连续性血液净化枸橼酸体外抗凝技术在高危出血患者中的应用

目的研究枸橼酸体外抗凝技术行连续性血液净化(continuous blood purification,CBP)的抗凝效果,解决高危出血倾向患者需行CBP时抗凝难的问题。方法32例高危出血倾向患者随机分为A、B两组,每组16例。均行CBP治疗,均采用枸橼酸抗凝剂为碱基的置换液。A组患者置换液输注速度为2 000 mL/h,血流量200 mL/min,枸橼酸浓度为13.3 mmol/L;B组置换液输注速度为4 000 mL/h,血流量250 mL/min,枸橼酸浓度为7 mmol/L。通过外周静脉补充钙剂。监测患者每日治疗前及结束时全血活化凝血时间(WBACT)、血气分析、血清离子钙及总钙水平。结果32例患者共行CBP治疗112次,总治疗时间1 238.3 h;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、6 h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无大幅度上升,无碱中毒出现;治疗前后血清总钙、离子钙水平无显著变化;不加重全身出血倾向,无其他严重不良反应。结论枸橼酸体外抗凝技术能解决高危出血倾向患者行CBP时抗凝难题。

Application of continuous blood purification with citrate anti-coagulant in patients at high risk of bleeding

Objective To evaluate the efficiency of continuous blood purification(CPB) with citrate anti-coagulant in patients at high risk of bleeding.Methods 32 patients with high risk for bleeding were treated with citrate-based pre-dilution.They were randomly divided into group A(16 cases) and B(16 cases).Blood flow rate was 200mL/min in group A,and 250mL/min in group B.Replacement solution was infused at 2000mL/hr with citrate 13.3mmol/L in group A and 4000mL/hr with citrate 7mmol/L in group B.Calcium gluconate was infused with a separate line.Calcium infusion rate was adjusted according to serum ionized calcium.Serum total calcium,ionized calcium,whole blood activated clotting time(WBACT) and acid-base changes were monitored pre and post-CPB.Complaints of the patients during treatment and each filter were recorded.Results 32 patients had undergone CPB 112 times.The total treatment time was 1238.3h.The levels of WBACT of pre-filter altered little during CPB.The levels of WBACT of post-filter were significantly prolonged compared with pre-filter at 2h,(4h),(6h) in group A and B,respectively.Total serum calcium and ionized calcium showed subtle changes during and post-CPB compared with that during pre-CPB.No metabolic alkalosis was found post-CPB.No bleeding episodes and serious side effects were found in the whole duration of(1238.3) hours of CPB.Conclusion Citrate-based replacement solution at high and low infusion rates during CPB can obtain effective anticoagulation for patients with high risk of bleeding.