血乳酸对局部枸橼酸抗凝下连续性肾脏替代治疗体外循环凝血的影响  

The impact of lactate on circuit clotting in regional citrate anticoagulation continuous renal replacement therapy

作　　者：段鹏程 卢慕荣 于婷婷 周丽珍 王双双 陈伟燕[2] 于红静[1] DUAN Peng-cheng;LU Mu-rong;YU Ting-ting;ZHOU Li-zhen;WANG Shuang-shuang;CHEN Wei-yan;YU Hong-jing(Department of Nursing,The Second Affiliated Hospital of Guangzhou Medical University,Guangzhou 510260,China;Department of Intensive Care Medicine,The Second Affiliated Hospital of Guangzhou Medical University,Guangzhou 510260,China)

机构地区：[1]广州医科大学附属第二医院护理部,广州510260 [2]广州医科大学附属第二医院重症医学科,广州510260

出　　处：《中国血液净化》2024年第8期586-589,595,共5页Chinese Journal of Blood Purification

基　　金：广东省医学科研基金(A2024166);广州医科大学高水平大学多中心临床研究项目(B195001009)。

摘　　要：目的旨在探讨枸橼酸局部抗凝(regional citrate anticoagulation,RCA)下连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)中血乳酸水平对体外循环凝血的影响。方法采用回顾性队列研究设计,收集广州医科大学附属第二医院重症医学科2021年6月—2023年7月局部枸橼酸抗凝下行CRRT治疗的体外循环数据,根据48小时内是否凝血下机分为凝血组和非凝血组。采用COX回归分析CRRT体外循环48小时内凝血的危险因素。结果共纳入114例患者,共179套CRRT体外循环和对应数据,其中凝血组105例,非凝血组74例。COX回归分析显示:静脉压高(HR=1.008,95%CI:1.000~1.016,P=0.045)、乳酸≥2 mmol/L(HR=1.517,95%CI:1.009~2.280,P=0.045)是CRRT体外循环48小时内凝血的独立危险因素;枸橼酸剂量≥3.2 mmol/L(HR=0.461,95%CI:0.312~0.682,P<0.001)是其保护因素。结论CRRT上机时应对体外循环进行充分预冲,运行前测试血液透析置管功能,调整好血液透析置管位置以避免静脉压升高。乳酸高,组织灌注差的患者应积极液体复苏,避免血液过度浓缩,有助于降低CRRT体外循环48小时内凝血的风险。Objective This retrospective study aimed to identify factors contributing to clotting within 48 hours in circuits of continuous renal replacement therapy(CRRT)using regional citrate anticoagulation(RCA).Methods Data from the intensive care unit of the Second Affiliated Hospital of Guangzhou Medical University between June 2021 and July 2023 were analyzed.Circuits were categorized into clotting and nonclotting groups based on 48-hour clotting occurrence.COX regression analysis was performed to identify clotting risk factors.Results A total of 114 patients with 179 sets of CRRT circuits and corresponding data were included in the study.Among them,clotting within 48 hours of initiation was observed in 105 cases,while 74 cases did not experience clotting within 48 hours.Venous pressure(HR=1.008,95%CI:1.0~1.016,P=0.045)and lactate level≥2 mmol/L(HR=1.517,95%CI:1.009~2.280,P=0.045)were identified as independent risk factors for circuit clotting within 48 hours of CRRT.On the other hand,citrate dose≥3.2 mmol/L(HR=0.461,95%CI:0.312~0.682,P<0.001)was identified as a protective factor.Conclusion In continuous renal replacement therapy using regional citrate anticoagulation,high venous pressure,increased platelet count,and elevated lactate levels were associated with increased clotting risk within 48 hours.Pre-filling circuits adequately and optimizing catheter positioning before CRRT initiation are recommended.Managing patients with high lactate levels and impaired tissue perfusion through fluid resuscitation can reduce clotting risk.

关 键 词：枸橼酸 连续性肾脏替代治疗 凝血 乳酸 

分 类 号：R459.5[医药卫生—治疗学]