改良连续静-静脉血液滤过中局部枸橼酸抗凝的应用

目的探讨应用局部枸橼酸抗凝法(RCA)对高危出血倾向患者行改良连续性静-静脉血液滤过(CVVH)治疗的可行性和安全性.方法将19例(68例次)具有高危出血倾向行CVVH治疗的患者随机分为观察组(34例次)和对照组(34例次).对照组采用传统无肝素生理盐水冲洗法,观察组采用体外局部枸橼酸抗凝法.比较两组患者的出血情况、治疗时间、实际超滤量、各种生化指标及体外循环凝血情况.结果两组透析器凝血、静脉壶凝血情况、治疗前后血肌酐、尿素氮以及治疗时间和实际超滤量比较,差异有显著性意义(P<0.05,P<0.01);观察组治疗前后血清游离钙、钠、碳酸氢根浓度及体外活化凝血时间(ACT)比较,差异无显著性意义(均P>0.05);68例次治疗过程中无1例次发生体外循环凝血,19例患者无1例诱发或加重出血,均未发生并发症.结论应用局部枸橼酸抗凝法对高危出血倾向患者行CVVH治疗安全有效,护理中需注意监测患者各项指标,保证治疗的顺利进行.     

枸橼酸与肝素在连续血液滤过中抗凝效果的比较

目的:比较局部枸橼酸与肝素抗凝在危重患者血液滤过(CVVHDF模式)中的有效性及安全性.方法:对2010年4月-2011年3月我院重症医学科合并有急性肾损伤需要行血液滤过治疗的危重患者进行的前瞻、随机、临床试验.结果:117人次患者(肝素组60人次,局部构橼酸组57人次)最终纳入试验.滤器使用时间分别为肝素组的47.8±18.32小时、局部枸橼酸组的65.04±9.67小时(p＜0.01).结论:在合并有急性肾损伤的危重患者进行血液滤过治疗时,局部枸橼酸抗凝要优于肝素抗凝．     

局部枸橼酸抗凝在高危出血倾向患者血液透析中的应用

目的探讨学生反思日记书写教学方法的可行性．以更好地提高临床学习效果。方法在59名护理本科生进行临床学习过程中．教师对其提出书写1周反思日记的要求,并由同一教师进行反馈．然后自设问卷对学生进行调查。结果47．3%学生认为反思日记书写频率为每周2～3篇为最合适;45．4％学生表示能坚持每周书写;学生最愿意与同学互相交流反思日记;学生认为临床学习来回奔波是阻碍日记书写的最大障碍;而希望对自己的学习有帮助是促进学生反思日记书写的最大动力;56．4％学生喜欢用书面的方式书写;38．2％学生表示喜欢反思日记书写这种教学方法。结论作为一种有效的促进学生学习的方法．学生对反思日记书写能接受。但需要时间和精神的支持;同时教师应详细讲解反思日记的书写方法．不能强迫学生书写：选择合适的反思日记反馈者也是保证有效书写的重要因素。     

改良连续静-静脉血液滤过中局部枸橼酸抗凝的应用

目的探讨家庭式温馨护理环境对精神分裂症患者的影响。方法将80例住院精神分裂症患者随机分为观察组（n=39）和对照组（n=41）。两组患者均给予抗精神病药物治疗，对照组住普通病室，予精神分裂症常规护理；观察组住家庭式温馨单间病房，并实施家庭式温馨护理，内容包括人员培训、营造温馨环境、家属教育干预、实行开放式护理管理等。采用NOSIE、BPRS、SDS、SAS和自制住院患者满意度及家属健康教育知识掌握程度调查问卷进行评价。结果观察组住院1个月时BPRS、SDS、NOSIE、SAS评分与对照组比较，差异有显著性意义（P〈0．05，P〈0．01）；两组满意度、家属健康教育知识掌握程度比较，差异有显著性意义（均P〈0．01）；观察组平均住院时间显著短于对照组（P〈0．01）。结论家庭式温馨护理环境可减轻患者的焦虑、抑郁情绪，提高患者对治疗的依从性，减轻精神症状；可提高患者对医院工作的满意度和家属对疾病相关知识的了解程度；缩短平均住院时间,提高经济效益和社会效益。     

