局部枸橼酸抗凝行连续性肾替代治疗对乳酸升高重症患者的效果  

Application of regional citrate anticoagulation CRRT in critical patients with elevated lactic acid

作　　者：张鹏[1] 张辉[1] 张爽[1] 陈炎堂[1] ZHANG Peng;ZHANG Hui;ZHANG Shuang;CHEN Yantang(Department of Critical Care Medicine,Jiangmen Central Hospital,Affiliated Jiangmen Hospital of Sun Yat-sen University,Jiangmen 529030,China)

机构地区：[1]江门市中心医院重症医学科,广东江门529030

出　　处：《实用医学杂志》2022年第7期863-867,872,共6页The Journal of Practical Medicine

基　　金：广东省医学科研基金项目(编号:A2022089);江门市科技计划项目(编号:2018A002);江门市中心医院科研杰青项目(编号:J202004)。

摘　　要：目的 探讨连续性静脉-静脉血液滤过透析(CVVHDF)和局部枸橼酸抗凝(RCA)在重症患者乳酸升高时应用的有效性和安全性。方法 采用回顾性分析,收集我院重症监护室2019年1月至2020年12月用局部枸橼酸抗凝行连续性肾替代治疗(CRRT)数据齐全的患者235例,分为乳酸正常组(Lac <2 mmol/L)A组125例,乳酸升高组(Lac 2~10 mmol/L)B组110例。比较两组患者的临床资料、CRRT治疗前及治疗24 h患者的乳酸值、血气分析(pH值、碳酸氢根)、体内iCa2+、血清总钙、总钙/iCa2+及血Na+等。记录患者并发症的出现情况及滤器使用情况。结果 A组治疗前后乳酸值、pH、HCO3-比较差异无统计学意义(P>0.05),B组患者经CRRT治疗24 h,乳酸值较治疗前下降,pH、HCO3-较治疗前上升(P <0.05)。CRRT治疗前,B组乳酸较A组高,p H、HCO3-较A组低(P <0.05)。CRRT治疗24 h,两组乳酸、pH、HCO3-等比较差异无统计学意义(P> 0.05)。发生枸橼酸蓄积6例(2.55%),均预后不佳死亡。A、B两组CRRT治疗的并发症发生率比较差异无统计学意义(P> 0.05)。结论 乳酸升高的重症患者行CVVHDF时局部用枸橼酸抗凝是安全有效的,但需要密切监测患者的血气、电解质等指标,枸橼酸蓄积发生率低,仅发生在因多器官衰竭而导致严重乳酸性酸中毒的患者中,一旦出现也预示患者预后不良。Objective To investigate the efficacy and safety of continuous veno-venous hemofiltration dialysis(CVVHDF)with regional citrate anticoagulation(RCA)in critical patients with elevated lactic acid.Methods A retrospective analysis was conducted.A total of 235 patients with complete data of regional citrate anticoagulation continuous renal replacement therapy(CRRT)admitted to intensive care unit of our hospital from January 2019 to December 2020 were enrolled and divided into normal lactate group(Lac < 2 mmol/L,group A,n = 125)and elevated lactate group(Lac 2 ~ 10 mmol/L,group B,n = 110).The basic information of patients in the two groups were compared,including lactic acid value,blood gas analysis(PH,bicarbonate),iCa2+,total serum calcium,total calcium/iCa2+and Na+before and 24 h of CRRT treatment,and the occurrence of complications and the use of filters were recorded.Results There were no statistically significant differences in lactic acid value,PH and HCO3-before and after treatment in group A(P > 0.05),while lactic acid value decreased and PH and HCO3-increased after 24 h of CRRT treatment in group B(P < 0.05).Before CRRT treatment,lactic acid in group B was higher than that of group A,while PH and HCO3-were lower than that of group A,with statistically significant differences(P < 0.05).There were no significant differences in lactic acid,PH and HCO3-between two groups(P > 0.05)24 h after CRRT treatment.Six patients were diagnosed with citric acid accumulation(2.55%),and all died with poor prognosis.There was no significant difference in the incidence of CRRT complications between group A and B(P > 0.05).Conclusion Regional citrate anticoagulation was safe and effective for critical patients with elevated lactic acid during CVVHDF,but patients’ blood gas,electrolytes and other indicators need to be closely monitored.The incidence of citric acid accumulation was low,which only occurs in patients with severe lactic acidosis caused by multiple organ failure,and once occurred,it also indicated poor prognosis.

关 键 词：连续性肾替代治疗 局部枸橼酸抗凝 乳酸升高 

分 类 号：R459.5[医药卫生—治疗学] R459.7[医药卫生—临床医学]