预冲式枸橼酸钠抗凝技术在连续性血液净化高危出血患者中的应用

目的观察局部枸橼酸抗凝在连续性血液净化中的应用效果，探讨高危出血倾向患者进行连续性血液净化时的安全性和有效性。方法选择67例高危出血倾向的患者随机分为2组：局部枸橼酸抗凝组（RCA组）43例，行血液净化106例次；对照组24例，行无肝素血液净化87例次。监测全血ACT（活化凝血时间）、观察体外循环凝血情况；监测血清游离钙、枸橼酸、血钠、碳酸氢根浓度；监测血尿素氮、肌酐、治疗时间、实际超滤量等。结果RCA组：置换液输入前WBACT与治疗前差异不显著，输入置换液后两组滤器后WBACT（s）较滤器前在2、4、6h各时间点的延长均有显著性差异（P〈0．01）；治疗后患者碱剩余（BE）及PH值无大幅度上升，无碱中毒出现；体内ACT较治疗前无明显延长。两组滤器凝血、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）；未发生高钠血症和代谢性碱中毒并发症。结论连续性血液净化治疗时，局部预冲式枸橼酸抗凝体外抗凝效果确切，对体内凝血功能无明显影响；并发症少，可以在临床推广应用。

Application of continuous veno-venous blood purification with citrate based replacement solution to renal failure patients at high risk of bleeding

Objective To evaluate the anticoagulation effect of citrate based continuous veno-venous blood purification in patients with renal failure at high risk of bleeding and metabolic complications. Methods Sixty-seven patients at high risk of bleeding with contraindications of heparin anticoagulation were randomly divided into regional citrate anticoagulant （RCA）group （n= 43） and control group （n= 24）. Serum total calcium, ionized calcium, whole blood activated clotting time（WBACT） and acid-base changes were monitored pre,during,and post-CVVH. Complains of the patients during treatment and the life span of each filter were recorded. Results In RCA group, the WBACTs of pre-filter altered little during continuous veno-venous blood purification, but the WBACTs of post-filter showed obvious prolongation as compared with pre-filter （P〈0. 01） ,and during 2,4,8 hours. The filter blood clotting, Crea and Urea levels, treatment time and ultrafiltration were significantly different between the two groups （P〈0.05,P〈0. 01）. No bleeding episode, metabolic alkalosis, hypernatremia and serious side effects were found in the RCA group. Conclusion Citrate-based and calcium, magnesium free replacement solution at high and low infusion rates during continuous veno-venous blood purification can obtain effective anticoagulation, and shows little side effect on systemic coagulation. It deserves wide application clinically