中国急救医学
中國急救醫學
중국급구의학
Chinese Journal of Critical Care Medicine
2015年
9期
849-853,854
,共6页
辛欣%李文雄%赵松%郑悦%黄立锋%隋峰
辛訢%李文雄%趙鬆%鄭悅%黃立鋒%隋峰
신흔%리문웅%조송%정열%황립봉%수봉
连续肾脏替代治疗(CRRT)%抗凝%枸橼酸盐局部抗凝(RCA)%疗效
連續腎髒替代治療(CRRT)%抗凝%枸櫞痠鹽跼部抗凝(RCA)%療效
련속신장체대치료(CRRT)%항응%구연산염국부항응(RCA)%료효
Continuous renal replacement therapy(CRRT)%Anticoagulation%Regional citrate anticoagulation(RCA)%Efficacy
目的：评价枸橼酸盐局部抗凝（ RCA）在连续肾脏替代治疗（ CRRT）中的临床效果与安全性。方法前瞻性收集2012－07～2013－12我院SICU接受CRRT患者的临床资料，包括每次CRRT是否为近期术后，开始CRRT前当天的血小板（ PLT）计数、国际标准化比值（ INR）、活化部分凝血活酶时间（ APTT）、血清尿素氮（ BUN）、肌酐（ Cr）、总胆红素（ TBIL）及急性生理与慢性健康状况评分（ APACHEⅡ）和序贯性器官衰竭评分（ SOFA）等。记录患者的抗凝方式和抗凝剂使用状况、每次CRRT的滤器寿命、出血状况、酸碱平衡失调与电解质紊乱等并发症发生状况。按抗凝方式将CRRT分为无抗凝组、肝素抗凝组和RCA组。采用生存分析比较不同抗凝方式的滤器寿命；采用多重线性回归分析患者基线特征、抗凝方式与滤器寿命的关系；采用Logistic回归分析患者基线特征、抗凝方式与患者出血风险的关系；采用χ2检验比较三组患者CRRT期间出血、血小板减少及代谢性并发症的差异。结果75例危重患者接受了CRRT，共行CRRT 295例次。其中无抗凝组97例次，肝素抗凝组110例次，RCA组88例次。无抗凝组、肝素抗凝组、RCA组的滤器寿命分别为（18．24±1．09）h、（24．53±1．60）h和（27．12±1．55）h，肝素抗凝组和RCA组的滤器寿命显著高于无抗凝组（P＜0．01），但肝素抗凝组与RCA组比较差异无统计学意义（P＞0．05）。显著影响滤器寿命的因素包括抗凝方式和血小板计数，对应的回归系数分别为0．20和0．18（ P＜0．05）。抗凝方式与出血风险无关（OR 3．03，P＞0．05），近期术后是与出血相关的独立危险因素（OR 26．67，P＜0．05）；三组患者中出血、血小板下降及代谢性并发症的发生率差异无统计学意义（P＞0．05）。结论 CRRT期间RCA效果与普通肝素相当，均优于无抗凝组。滤器寿命主要与抗凝方式和基线血小板值有关。近期术后是CRRT期间患者发生出血的独立危险因素，抗凝方式与出血风险和其他并发症的发生率无关。
目的：評價枸櫞痠鹽跼部抗凝（ RCA）在連續腎髒替代治療（ CRRT）中的臨床效果與安全性。方法前瞻性收集2012－07～2013－12我院SICU接受CRRT患者的臨床資料，包括每次CRRT是否為近期術後，開始CRRT前噹天的血小闆（ PLT）計數、國際標準化比值（ INR）、活化部分凝血活酶時間（ APTT）、血清尿素氮（ BUN）、肌酐（ Cr）、總膽紅素（ TBIL）及急性生理與慢性健康狀況評分（ APACHEⅡ）和序貫性器官衰竭評分（ SOFA）等。記錄患者的抗凝方式和抗凝劑使用狀況、每次CRRT的濾器壽命、齣血狀況、痠堿平衡失調與電解質紊亂等併髮癥髮生狀況。按抗凝方式將CRRT分為無抗凝組、肝素抗凝組和RCA組。採用生存分析比較不同抗凝方式的濾器壽命；採用多重線性迴歸分析患者基線特徵、抗凝方式與濾器壽命的關繫；採用Logistic迴歸分析患者基線特徵、抗凝方式與患者齣血風險的關繫；採用χ2檢驗比較三組患者CRRT期間齣血、血小闆減少及代謝性併髮癥的差異。結果75例危重患者接受瞭CRRT，共行CRRT 295例次。其中無抗凝組97例次，肝素抗凝組110例次，RCA組88例次。無抗凝組、肝素抗凝組、RCA組的濾器壽命分彆為（18．24±1．09）h、（24．53±1．60）h和（27．12±1．55）h，肝素抗凝組和RCA組的濾器壽命顯著高于無抗凝組（P＜0．01），但肝素抗凝組與RCA組比較差異無統計學意義（P＞0．05）。顯著影響濾器壽命的因素包括抗凝方式和血小闆計數，對應的迴歸繫數分彆為0．20和0．18（ P＜0．05）。抗凝方式與齣血風險無關（OR 3．03，P＞0．05），近期術後是與齣血相關的獨立危險因素（OR 26．67，P＜0．05）；三組患者中齣血、血小闆下降及代謝性併髮癥的髮生率差異無統計學意義（P＞0．05）。結論 CRRT期間RCA效果與普通肝素相噹，均優于無抗凝組。濾器壽命主要與抗凝方式和基線血小闆值有關。近期術後是CRRT期間患者髮生齣血的獨立危險因素，抗凝方式與齣血風險和其他併髮癥的髮生率無關。
목적：평개구연산염국부항응（ RCA）재련속신장체대치료（ CRRT）중적림상효과여안전성。방법전첨성수집2012－07～2013－12아원SICU접수CRRT환자적림상자료，포괄매차CRRT시부위근기술후，개시CRRT전당천적혈소판（ PLT）계수、국제표준화비치（ INR）、활화부분응혈활매시간（ APTT）、혈청뇨소담（ BUN）、기항（ Cr）、총담홍소（ TBIL）급급성생리여만성건강상황평분（ APACHEⅡ）화서관성기관쇠갈평분（ SOFA）등。기록환자적항응방식화항응제사용상황、매차CRRT적려기수명、출혈상황、산감평형실조여전해질문란등병발증발생상황。안항응방식장CRRT분위무항응조、간소항응조화RCA조。채용생존분석비교불동항응방식적려기수명；채용다중선성회귀분석환자기선특정、항응방식여려기수명적관계；채용Logistic회귀분석환자기선특정、항응방식여환자출혈풍험적관계；채용χ2검험비교삼조환자CRRT기간출혈、혈소판감소급대사성병발증적차이。결과75례위중환자접수료CRRT，공행CRRT 295례차。기중무항응조97례차，간소항응조110례차，RCA조88례차。무항응조、간소항응조、RCA조적려기수명분별위（18．24±1．09）h、（24．53±1．60）h화（27．12±1．55）h，간소항응조화RCA조적려기수명현저고우무항응조（P＜0．01），단간소항응조여RCA조비교차이무통계학의의（P＞0．05）。현저영향려기수명적인소포괄항응방식화혈소판계수，대응적회귀계수분별위0．20화0．18（ P＜0．05）。항응방식여출혈풍험무관（OR 3．03，P＞0．05），근기술후시여출혈상관적독립위험인소（OR 26．67，P＜0．05）；삼조환자중출혈、혈소판하강급대사성병발증적발생솔차이무통계학의의（P＞0．05）。결론 CRRT기간RCA효과여보통간소상당，균우우무항응조。려기수명주요여항응방식화기선혈소판치유관。근기술후시CRRT기간환자발생출혈적독립위험인소，항응방식여출혈풍험화기타병발증적발생솔무관。
Objective To investigate the efficacy and safety of regional citrate anticoagulation in critically ill patients treated with continuous renal replacement therapy ( CRRT ) . Methods A prospective study was conducted on the patients treated with CRRT in our hospital from July 2012 to December 2013.At start of CVVH, baseline data of the patients was collected , including recent surgery, platelets, international normalized ratio (INR), activated partial thromboplastin time (APTT), blood urea nitrogen (BUN) and serum creatinine (Cr), total bilirubin (TBIL),acute physiology and chronic health evaluation ( APACHEⅡ), sequential organ failure assessment ( SOFA).Also, the survival time of the filters , bleeding complication , acid-base imbalance , electrolyte disturbance were recorded during CRRT .Based on different anticoagulation , the CRRT was divided into three groups:non-anticoagulation group , heparin anticoagulation group and regional citrate anticoagulation ( RCA ) group.The survival time of the filters was analyzed among the three groups , the relationship among baseline characteristics , anticoagulation ways and the survival time of the filters was observed by multiple linear regression analysis , and the relationship was analyzed among baseline characteristics , anticoagulation ways and risk for bleeding complication by Logistic regression analysis .The Bleeding complication, thrombocytopenia , metabolic complication were compared with Chi -square statistics between groups.Results 75 critically ill patients who received 295 times of CRRT.Based on different anticoagulation , with 97 times in non-anticoagulation group , 110 times in heparin anticoagulation group and 88 times in citrate anticoagulation group .The survival time of the filters was (18.24 ±1.09) hours in no anticoagulation group, (24.53 ±1.60) hours in heparin anticoagulation group, and (27.12 ± 1.55 ) hours in RCA group .The survival time of the filters was longer in the heparin anticoagulation group and the RCA group than the non -anticoagulation group (P<0.01), and there was no significant differences between heparin anticoagulation group and RCA group .Anticoagulation ways and baseline platelets were significantly associated with the survival time of the filter ,the regression coefficients of the anticoagulation ways and baseline platelets were 0.20 (P<0.05) and 0.18 (P<0.05), respectively. For bleeding risk, no correlation existed between the anticoagulation ways and bleeding risk [OR 3.03, P>0.05].Recent surgery was the independent risk factor in relation to bleeding (OR 26.67, P<0.05 ) .Bleeding complication , thrombocytopenia , metabolic complication were observed no statistically significant differences in three groups ( P>0.05 ) .Conclusion The efficacy of anticoagulation was comparable between the RCA group and the heparin anticoagulation group , but superior to the non -anticoagulation group during CRRT .The survival time of the filters was mainly associated with the anticoagulation ways and baseline platelets .Recent surgery was the independent risk factor in relation to bleeding during CRRT .Additionally , no significant correlation between bleeding complications and the anticoagulation ways was observed .
