Regional citrate anticoagulation using a citrate-based substitution solution for continuous venovenous hemofiltration in cardiac surgery patients

OBJECTIVE: To evaluate the feasibility, efficacy, safety and side effects of routinely performed continuous venovenous hemofiltration (CVVH) with regional citrate anticoagulation using a citrate-containing substitution solution as compared with conventional systemic low-dose unfractionated heparin-anticoagulation in postoperative cardiac surgery patients. DESIGN/SETTING: Database review of all patients on CVVH during a three-year period at a cardiovascular intensive care unit of a tertiary referring university hospital. PATIENTS: Patients who had undergone cardiac surgery with acute or chronic renal failure were studied. Thirty-seven citrate CVVH courses in 31 patients (January to November 2000) and 59 heparin CVVH courses in 50 patients (1998 and 1999) had been undertaken postoperatively. Indications for hemofiltration were acute renal failure in 24 and chronic renal failure in 7 of the citrate patients, and acute renal failure in 44 and chronic renal failure in 6 of the heparin patients. INTERVENTIONS: CVVH with either regional citrate anticoagulation using a custom-made citrate-based substitution solution or unfractionated heparin anticoagulation. MEASUREMENTS: The following parameters were measured: median filtration time, hemofilters used per day, differences in creatinine and blood urea levels as opposed to baseline, blood loss within the first 24 h of hemofiltration, incidence of bleeding-related resternotomies, acidosis, and alkalosis. RESULTS: No significant differences in any of the measured parameters were registered. No serious electrolyte imbalance was observed in either group. Furthermore, the two groups did not differ in terms of mortality, duration of stay in the intensive care unit or in hospital, and restoration rate of normal renal function. CONCLUSIONS: We conclude that citrate-based regional anticoagulation is effective, safe and easy to use in CVVH following cardiac surgery and might become the first choice for anticoagulation in patients in whom the application of systemic heparin is contraindicated.     

Regional citrate anticoagulation during continuous hemofiltration in cardiosurgical patients

Different citrate anticoagulation protocols are widely used during continuous renal replacement therapy. The investigation was to study the efficiency and safety of citrate coagulation in patients after cardiovascular interventions. Thirty-eight patients underwent continuous hemofiltration (CHF) with anticoagulation with 0.2% Prismocitrate 10/2 solution by the protocol of the company (Gambra Medical) after operations on the heart and large vessels. The clinical data, changes in azotemia, blood electrolytes and gases, as well as the mean values of citrate anticoagulation, and mean hemofilter life span were studied. The mean duration of citrate anticoagulation was 68 +/- 13.7 hours and its maximum duration wa 18 days. Predilution administration of Prismocitrate 10/2 along with postdilution replacement with routine solutions ensured the CHF dose of 35 ml/kg/hr. But for terminal conditions, volume metabolic control and effective anticoagulation were achieved without negative metabolic sequels and clinical complications. The mean life span of a hemofilter, with its mandatory replacement every 35-48 hours, was 40 hours. It is concluded that Prismocitrate 10/2 anticoagulation is an effective, safe, and easy-to-use method for CHF after cardiosurgical operations, which may be widely recommended when use of heparin is contraindicated.     

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.     

局部肝素抗凝在高危出血倾向患者行血液透析中的应用及护理

目的探讨鱼精蛋白中和的局部肝素化在高危出血倾向患者血液透析中临床应用的有效性和安全性。方法采用自身对照法将44例高危出血倾向的血液透析患者按治疗单、双日分为观察组和对照组。观察组采用鱼精蛋白中和的局部肝素化抗凝血液透析治疗56例次,对照组采用传统的无肝素生理盐水冲洗法血液透析治疗39例次,比较两组患者的出血情况、透析器和静脉壶的凝血情况、治疗时间和超滤量以及透析前后的各项生化指标。结果两组无1例诱发或加重出血,观察组的透析器和静脉壶的凝血情况、治疗时间和超滤量以及透析前后生化指标差值明显优于对照组(P<0.05)。结论鱼精蛋白中和的局部肝素抗凝应用于高危出血倾向患者行血液透析安全有效。     

