对比两种抗凝方式在危重患者行肾脏替代治疗时的安全性及有效性

发布时间：2018-01-05 01:17

  本文关键词：对比两种抗凝方式在危重患者行肾脏替代治疗时的安全性及有效性　出处：《延安大学》2016年硕士论文　论文类型：学位论文

  更多相关文章： 连续性肾脏替代治疗 持续性静-静脉血液滤过 枸橼酸 肝素 抗凝

【摘要】：目的:连续性肾脏替代治疗(Continuous Renal Replacement Therapy,CRRT)技术在临床中的应用日益增多,尤其是重症监护室,现已成为重症监护室中必备抢救技术;而肾脏替代治疗能否顺利实施,依赖于体外循环管路的抗凝效果,抗凝效果同时也是患者病情能否得到及时、有效控制以及医疗工作能否有条不紊进行的关键。本研究旨在比较两种不同抗凝方式在危重患者行肾脏替代治疗时的安全性及有效性,为临床医师制定相对优化的抗凝方案提供一定的理论依据。方法:对延安大学附属医院东关心脑血管病区重症监护室行CRRT的患者进行研究,根据抗凝方案分为肝素组、枸橼酸组。根据纳入、排除标准,筛选出肝素组20例、枸橼酸组20例。入选患者行该治疗时均选择8G 20cm双腔血滤管,经股静脉置入,用含1.25万单位肝素的生理盐水冲洗体外管路及滤器后,连接PRISMA FLEX血滤机与血滤管的引血端,并开始引血,将预充液排出体外后将管路另一端连接到回血端,设置初始血流速为100-200ml/min,采用前稀释50%、后稀释50%,置换液均采用延安大学附属医院东关分院重症医学科常规配方。肝素组(A组):首次剂量30IU/Kg,随后以10IU/Kg/h持续泵注,根据患者凝血指标调整用量。枸橼酸组(B组):研究中枸橼酸均采用4%枸橼酸钠抗凝剂(200ml:8.0g)。初始4%枸橼酸钠泵速(ml/h)设置为血流速度的1.2倍,10%葡萄糖酸钙泵速为4%枸橼酸钠泵速的7.3%,根据滤器后离子钙浓度及时调整枸橼酸泵入速度,根据体内离子钙浓度调整10%葡萄糖酸钙泵入速度。分别观察CRRT前后的血常规:白细胞(WBC)、血红蛋白(HB)、血小板计数(PLT),肾功能:血尿素氮(BNU)、血肌酐(SCr),血清电解质:钠(Na)、钾(K)、氯(Cl)、钙(Ca),凝血功能:活化部分凝血活酶时间(APTT)、凝血酶原时间(PT),血气分析:p H值、碳酸氢盐(HCO3-)、碱剩余(BE)、血乳酸浓度(Lac),代谢方面指标及滤器寿命,综合评价两种抗凝方案的有效性及安全性。结果:该研究共纳入40例患者,其中肝素组(A组)20例、枸橼酸组(B组)20例,两组患者治疗前的性别、年龄、体重、APACHEⅡ评分差异无显著性(P0.05);对治疗前A、B两组的血常规(WBC、HB、PLT)、凝血功能(APTT、PT)、肾功能(BNU、SCr)、血清电解质(Na、K、Cl、Ca)进行组间比较,差异均无统计学意义(P0.05)。A组中WBC、HB、PLT在治疗后较治疗前下降(P0.05),B组中WBC、PLT在治疗后较治疗前下降(P0.05);A组活化部分凝血活酶时间(APTT)在治疗后较治疗前延长(P0.05),而对B组治疗前后APTT进行统计学分析,无统计学差异(P0.05);两组患者治疗后血肌酐(SCr)及血尿素氮(BUN)均较前下降(P0.05),对治疗前后下降值进行组间比较,两组患者治疗前后血尿素氮下降值有统计学差异(P0.05),而两组患者治疗前后血肌酐下降值之间比较无统计学差异(P0.05);两组患者的血清电解质(Na、K、Cl、Ca)在治疗前后组内比较有统计学意义(P0.05),B组在治疗各时间点的滤器前离子钙和滤器后离子钙分别进行组内比较差异无统计学意义(P0.05),分别对治疗后6h、12h时的滤器前后离子钙进行组间比较,有统计学差异(P0.05);对两组血气指标(p H值、HCO3-、BE、Lac)治疗前后分别进行组内比较,差异有统计学意义(P0.05);滤器使用寿命用均数±标准差表示,肝素组为13.9±4.69h,枸橼酸组为30.2±7.90h,枸橼酸组滤器寿命长于肝素组,组间比较P=0.047(P0.05),差异有统计学意义。结论:1.枸橼酸组的滤器寿命明显长于肝素组,枸橼酸抗凝效果优于肝素;2.枸橼酸对活化部分凝血活酶时间无影响,虽两组出血并发症无统计学意义,但可认为枸橼酸组在安全性上更有优势;3.枸橼酸组对肾功能的影响优于肝素组。
[Abstract]:Objective: continuous renal replacement therapy (Continuous Renal Replacement Therapy, CRRT) the clinical application is increasing, especially in ICU, ICU has become necessary rescue techniques; renal replacement therapy and the smooth implementation of the anticoagulant effect depends on the extracorporeal circulation pipeline, patients can also anticoagulant effect timely, effective control of key and medical work can be carried out. Everything in good order and well arranged the purpose of this study was to compare two different methods of anticoagulation efficacy and safety in critically ill patients undergoing renal replacement therapy, provide a theoretical basis for clinicians to develop relatively optimal anticoagulation. Methods: the study of cardiovascular intensive care ward of Affiliated Hospital of Yan'an University, Dongguan for CRRT patients, according to anticoagulation is divided into heparin group, citrate group. According to the inclusion and exclusion criteria. Quasi, screened the heparin group 20 cases, 20 cases were citrate group. 8G 20cm double cavity filter for the treatment of patients with blood, through the femoral vein implantation in vitro, flushing piping and filters with saline containing 12 thousand and 500 units of heparin, blood lead connected PRISMA FLEX filter and filter the blood of blood and start, blood lead to priming fluid excreted after the pipeline is connected to the other end to end blood, set the initial blood flow rate was 100-200ml/min, the dilution of 50%, after the replacement liquid was diluted to 50% with conventional medicine in the Dongguan branch of Affiliated Hospital of Yan'an University formula. The heparin group (A group): the first dose of 30IU/Kg, then with 10IU/Kg/h continuous infusion, according to blood coagulation indexes in patients with. Adjust the amount of citric acid group (B group): the study of citrate were used 4% Sodium Citrate Injection for Transfusion (200ml:8.0g). The initial 4% sodium citrate pump speed (ml/h) set to 1.2 times the flow velocity, 10% calcium gluconate pump 閫熶负4%鏋告┘閰搁挔娉甸，

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