改良式无肝素抗凝在高危出血倾向患者连续性血液滤过中的应用

目的探讨改良式无肝素抗凝在高危出血倾向患者连续性静脉-静脉血液滤过(CVVH)应用中的可行性和安全性。方法采用自身对照法将36例具有高危出血倾向行无肝素CVVH治疗的患者按治疗单、双日分为观察组、对照组。对照组采用传统无肝素抗凝治疗64例次,观察组采用改良式无肝素抗凝治疗64例次。比较两组患者治疗前后临床指标变化、体外循环凝血及治疗后出血并发症情况。结果治疗前、后两组Hb、PT、APTT组内比较,差异无统计学意义(均P>0.05),而PLT和Fbg治疗前后比较,差异有统计学意义(均P<0.05)。两组间Hb、PT、APTT、PLT、Fbg比较,差异无统计学意义(均P>0.05)。两组滤器和静脉壶凝血情况比较,差异有统计学意义(均P<0.01)。两组无一例诱发或加重出血。结论对高危出血倾向患者行改良式无肝素CVVH治疗能起到安全有效的抗凝效果,还可降低滤器和静脉壶凝血发生率。     

枸橼酸抗凝在血液透析中的应用

目的：研究局部枸橼酸抗凝（regional citrate anticoagulation,RCA）在血液透析中的安全性,解决高危出血倾向血液透析中的抗凝问题.方法：选择有高危出血倾向的透析患者37例,透析中用枸橼酸抗凝,输入速度为51 mmol/h,血流量200～230 ml/min.所用透析液的钠离子为135 mmol/L,钙离子1.5 mmol/L,碱基32～34 mmol/L.分别在透析前与透析1 h、2 h、4 h及结束时监测患者透析管路动静脉端全血活化凝血时间（WBACT）、血pH、剩余碱（BE）及血清总钙水平,并记录治疗中的不良反应及体外循环凝血情况.结果：37例患者共行420次透析.透析管路静脉端WBACT较动脉端明显延长,P＜0.001.透析后酸中毒纠正,无碱中毒发生,pH、BE与透析前比较,P＜0.05.透析前后血钙变化无统计学意义.透析器的血室容积下降率均＜20%,无1例发生严重的出血或透析途中凝血现象.结论：RCA具有良好的局部抗凝效果,是解决高危出血倾向患者透析抗凝的理想选择.     

实施简化枸橼酸抗凝后稀释连续性静脉-静脉血液透析滤过治疗时滤后游离钙靶目标校正的研究

目的 在实施简化枸橼酸抗凝、采用连续性静脉-静脉血液透析滤过(continuous veno-venous hemodiafiltration,CVVHDF)模式后稀释的治疗情况下,在当前公认的滤后游离钙目标控制范围内,探究静脉壶及之后体外管路中血游离钙水平是否达标.如未达标,则进一步探讨新的滤后游离钙控制目标设定.方...     

局部枸橼酸抗凝在血液净化治疗中的应用

本文综述了局部枸橼酸抗凝的机理、临床应用以及不良反应的防治,旨在能够更好的将这一方法应用于临床.     

持续性静脉-静脉血液滤过治疗重症急性肾衰竭的临床疗效

2001年6月至2005年12月我们应用血液净化抢救56例重症ARF患者,报道如下。 资料与方法 临床资料：2001年6月至2005年12月我院共收治56例重症急性肾衰竭患者,其中29例行持续性静脉-静脉血液滤过（CVVH组）,27例行间歇性血液透析（IHD组）。CVVH组男16例、女13例,平均年龄（36．1±9．7）岁;IHD组男15例、女12例,平均年龄（35．4±9．5）岁。[第一段]     

Treatment of Acute Renal Failure in the Intensive Care Unit: Lower Costs by Intermittent Dialysis Than Continuous Venovenous Hemodiafiltration

Intermittent and continuous renal replacement therapies (RRTs) are available for the treatment of acute renal failure (ARF) in the intensive care unit (ICU). Although at present there are no adequately powered survival studies, available data suggest that both methods are equal with respect to patient outcome. Therefore, cost comparison between techniques is important for selecting the modality. Expenditures were prospectively assessed as a secondary end point during a controlled, randomized trial comparing intermittent hemodialysis (IHD) with continuous venovenous hemodiafiltration (CVVHDF). The outcome of the primary end points of this trial, that is, ICU and in-hospital mortality, has been previously published. One hundred twenty-five patients from a Swiss university hospital ICU were randomized either to CVVHDF or IHD. Out of these, 42 (CVVHDF) and 34 (IHD) were available for cost analysis. Patients' characteristics, delivered dialysis dose, duration of stay in the ICU or hospital, mortality rates, and recovery of renal function were not different between the two groups. Detailed 24-h time and material consumption protocols were available for 369 (CVVHDF) and 195 (IHD) treatment days. The mean daily duration of CVVHDF was 19.5 ± 3.2 h/day, resulting in total expenditures of €436 ± 21 (21% for human resources and 79% for technical devices). For IHD (mean 3.0 ±  0.4 h/treatment), the costs were lower (€268 ± 26), with a larger proportion for human resources (45%). Nursing time spent for CVVHDF was 113 ± 50 min, and 198 ± 63 min per IHD treatment. Total costs for RRT in ICU patients with ARF were lower when treated with IHD than with CVVHDF, and have to be taken into account for the selection of the method of RRT in ARF on the ICU.     