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     

连续性静脉-静脉血液滤过治疗心脏病术后急性肾功能衰竭的护理

目的:观察连续性静脉-静脉血液滤过(CVVH)治疗心脏病术后急性肾功能衰竭(ARF)的效果,减少护理并发症,提高治疗的安全性和有效性。方法:对53例心脏病术后并发重症ARF患者进行CVVH治疗,观察治疗前后患者MAP,CVP,BUN,Scr,K+等的变化,观察治疗过程中护理并发症发生情况。结果:53例患者经过CVVH治疗后32例存活,15例死亡,6例放弃治疗。存活患者经过CVVH治疗后CVP,Scr,BUN,K+,MAP升高。结论:连续性静脉-静脉血液滤过治疗ARF对于缓解患者临床症状和改善预后是一个有效的治疗手段,治疗过程中科学的护理计划,严密的护理监测和管理是使患者安全及治疗有效的保证。     

静脉静脉血液滤过治疗对心脏术后伴ARF的MODS患者氧化应激的影响

目的 前瞻性观察连续性静脉静脉血液滤过（CVVH）治疗心脏术后伴急性肾衰竭（ARF）的多脏器功能障碍综合征（MODS）患者氧化应激指标的变化。方法 16例心脏术后伴ARF的MODS患者使用HF700型聚砜膜血滤器行CVVH治疗。分别在治疗前和治疗后2,6、12、24和48h取血检测血清丙二醛（MDA）、超氧化物歧化酶（SOD）、谷胱甘肽过氧化物酶（GSH-Px）和总抗氧化能力（TAS）指标的变化，同时对患者进行动态APACHE Ⅲ评分和MODS评分。结果 ①与健康对照组相比，心脏术后伴ARF的MODS患者TAC、SOD升高，GSH-P）（明显下降，MDA显著升高。②心脏术后伴ARF的MODS患者TAC在CVVH治疗2h后明显下降，SOD在治疗6h后明显下降，MDA在治疗24h后明显下降，在上述各时问点后TAC、SOD、MDA随治疗时间延长有不断下降趋势；GSH-Px在CVVH治疗2h后较治疗前明显下降，6h后随治疗时间延长有不断升高趋势，但较治疗前无明显变化。③CVVH治疗2h后，APACHE Ⅲ评分即可改善，并随着治疗时间的延长有不断下降趋势。CVVH治疗24h后，MODS评分获得改善，同时随治疗时间延长有下降趋势。结论 ①心脏术后伴ARF的MODS患者发生了氧化应激。②CVVH能改善心脏术后伴ARF的MODS患者的氧化应激，减轻氧化损伤。③CVVH能改善心脏术后伴ARF的MODS患者的病情。     

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。     

Continuous venous hemodiafiltration with trisodium citrate anticoagulation in cardiac surgery patients

Despite advances in perioperative organ protection during cardiovascular surgery, acute renal failure remains a serious complication. The purpose of this clinical article is to describe the role of continuous renal replacement therapy (CRRT) in proactive maintenance of fluid and electrolyte balance and treatment of acute renal failure in patients following cardiovascular surgery. Implications for nursing practice, education, and future research will be delineated using a case study of a patient who required mechanical circulatory support and CRRT. The complexity of the patient's care was compounded by the need to alter conventional anticoagulation therapy to trisodium citrate.     

