A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status
A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status
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DOI：
10.1097/ccm.0b013e3181a00a92
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发表时间：
2009-06-01
影响因子：
8.8
通讯作者：
Neumayer, Hans-Hellmut
中科院分区：
文献类型：
--
作者：
Morgera, Stanislao;Schneider, Michael;Neumayer, Hans-Hellmut
目的：对于需要连续性肾脏替代治疗的重症患者，枸橼酸盐抗凝是肝素抗凝的一种极佳替代方法。在本文中，我们提供了一种安全且易于操作的枸橼酸盐抗凝方案，该方案具有可变的治疗剂量以及对酸碱状态的良好控制。
设计：前瞻性观察研究。
地点：大学医院。
患者：162例需要肾脏替代治疗的急性肾衰竭患者被纳入研究。
干预措施：采用一种基于连续性静脉 - 静脉血液透析的枸橼酸盐抗凝方案，使用4%的枸橼酸钠溶液、一种专门设计的透析液以及连续性钙输注。研究周期为6天。治疗72小时后常规更换滤器。根据体重将患者分组，体重低于60kg的患者为第1组，体重至少60kg且不超过90kg的患者为第2组，体重超过90kg的患者为第3组。透析液流量根据体型进行调整，对于平均体型的患者，大约匹配2L/小时。血流、枸橼酸盐流量和钙流量根据所使用的透析液流量进行调整。
测量及主要结果：滤器中位运行时间为61.5小时（四分位间距：34.5 - 81.1小时）。由于凝血，仅有5%的滤器需要更换。所有患者都达到了规定的治疗剂量。所有组的酸碱和电解质控制都非常好。在枸橼酸盐抗凝过程中极少数代谢紊乱的病例中，通过调整透析液流量或者血流速度，酸碱值能迅速得到纠正。8例患者（5%）出现枸橼酸盐蓄积的迹象，表现为总钙>3mmol/L或需要高剂量的钙替代。
结论：我们提供了一种安全且易于操作的枸橼酸盐抗凝方案，该方案能够对急性肾衰竭的重症患者实现良好的酸碱和电解质控制。该方案可根据患者的需求进行调整，允许有广泛的治疗剂量范围。（《重症医学》2009年；37卷：2018 - 2024页）
Objective. Citrate anticoagulation is an excellent alternative to heparin anticoagulation for critically ill patients requiring continuous renal replacement therapy. In this article, we provide a safe and an easy-to-handle citrate anticoagulation protocol with variable treatment doses and excellent control of the acid-base status.Design: Prospective observational study.Setting. University hospital.Patients: One hundred sixty-two patients with acute renal failure requiring renal replacement therapy were enrolled in the study.Intervention: A continuous venovenous hemodialysis-based citrate anticoagulation protocol using a 4% trisodium solution, a specially designed dialysate fluid, and a continuous calcium infusion were used. The study period was 6 days. Hemofilters were changed routinely after 72 hours of treatment. The patients were grouped according to body weight, with patients below 60 kg body weight in group 1, patients with at least 60 kg and up to 90 kg body weight in group 2, and patients with a body weight of above 90 kg in group 3. Dialysate flow was adapted according to body size and matched approximately 2 L/hr for a patient with average body size. Blood flow, citrate flow, and calcium flow were adjusted according to the dialysate flow used.Measurements and Main Results: Median filter run time was 61.5 hours (interquartile range: 34.5-81.1 hours). Only 5% of all hemofilters had to be changed because of clotting. The prescribed treatment dose was achieved in all patients. Acid-base and electrolyte control were excellent in all groups. In the rare cases of metabolic disarrangement during citrate anticoagulation, acid-base values were rapidly corrected by modifying either the dialysate flow or alternatively the blood flow rate. Eight patients (5%) developed signs of citrate accumulation indicated by an increase of the total calcium >3 mmol/L or a need for high calcium substitution.Conclusions. We provide a safe and an easy-to-handle citrate anticoagulation protocol that allows an excellent acid-base and electrolyte control in critically ill patients with acute renal failure. The protocol can be adapted to patients' need, allowing a wide spectrum of treatment doses. (Crit Care Med 2009; 37:2018-2024)