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局部柠檬酸与低分子肝素在重症患者连续性肾脏替代治疗中的抗凝效果及其影响因素分析
作者:郭利涛 赵小利 刘昱 张蕾 
单位:710061 西安交通大学第一附属医院重症医学科 
关键词:连续性肾脏替代治疗 柠檬酸 低分子肝素 抗凝 
分类号:R 459.5
出版年,卷(期):页码:2017,12(11):1715-1719
摘要:

【摘要】目的    分析局部柠檬酸与低分子肝素在重症患者连续性肾脏替代治疗(CRRT)中的抗凝效果及其相关影响因素。方法    选择2015年11月至2016年10月在西安交通大学第一附属医院重症医学科行CRRT治疗的重症患者65例。根据CRRT治疗时抗凝方式的不同,分为柠檬酸抗凝组(24例)和低分子肝素抗凝组(41例)。比较2组患者一般资料、治疗前后生化指标、不同静脉置管部位平均治疗时间及下机时跨膜压水平,并采用单因素及多因素线性回归分析CRRT治疗时间的相关影响因素。结果    65例患者行CRRT治疗156次,其中柠檬酸抗凝组行CRRT治疗58次,低分子肝素抗凝组行CRRT治疗98次。柠檬酸抗凝组完成整个配套的治疗(72 h)比例和治疗时间高于、而下机时跨膜压水平低于低分子肝素抗凝组[37.9%(22/58) 比 16.3%(16/98)、(50±25)h 比 (37±21)h、(278±120)cmH2O (1 cmH2O=0.098 kPa)比(351±104)cmH2O],差异均有统计学意义(均P<0.05)。治疗前,2组各生化指标水平比较,差异均无统计学意义(均P>0.05)。治疗后,柠檬酸抗凝组氯离子水平、凝血酶时间低于,而pH值、碳酸根离子、血小板计数、纤维蛋白原水平高于低分子肝素抗凝组,差异均有统计学意义(均P<0.05)。柠檬酸抗凝组右颈内静脉通路平均治疗时间长于、下机时跨膜压低于,右股静脉平均治疗时间长于低分子肝素抗凝组,差异均有统计学意义(均P<0.05)。单因素及多因素线性回归分析显示,抗凝方式、护士工作年限、血肌酐与CRRT治疗时间存在明显相关性(比值比=-9.187、12.122、0.032,95%置信区间:-16.706~-1.667、5.215~19.030、0.003~0.061,P=0.017、0.001、0.033)。结论    抗凝方式是影响CRRT治疗时间最重要的因素,其次护士工作年限、血肌酐与CRRT治疗时间明显相关。采用右颈内静脉血管通路时,选用柠檬酸抗凝能够延长CRRT治疗时间。

Influence factors of anticoagulant effects of regional citrate and low molecular weight heparin on critical patients undergoing continuous renal replacement therapy
Guo Litao, Zhao Xiaoli, Liu Yu, Zhang Lei
Intensive Care Unit, the First Affiliated Hospital of Xi′an Jiaotong University, Xi′an 710061, China
Corresponding author: Zhang Lei, Email: diannazhang@yeah.net
【Abstract】Objective    To analyze influence factors of anticoagulant effects of regional citrate and low molecular weight heparin on continuous renal replacement therapy(CRRT). Methods    Sixty-five critical patients who had CRRT in Intensive Care Unit of the First Affiliated Hospital of Xi′an Jiaotong University from November 2015 to October 2016 were enrolled. According to the difference of anticoagulant methods, the patients were divided into citrate group(24 cases) and low molecular weight heparin group(41 cases). General information, biochemical indexes, average therapy time and average off-therapy transmembrane pressure of different locations of venous cather were recorded. Influence factors of CRRT time were analyzed by univariate and multivariate linear regression. Results    Sixty-five patients were treated with 156 times of CRRT; the citrate group had 58 times of CRRT; the low molecular weight heparin group had 98 times of CRRT. In citrate group, the completion rate of 72 h whole therapy was significantly higher, average therapy time was significantly longer and average off-therapy transmembrane pressure was significantly lower than those in low molecular weight heparin group[37.9%(22/58) vs 16.3%(16/98), (50±25)h vs (37±21)h, (278±120)cmH2O vs (351±104)cmH2O](P<0.05). Biochemical indexes had no significant differences between groups before treatment(P>0.05). Chloridion concentration and thrombin time in citrate group were significantly lower and pH value, carbanion concentration, platelet count and fibrinogen level were significantly higher than those in low molecular weight heparin group after treatment(P<0.05). Right internal jugular vein therapy time was significantly longer, right internal jugular vein off-therapy transmembrane pressure was significantly lower, and right femoral vein therapy time was significantly longer in citrate group than those in low molecular weight heparin group(P<0.05). Linear regression analysis showed significant correlations among anticoagulant method, years of nursing work, serum level of creatinine and CRRT time(odds ratio=-9.187, 12.122, 0.032; 95% confidence interval: -16.706 to -1.667, 5.215-19.030, 0.003-0.061; P=0.017, 0.001,0.033). Conclusions    Anticoagulant method has crucial influence on the therapeutic effect of CRRT; years of nursing work and serum level of creatinine are associated with the duration time of CRRT. Citrate anticoagulation can prolong the duration of therapy with right internal jugular vein as a vascular access of CRRT.
【Key words】Continuous renal replacement therapy;Citrate;Low molecular weight heparin;Anticoagulation

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