低浓度枸橼酸钠局部抗凝血液透析在高危出血尿毒症患者中应用的研究

目的评价低浓度（2．5％）枸橼酸钠局部抗凝血液透析（RCAHD）在高危出血尿毒症患者中应用的效果及安全性。方法采用自身对照将18例高危出血尿毒症患者按治疗单、双日设为观察组与对照组。观察组采用2．5％枸橼酸钠RCAHD36例次,对照组采用无肝素0．9％氯化钠注射液冲洗法HD22例次,观察两组患者在血液透析过程中出、凝血情况,不良反应;透析充分性,活化凝血时间,血气,肾功能与电解质变化。结果观察组静脉壶凝血、透析器血室容积优于对照组（x2分别=36．04、4．56,P均〈0．05）,治疗时间、实际超滤量、透析充分性均优于对照组（t分别=2．73、3．08、2．45,P均〈0．05）;观察组透析管路静脉端各时间点较动脉端相应时间点活化凝血时间明显延长（t=-3．26,P〈0．05）;观察组静脉端血清钙在透析1h、2h、4h时与动脉端比较明显降低（t=-3．12,P〈0．05）;透析1h、2h、4h及结束时,动脉端血pH、剩余碱与透析前比较明显升高（t分别=2．53、2．78,P均〈0．05）。结论低浓度枸橼酸钠局部抗凝效果确切,透析充分,不增加出血风险．是高危出血尿毒症患者行HD安全有效的抗凝方法．     

多器官功能障碍综合征患者行连续性静脉-静脉血液滤过的临床研究

目的探讨连续性静脉-静脉血液滤过（CVVH）对多器官功能障碍综合征（MODS）患者的治疗作用及临床监护要点。方法对22例MODS患者经中心静脉插管留置单针双腔导管,使用BRAUN Diapact CRRT机行CVVH方式治疗。于治疗前后30min抽取静脉血,检测尿素氮（BUN）、血清肌酐（Scr）及血清K^＋的浓度,采用ELISA法测定血浆肿瘤坏死因子α（TNF-α）、自细胞介素1（IL-1）、白细胞介素8（IL-8）,同时抽取动脉血进行血气分析。并对治疗过程中生命体征进行监测。结果所有患者的CVVH治疗过程中生命休征稳定。CVVH后血清BUN、Scr、K^＋均逐渐下降,与治疗前比较差异显著,血浆TNF-α、IL-1、IL-8水平均逐渐降低,与治疗前比较差异显著。结论CVVH能改善血液生化指标,能清除血浆中多种细胞因子,且治疗过程中生命体征稳定,适用于MODS的治疗。     

多器官功能障碍综合征患者行连续性静脉一静脉血液滤过的临床研究

目的 探讨连续性静脉-静脉血液滤过(CVVH)对多器官功能障碍综合征(MODS)患者的治疗作用及临床监护要点.方法 对22例MODS患者经中心静脉插管留置单针双腔导管,使用BRAUN Diapact CRRT机行CVVH方式治疗.于治疗前后30 min抽取静脉血,检测尿素氮(BUN)、血清肌酐(Scr)及血清K+的浓度,采用ELISA法测定血浆肿瘤坏死因子α(TNF-α)、白细胞介素1(IL-1)、白细胞介紊8(IL-8),同时抽取动脉血进行血气分析.并对治疗过程中生命体征进行监测.结果 所有患者的CVVH治疗过程中生命体征稳定.CVVH后血清BUN、Scr、K+均逐渐下降,与治疗前比较差异显著,血浆TNF-α、IL-1、IL-8水平均逐渐降低,与治疗前比较差异显著.结论 CVVH能改善血液生化指标,能清除血浆中多种细胞因子,且治疗过程中生命体征稳定,适用于MODS的治疗.     

低分子肝素钠与枸橼酸钠对血液透析在高危出血风险患者中的临床对比观察

目的 探讨在接受常规血液透析的高危出血倾向患者中应用构橼酸透析管路局部抗凝对出凝血指标的影响,评价其安全性.方法 选择2018年05月～2020年05月入本院行维持性血液透析伴高危出血倾向患者共96人,随机分为对照组和观察组,每组各48人.对照组采用普通肝素全身抗凝,观察组采用枸橼酸钠体外透析管路局部抗凝.比较2组体内...     

高容量连续性静脉-静脉血液滤过对多器官功能障碍综合征患者外周血细胞因子的影响

目的　应用高容量连续性静脉 静脉血液滤过 (Hv -CVVH)技术 ,探讨其对多器官功能障碍综合征 (MODS)患者外周血细胞因子的影响。方法　 2 0例非创伤性MODS患者经中心静脉插管留置单针双腔导管 ,使用BaxterBM2 5机器行Hv CVVH方式治疗。于治疗前和治疗后 2、 4、 6、 8h时分别抽取静脉血 ,采用ELISA法测定血浆肿瘤坏死因子α (TNF -α)、白细胞介素 1(IL - 1)、白细胞介素 6 (IL - 6 )、白细胞介素 8(IL - 8)的含量 ,并在每日早晨抽取静脉血检测Bun、Scr、K+ 的浓度 ,同时抽取动脉血作血气分析。结果　所有患者的Hv CVVH后血清Bun、Scr、K+ 均逐渐明显下降 (P <0 0 5或P <0 0 1) ,血浆TNF -α、IL - 1、IL - 8水平均逐渐降低 (P <0 0 5 ) ,血浆IL 6水平在CBP前后均无统计学差异 (P >0 0 5 )。结论　Hv CVVH能清除MODS患者血浆中多种细胞因子 ,并改善血液生化指标 ,因此可以用于MODS的治疗     

连续性静脉-静脉血液滤过治疗血液透析伴发顽固性高血压患者的临床研究

目的 探讨连续性静脉-静脉血液滤过(CVVH)治疗血液透析患者伴发顽固性高血压的短期临床疗效及其可能的机制.方法 选择2005年以来在我院进行血液透析伴发顽固性高血压患者34例作为治疗组,经过2～3次、每次8～10 h的CVVH治疗,观察其降压效果和治疗前后干体重、血浆甲状旁腺激素(PTH)、肾素(RA)及血管紧张素Ⅰ、Ⅱ(AT Ⅰ、ATⅡ)和醛固酮(Ald)水平的变化.另外选择同期血压控制良好的血液透析患者30例作为对照组.结果 (1)治疗组所有患者经过2～3次的CVVH治疗,血压均较治疗前有明显下降,显效率64.7%,有效率100.0%;(2)治疗组治疗前与对照组比较,血浆RA[分别为(1.10±0.25)、(0.78±0.26)μg(L·h)]、AT Ⅰ[分别为(0.89±0.21)、(0.52±0.14)μg/L]、ATⅡ[分别为(177.68±89.46)、(89.25±12.84)]ng/L、Ald[分别为(72.06±11.47)、(48.92±8.65)ng/L]和PTH[(306.81±69.37)、(248.76±134.62)ng/L]水平均明显升高(P均＜0.01);(3)治疗组CVVH治疗后与治疗前比较,血浆RA[分别为(0.76±0.17)、(1.10±0.25)μg/(L·h)]、AT Ⅰ[分别为(0.50±0.12)、(0.89±0.21)μg/L]、ATⅡ[分别为(87.13±14.22)、(177.68±89.46)ng/L]、Ald[分别为(46.01±9.86)、(72.06±11.47)ng/L]和PTH(186.53±32.93)、(306.81±69.37)ng/L]水平均明显下降(P均＜0.01);而对照组常规血液透析治疗前后上述指标无明显变化(P均＞0.05).结论 CVVH不失为治疗血液透析伴发顽固性高血压的一种有效方法,其降压效果可能与CVVH能有效清除患者体内多余水分以及降低血浆RA、AT Ⅰ、ATⅡ、Ald、PTH水平有关.

