中国血液净化

中国血液净化 ›› 2018, Vol. 17 ›› Issue (04): 217-221.doi: 10.3969/j.issn.1671-4091.2018.04.001

• 临床研究 •    下一篇

局部枸橼酸抗凝在重症中毒患者血液灌流治疗中的应用研究

张海钢1,吴京兰1,黄镭1,林进团1,黎锐发1   

  1. 1. 深圳市第六人民医院（南山医院）急诊ICU
  • 收稿日期:2017-10-09 修回日期:2018-01-30 出版日期:2018-04-12 发布日期:2018-04-12
  • 通讯作者: 张海钢 breezing_snow@sina.com E-mail:breezing_snow@sina.com
  • 基金资助:

    深圳市知识创新计划基础研究项目(JCYJ20150402152130168)

Application of regional citrate anticoagulation in hemoperfusion therapy for patients with severe poisoning

  • Received:2017-10-09 Revised:2018-01-30 Online:2018-04-12 Published:2018-04-12

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摘要： 【摘要】目的对比局部枸橼酸抗凝(regional citrate anticoagulant,RCA)、普通肝素(unfractionated heparin，UFH)、低分子肝素(low molecular weight heparin, LMWH)3 种抗凝方法在重症中毒患者血液灌流的应用，观察局部枸橼酸抗凝在血液灌流治疗中的有效性及安全性。方法选择我院2014 年1 月～2017 年9 月行血液灌流治疗的30 例重症中毒患者，按性别、病种分层随机分为局部枸橼酸抗凝、普通肝素抗凝和低分子肝素抗凝组，每组各10 例。观察并比较3 组的管路凝血、出血情况及血小板计数、部分凝血活酶时间(activated partial thromboplastin time，APTT)、凝血酶原时间(prothrombin time，PT)及纤维蛋白原(fibrinogen,Fib)。比较RCA 组血液灌流前后的血清游离钙、血清总钙、血PH 值。结果RCA 组未发生灌流器凝血，UFH 组有2 例、LMWH 有1 例出现Ⅲ级灌流器凝血；RCA 组无穿刺
点或其他部位出血；UFH 组有3 例穿刺点出血、3 例皮下出血和2 例其他部位出血，发生率高于RCA 组(χ2=9.436，P=0.022)；LMWH 组有3 例穿刺点出血、2 例皮下出血和1 例其他部位出血，发生率高于RCA 组(χ2=8.556, P=0.036)。与治疗前比较，血液灌流治疗后3 组均有Fib 及血小板计数降低，UFH 组的APTT(t=
2.722, P=0.009)、PT(t=2.234, P=0.016)、血小板计数(t=3.893, P=0.001)、Fib(t=4.056, P＜0.001)与RCA组比较有显著性差异；LMWH 组的APTT(t=2.459,  P=0.012)、PT(t=2.168, P=0.021)、血小板计数(t=3.608,P=0.001)、Fib(t=3.892,P=0.001)与RCA 组比较有显著性差异。RCA 组血液灌流后血清游离钙(t=0.452,
P=0.594)、血清总钙(t=0.307,P=0.681)、血PH 值(t=0.260,P=0.758)无明显变化。结论局部枸橼酸抗凝较普通肝素、低分子肝素具有更好的抗凝效果，能有效降低出血发生率，安全性好，可在血液灌流治疗中常规使用。

关键词: 局部枸橼酸抗凝, 血液灌流, 抗凝, 中毒

Abstract: 【Abstract】Objective To compare the three anticoagulant methods, regional citrate anticoagulation (RCA), unfractionated heparin (UFH) anticoagulation and low molecular weight heparin (LMWH) anticoagulation, in hemoperfusion therapy for severe poisoning patients, and to assess the efficacy and safety of RCA in hemoperfusion therapy. Methods Thirty severe poisoning patients treated with hemoperfusion therapy from Jan. 2014 to Sept. 2017 were randomly divided into RCA group (n=10), UFH group (n=10) and LMWH group (n=10). Blood coagulation, bleeding, blood platelet count (BPC), activated partial thromboplastin time (APTT), prothrombin time (PT) and fibrinogen (Fib) were compared between the 3 groups. Serum ionized Ca+2, total calcium and blood pH were compared before and after hemoperfusion in RCA group. Results Blood coagulation in perfusion apparatus was not found in RCA group, but occurred in 2 cases in UFH group and in one case with level III blood clotting in LMWH group. There was no bleeding at puncture site in RCA group. In IFH group, bleeding happened in 3 cases at puncture site, 3 cases in subcutaneous tissues and 2 cases at other sites (χ2=9.436, P=0.022, as compared with that in RCA group). In LMWH group, bleeding was found in 3 cases at puncture site, 2 cases in subcutaneous tissues and one case at other sites (χ2=8.556, P=0.036, as compared with that in RCA group). After hemoperfusion therapy, Fib and BPC decreased in the 3 groups; APTT, PT, BPC, and Fib changed more in UFH group than in RCA group (t=2.722, P=0.009 for APTT; t=2.234, P=0.016 for PT; t=3.893, P=0.001 for BPC; t=4.056, P＜0.001 for Fib) and more in LMWH group than in RCA group (t=2.459, P=0.012 for APTT; t=2.168, P=0.021 for PT; t=3.608, P=0.001 for BPC; t=3.892, P=0.001 for Fib). Serum ionized Ca + 2, total calcium, blood pH changed insignificantly in RCA group (t=0.452, P=0.594 for serum ionized Ca + 2; t=0.307, P=0.681 for serum total calcium; t=0.260, P=0.758 for blood pH). Conclusion RCA was better than UFH and LMWH in anticoagulation effect, lower incidence of bleeding and safety for use. Thus RCA is suitable for routine use in hemoperfusion therapy.

Key words: regional citrate anticoagulation , Hemoperfusion, Anticoagulation, poisoning