抗凝策略分析.pptVIP

* 低分子肝素（法安明）和普通肝素在滤器使用寿命及出血风险方面均无显著差别 * * * So in CRRT we use a differentt kind of anticoagulation. No heparin and anticoagulating the entire body. Here only the blood circuit is anticoagulated and tri sodium citrate is used to bind calcium. Without calcium blood cannot clot. The citrate binds the calcium. Some calcium is removed in the dialysis process. The citrate gets converted to bicarbonate and the calcium it has been binding is released. The patient has to be given calcium because of the calcium removed in the dialysis process. * 此研究中无抗凝组滤器寿命长于肝素组（但要注意无抗凝组本身就是出血风险较大，入选时血小板水平及INR水平要显著低于肝素组，实验结果可能受此影响），而且无抗凝组无出血并发症，对于有高度出血风险的患者是安全的。 * * 肝硫素、硫酸皮肤素、软骨素 * * 局部枸橼酸抗凝的优势 与达肝素钠、普通肝素相比，枸橼酸抗凝组细胞粘附率及血栓形成最低。[1] 枸橼酸抗凝组滤器平均寿命为70小时，肝素组为40小时(p= 0.0007)。 CVVH模式下，枸橼酸组患者每天输注红细胞的单位数为0.2U，对应的肝素组为1.0U(p= 0.0008) 。[2] [1].Hofbauer R, Moser D, Frass M, Oberbauer R, Kaye AD, Wagner O, Kapiotis S, Druml W: Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int 56:1578–1583, 1999. [2].Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P: Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265, 2004. Mehta,RL. Regional Citrate anticoagulation for CAVHD in critically ill patients . Kidney Int, 38; 976-978, 1990. Filter Life (hours) Citrate Heparin Saline Flushes 肝素VS.枸橼酸 枸橼酸VS.肝素: 两项随机对照研究 No additional bleeding risk Longer hemofilter life Kutsogiannis DJ et al. Kidney Int 2005;67:2361-7 Monchi M et al. Intensive Care Med. 2004 ;30:260-5 普通肝素 vs. 低分子肝素 vs.枸橼酸 Unfractionated Heparin LMW Heparin Citrate Hoffbauer R et al. Kidney Int 1999;56:1578-1583. 1 管路护理相对复杂，劳动量相对大 2 电解质监测相对频繁 3 严重肝功能衰竭和乳酸酸中毒的患者在枸橼酸代谢方面存在缺陷 缺点 枸橼酸代谢 血浆半衰期为 5 mins 通过肝、肾、骨骼肌细胞代谢 Na3Citrate + 3H2CO3 Citric Acid + 3NaHCO3 3H2CO3 + H2O + 3NaHCO3 4H2O + 6CO2 潜在的并发症 高钙血症 低钙血症 高钠血症 代谢性碱中毒 枸橼酸并发症:“Citrate Lock” 总钙增加，游离钙正常或降低 本质是枸橼酸输入超过肝脏代谢及CRRT清除能力 “citrate lock” 处理 减少或停止枸橼酸 10-30 mi