Abstract：

Objective To study the short-term clinical efficacy and its possible mechanism of refractory hypertension(RH) treated by continuous veno-venous hemofiltration (CVVH) in maintenance hemodialysis (MHD) patients. Methods Thirty-four MHD patients with RH treated with CVVH enrolled in the treatment group,all these patients were treatment of 2 -3 times,each time 8 - 10 hours. Thirty MHD patients with wellcontroled blood pressure were recruited as control. Changes of blood pressure, dry weight, plasma levels of parathyroid hormone (PTH), renin ( RA), angiotensin Ⅰ , Ⅱ ( AT Ⅰ , AT Ⅱ ), aldosterone ( Ald ) were observed before and after hemodialysis. Results In the treatment group,compared with pre-treatment, the blood pressure decreased significantly with an effective rate of 64.7% and efficient rate of 100. 0%. Before treatment, plasma RA was ([1.10 ±0.25] μg/(L · h)and [0:78 ±0.26] μg/(L · h),AT Ⅰ was [0.89 ±0.21] μg/L and [ 0. 52 ± 0. 14 ] μg/L, AT Ⅱ was [ 177.68 ± 89.46 ] ng/L and [ 89. 25 ± 12. 84 ] ng/L, Ald was [72. 06 ± 11.47 ]ng/L and [ 48.92 ± 8. 65 ] ng/L, PTH was [ 306. 81 ± 69. 37 ] ng/L and [ 248.76 ± 134. 62 ] ng/L in the treatment and control group respectively. All the measurements in the treatment group were significantly higher than those in the control group (P ＜ 0. 05 ). In the treatment group, compared to pre-treatment, plasma RA significantly decreased ( [ 1.10 ± 0. 25 ]μg/ ( L · h) vs [ 0. 76 ± 0. 17 ] μg/( L · h ), as well as AT Ⅰ ( [ 0. 89 ±0.21]μg/L vs [0.50 ±0.12] μg/L),ATⅡ([177.68±89.46]ng/L vs [ 87.13±14.22] ng/L),Ald ([72.06±11.47]ng/Lvs [ 46. 01± 9. 86 ] ng/L ) and PTH ( [ 306. 81 ±69.37]ng/L vs [ 186.53 ±32.93 ] ng/L) ( P ＜ 0. 05 ). However, there was no significant changes in the above mentioned measurements between before and after hemodialysis in the control group (P ＞ 0. 05). Conclusion CVVH may be an effective methods in the treatment of MHD patients with RH, and its antihypertensive mechanisms may be that CVVH can effectively remove the excess water in the body, and reduce plasma RA, AT Ⅰ , AT Ⅱ ,Ald and PTH levels.     

连续性静-静脉血液滤过患者延长美罗培南静脉输注时间的药代动力学研究

目的 探讨连续性静-静脉血液滤过(CVVH)患者延长美罗培南静脉输注时间的药代动力学特点.方法 10例CVVH患者给予美罗培南500 mg静脉输注,输注时间3h,6h给药1次.第4次开始给药前即刻(0 h)及给药后0.25、0.5、1、1.5、2、3、4、5、6h(下一次给药前即刻)留取血液标本,用高效液相色谱法测定血药浓度,并绘制血药浓度-时间曲线.结果 CVVH患者延长美罗培南输注时间至3h的药物峰浓度(Cmax)达(25.05±5.64)mg/L,至6h达谷浓度(Cmin)为(13.03± 3.01)mg/L,血药浓度曲线下面积(AUC)为(118.42±26.78)mg· h-1· L-1,药物清除半衰期(T1/2)为(3.74±0.55)h,药物平均滞留时间(MRT)为(4.99±0.84)h,药物表观分布容积(Vd)为(22.85±9.85)L,药物清除率(CL)为(4.49±1.32)L/h.10例患者血药浓度大于最低抑菌浓度(MIC)的时间占给药间隔时间的百分比(％T＞MIC)均达到100％(MIC 8 mg/L).结论 CVVH患者应用美罗培南500 mg,6h给药1次,延长输注时间至3h,可达到满意的药效学指标.     

Hemostasis during low molecular weight heparin anticoagulation for continuous venovenous hemofiltration: a randomized cross-over trial comparing two hemofiltration rates

Introduction  

Renal insufficiency increases the half-life of low molecular weight heparins (LMWHs). Whether continuous venovenous hemofiltration (CVVH) removes LMWHs is unsettled. We studied hemostasis during nadroparin anticoagulation for CVVH, and explored the implication of the endogenous thrombin potential (ETP).