Effect of Regional Citrate Anticoagulation on Thrombogenicity and Biocompatibility During CVVHDF

This study was designed to assess the principal markers of thrombogenicity and biocompatibility during continuous venovenous hemodiafiltration (CVVHDF) using regional citrate anticoagulation (RCA). In a prospective study, 11 procedures with a polysulfone membrane were performed in nine critically ill patients with acute renal failure and impaired hemostasis. Blood samples were taken before and during CVVHDF at diafilter outlet—before calcium-induced reversal of the effect of citrate—at 15, 60, 360, and 1440 minutes. In four patients, 10 CVVHDF sessions were performed with systemic heparin anticoagulation (HA) using a polyacrylonitrile membrane. During RCA, blood thrombocyte count, plasma thrombin-antithrombin III complexes, beta-thromboglobulin, and von Willebrand factor levels did not differ significantly from baseline. Plasma D dimer levels rose significantly at 360 minutes; however, the difference between diafilter inlet and outlet levels was nonsignificant. There was a significant increase in plasma C5a concentrations and a decline in blood leukocyte count in the early phase of CVVHDF. Just as in RCA, no increase in plasma thrombogenicity indices was observed during HA. However, clotting times in blood entering patients' circulation were significantly prolonged. Plasma C5a concentrations increased significantly at the beginning of CVVHDF. RCA can effectively inhibit the thrombogenic effect of the extracorporeal circuit in CVVHDF. The effect of HA may be similar, however, at the expense of systemic anticoagulation and risk of bleeding. RCA, performed in a way that overcomes thrombogenicity, does not completely eliminate complement activation and/or transient leukopenia during CVVHDF.     

Renal Protective Effects of Early Continuous Venovenous Hemofiltration in Rhabdomyolysis: Improved Renal Mitochondrial Dysfunction and Inhibited Apoptosis

Rhabdomyolysis (RM) and subsequent myoglobin (Mb) deposition can lead to acute kidney injury. Continuous venovenous hemofiltration (CVVH) can remove Mb, but direct renal protection is unclear. We hypothesized that CVVH can improve renal mitochondrial dysfunction in its early stage. Twenty‐four mongrel dogs were randomly divided into four groups: (A) control; (B) model; (C) model + CVVH (50 mL/kg/h); and (D) model + CVVH (30 mL/kg/h). RM was induced by glycerol via intramuscular injection. The dogs were closely monitored for urine flow and renal function. Mb, plasma tumor necrosis factor‐α (TNF‐α), and interleukin (IL)‐6 were measured by enzyme‐linked immunosorbent assay. After 8 h of CVVH, the morphological changes of renal mitochondria were observed and mitochondrial function indicators (reactive oxygen species, malondialdehyde, and respiratory control index) were detected. Western blot analysis was used to detect the expression of Mb, TNF‐α, and IL‐6 in renal tubules. The terminal deoxynucleotidyl transferase‐mediated dUTP‐biotin nick end labeling assay method and Western blot analysis were used to detect apoptosis and apoptosis‐related proteins. In group B, the dog urine output gradually decreased with increased blood creatinine. In groups C and D, the urine output was normal and stable. CVVH effectively eliminated Mb. High‐dose CVVH was significantly better for removal efficiency than low‐dose CVVH. CVVH significantly reduced the deposition of circulating Mb in the kidney in a dose‐dependent manner. The impact of CVVH on TNF‐α and IL‐6 were not observed. The morphological changes of mitochondria and function indicators were significantly improved in group C compared with groups D and B. Compared with group B, renal apoptosis and apoptosis‐related protein expression were inhibited in groups C and D. Group C was significantly better for mitochondrial improvement and apoptosis inhibition than group D. At the cellular and molecular level, CVVH can improve renal mitochondrial function and inhibit cell apoptosis. Early CVVH can protect from RM‐caused renal injuries in a dose‐dependent manner.     

Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation

Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW.