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目的研究局部枸橼酸抗凝(RCA)与全身肝素抗凝在围术期重症患者持续静脉-静脉血液滤过(CVVH)中的效果及安全性。方法回顾性分析192例进行CVVH的围术期重症患者的资料,其中全身普通肝素抗凝CVVH组(以下简称肝素组)98例,RCA-CVVH组(以下简称RCA组)94例。比较两组患者在滤器寿命、血滤终止原因及内环境影响、肝功能影响及临床出血并发症等方面的差异。结果肝素组平均滤器寿命比RCA组明显要短[(21.60±8.76)小时vs(65.75±10.17)小时],而两组导致CVVH终止的原因中由滤器凝血导致CVVH被迫终止的分别为76.5%和9.2%,因治疗达到目标选择性终止CVVH的为8.4%和63.8%,因其他治疗需要终止CVVH的为5.1%和17.0%。内环境变化方面,两组患者在代谢性碱中毒、低钙血症、高钠血症、肝脏功能变化方面差异无显著性。枸橼酸中毒在RCA组发生率仅为2.13%,临床出血情况肝素组高于RCA组(15.3%vs 5.3%)。结论 RCA-CVVH对于出血风险高的围术期重症患者来说是一种安全、有效的肾脏替代治疗方式,特别是在延长滤器寿命方面具有优势,而在内环境、肝功能损害无明显差别,与肝素抗凝相比能减少出血并发症。
Objective To investigate the efficacy and safety of local citrate anticoagulation (RCA) and systemic heparin anticoagulation in patients with severe venous-venous hemofiltration (CVVH) during perioperative period. Methods The data of 192 patients with perioperative severe CVVH were retrospectively analyzed. Among them, 98 cases were treated with unfractionated heparin anticoagulation CVVH group (hereinafter referred to as heparin group), 94 cases were RCA-CVVH group (hereinafter referred to as RCA group). The differences in the life span of the filter, the causes of the termination of the hemofiltration, the influence of the internal environment, the effects of liver function and the complication of clinical bleeding were compared between the two groups. Results The mean filter life in the heparin group was significantly shorter than that in the RCA group [(21.60 ± 8.76) hours vs (65.75 ± 10.17) hours], while CVVH forced termination by coagulation in the two groups was 76.5% And 9.2%, respectively, with selective treatment of CVVHs ending at 8.4% and 63.8% due to treatment goals and 5.1% and 17.0% of other treatments requiring termination of CVVH. Changes in the internal environment, the two groups of patients in the metabolic alkalosis, hypocalcemia, hypernatremia, liver function was no significant difference. The incidence of citrate poisoning in RCA group was only 2.13%, and the clinical bleeding was higher in heparin group than in RCA group (15.3% vs 5.3%). Conclusion RCA-CVVH is a safe and effective renal replacement therapy for perioperative patients with high risk of bleeding, especially for prolonging the life span of the filter. However, there is no significant difference in the internal environment and liver function impairment, Compared with heparin anticoagulation can reduce bleeding complications.