血栓弹力图在连续肾替代治疗抗凝检测中的应用

发布时间：2018-03-03 19:27

本文选题：肝素　切入点：抗凝　出处：《河北医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:肝素是目前全球血液净化治疗的主要抗凝剂,传统应用部分凝血酶原时间(Application of partial thromboplastin time,APTT)监测凝血功能调整肝素用量,但患者出血风险和滤器寿命的改善并不理想。快速血栓弹力图(Rapid thromboelastograph,r TEG)是从凝血因子、血小板、纤溶系统功能方面,动态监测全血凝血状态的一种检验方法。本研究应用常规APTT联合快速血栓弹力图评估连续肾替代治疗患者肝素抗凝的效果,指导调整肝素剂量,以改善滤器凝血,降低患者出血风险。方法:本研究选取沧州市中心医院重症医学科在2014年3月---2014年12月收治的应用连续肾替代治疗(continuous renal replacement therapy,CRRT)治疗的患者,排除应用抗凝剂、活动性出血、肝素抗凝禁忌、肝功能衰竭患者,共选取病例40例,随机分为2组,实验组20例应用APTT联合r TEG肝素酶对比试验凝血因子激活时间(active time,ACT)时间缩短率(ACT%)监测抗凝效果调整肝素剂量,对照组20例应用APTT监测抗凝调整肝素剂量。两组患者性别、年龄、体重、治疗前血小板、APTT、水平均无统计学意义(P0.05)。两组均采用CVVH模式,前稀释,置换液量2000ml/h,血流速150ml/min。实验组治疗过程中监测r TEG肝素酶对比实验,了解肝素抗凝效果调整肝素剂量及凝血过程中影响凝血的因素,为抗凝作出指导。对照组依照常规应用APTT调整肝素剂量。两组均记录第一个滤器使用时间,出血情况。患者皮肤新出现淤血、鼻腔粘膜出血、牙龈出血、消化道出血,呼吸道出血,采血部位充分压迫止血后仍出现明显瘀斑为出血倾向。治疗过程中监测跨膜压达到300、报滤器凝血或静脉小壶可见明显凝血块,终止治疗。比较两组间滤器使用时间、肝素用量及出血发生率。结果:实验组滤器时间23.4±3.92h比对照组18.5±3.23h延长有统计学意义(P0.05)。肝素用量实验组17697.5±3255.02U,对照组17700.0±4781.96U无统计学差异(P=0.99)。实验组发生出血倾向2例,对照组5例,出血发生率分别为4.27/1000h和15.97/1000h。结论:血栓弹力图以图形的方式动态检测血块形成的全过程,分析全血粘弹性特点,同时体现了更多的个体化细胞成分及其相互作用的定性分析,能更全面的反映凝血全过程。因此应用血栓弹力图监测连续肾替代治疗患者的凝血状态,可准确反应患者的凝血功能,在影响滤器凝血因素方面提供APTT不能体现的血小板功能。肝素酶对比实验,能提供更好的肝素抗凝效果指导,准确调整肝素剂量,延长滤器使用时间,减轻医疗人员工作负担,增强治疗效果,减少出血并发症,减少由此带来的风险。血栓弹力图是一种实用、有效的监测手段,可作为连续肾替代治疗抗凝监测和指导的良好指标。
[Abstract]:Objective: heparin is the main anticoagulant in global blood purification therapy. The traditional application of partial prothrombin time (Application of partial thromboplastin time APTT) is used to monitor the blood coagulation function and adjust the dosage of heparin. But the risk of bleeding and the improvement of filter life were not ideal. Rapid thromboelastography and TEG were based on coagulation factors, platelets and fibrinolytic system function. In this study, routine APTT combined with rapid thromboelastography was used to evaluate the anticoagulant effect of heparin in patients with continuous renal replacement therapy, and to guide the adjustment of heparin dose to improve the coagulation of filter. Methods: patients treated with continuous renal replacement therapy (CRRT) from March 2014 to December 2014 were selected to exclude the use of anticoagulant and active bleeding. 40 cases of heparin anticoagulant contraindication and hepatic failure were randomly divided into two groups. The anticoagulant effect and heparin dose were monitored by APTT combined with r TEG heparinase contrast test in 20 patients in the experimental group, and 20 patients in the control group were monitored by the anticoagulant effect and heparin dose. The sex and age of the patients in the two groups were compared with those in the control group, and the control group was used to monitor the anticoagulant effect and the dose of heparin in the control group. Body weight, platelet count before treatment were not statistically significant (P 0.05). Both groups were treated with CVVH model, pre-dilution, replacement fluid volume of 2000ml / h, and blood flow velocity of 150ml / min. The contrast experiment of r TEG heparinase was performed in the experimental group during the course of treatment. To understand the anticoagulant effect of heparin in adjusting heparin dose and the factors affecting coagulation during coagulation, and to provide guidance for anticoagulation. The control group was treated with conventional APTT to adjust the dose of heparin. The first filter time was recorded in both groups. Bleeding. New bleeding in the skin, nasal mucosal bleeding, gingival bleeding, gastrointestinal bleeding, respiratory bleeding, The bleeding tendency was still obvious after the full compression of the blood collection site. During the treatment, the transmembrane pressure reached 300, and the filter coagulation or venous jug could be seen, and the treatment was terminated. The time of using the filter between the two groups was compared. Results: the filter time of the experimental group was 23.4 卤3.92h longer than that of the control group (18.5 卤3.23h). The dosage of heparin was 17697.5 卤3255.02U in the experimental group and 17700.0 卤4781.96U in the control group. The incidence of hemorrhage was 4.27 / 1000 h and 15.97% / 1000 h respectively. Conclusion: thromboelastogram can dynamically detect the whole process of blood clot formation, analyze the characteristics of whole blood viscoelasticity, and reflect the qualitative analysis of more individual cell components and their interactions. Thromboelastogram can be used to monitor the coagulation state of patients with continuous renal replacement therapy, and can accurately reflect the coagulation function of the patients. In the aspect of influencing the coagulation factors of filter, we can provide platelet function that APTT can not reflect. The contrast experiment of heparinase can provide better guidance on anticoagulant effect of heparin, adjust the dose of heparin accurately, prolong the use time of filter, and lighten the work burden of medical personnel. Thromboelastography is a practical and effective monitoring method and can be used as a good index for monitoring and guiding anticoagulant therapy of continuous renal replacement therapy.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R459.7

【引证文献】