效果充分，与普通肝素抗凝组比较无显著差别；枸橼酸钠抗凝组透析前后血HCO3^-浓度、离子Ca^＋＋、K^＋浓度和Na^＋浓度变化明显（P〈0．0l或P〈0．05），但均在正常范围内，凝血时间无明显变化；枸橼酸钠抗凝组发生透析器和管路凝血例次高于同期常规肝素透析组（P〈0．05）。结论 高浓度枸橼酸钠抗凝用于含钙透析液常规血液透析安全可行，是高危出血透析患者较为理想的透析方式。     

Prostacyclin versus citrate in continuous haemodiafiltration: an observational study in patients with high risk of bleeding

BACKGROUND: The efficacy and safety of prostacyclin (PGI2) and citrate (ACD) anticoagulation were observed and compared during continuous haemodiafiltration. METHODS: Mechanically ventilated patients received either the PGI2 analogue epoprostenol (group A, n = 17) in escalating doses of 4.5-10.0 ng.kg(-1).min(-1) in combination with heparin (6 IU.kg(-1).h(-1)) or 2.2% ACD (group B, n = 15). Blood flow was set to match the circuit-filling volume per unit time equal to the intravascular half-life of PGI2. RESULTS: Median filter lifetimes were 26 h (interquartile range 16-37) in group A (39 filters) and 36.5 h (interquartile range 23-50) in group B (56 filters; p < 0.01). In group A, 4 patients (23.5%, p < 0.05) had the dose reduced due to hypotension. The final mean dose of PGI2 was 8.7 +/- 2.4 ng.kg(-1).min(-1). Four patients in group A (23.5%, p < 0.05) were switched to ACD due to a decrease in platelet count. No bleeding episodes, decrease in platelet count or adverse haemodynamic effects were encountered in group B. The cost of epoprostenol plus low dose heparin (EUR 204.73 +/- 53.04) was significantly higher than the cost of ACD-based anticoagulation (EUR 93.92 +/- 45.2, p < 0.05). CONCLUSION: ACD offers longer filter survival, has no impact on platelet count and is less expensive. Increasing the dose of PGI2 up to the average of 8.7 ng.kg(-1).min(-1) did not increase the haemodynamic side effects.     

无首剂肝素抗凝连续性肾脏替代治疗在高出血风险急性肾损伤患儿中的疗效

目的探讨无首剂肝素抗凝在高出血风险急性肾损伤(acute kidney injury,AKI)患儿实施连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)中的有效性和安全性。方法选择22例行CRRT治疗的高出血风险急性肾损伤患儿,随机分为无首剂肝素抗凝组(11例,行CRRT 33例次)和无肝素组(11例,行CRRT 38例次)。两组均采用持续性静脉-静脉血液透析滤过模式,监测治疗前后血肌酐、凝血功能指标变化。记录患者生命体征、血滤器凝血情况及临床出血事件。结果两组患儿治疗后血肌酐均显著下降,无首剂肝素抗凝组下降明显高于无肝素组[(80.2±8.5)%vs (70.3±10.5)%,P0.05];无首剂肝素抗凝组平均治疗时间为(18.2±6.6) h,无肝素组为(10.5±3.5) h,差异有统计学意义(P0.05)。与治疗前比较,两组患者治疗后凝血功能均无明显变化(均P 0.05)。两组患者治疗过程中生命体征稳定,均无出血事件发生。结论高出血风险急性肾损伤患者行CRRT时,无首剂肝素抗凝模式安全、有效。     

Recombinant activated factor VII in patients at high risk of bleeding

Currently, recombinant activated factor VII (rFVIIa) (NovoSeven) is indicated for the treatment of spontaneous and surgical bleeding in congenital haemophilia A and B patients with inhibitors to factors VIII (FVIII) and IX (FIX) >5 Bethesda units (BU) worldwide, and in patients with acquired haemophilia, congenital FVII deficiency and Glanzmann's thrombasthenia in Europe. Until April 2003, almost three-quarters of a milion doses of rFVIIa have been administered proving its efficacy and excellent safety record. According to results from initial clinical trials and a large number of case reports, the rFVIIa may be effective not only in treating haemophilia patients but also in treatment of bleeding in patients on oral anticoagulation or heparin, patients with liver diseases, von Willebrand disease (vWD), thrombocytopenia, various platelet defects, congenital or acquired deficiency of FVII, and in subjects without any pre-existing coagulopathy with diffuse life-threatening bleeding triggered by surgery or trauma. This review will briefly summarize rFVIIa mode of action in haemostasis, the current clinical experience with rFVIIa and focus on the alternative use of rFVIIa in patients at the high risk of bleeding in both spontaneous cases and clinical trials reports.