枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用

doi:10.3877/cma.j.issn.1673-5250.2016.06.020

中华妇幼临床医学杂志(电子版) ›› 2016, Vol. 12 ›› Issue (06) : 726 -730. doi: 10.3877/cma.j.issn.1673-5250.2016.06.020

所属专题：文献；

论著

枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用

郭妍南¹, 明华², 陈秀英¹, 王峥¹^,^†(

)

^1. 610041成都，四川大学华西第二医院儿科、出生缺陷与相关妇儿疾病教育部重点实验室
^2. 610041武警四川省总队成都医院内科

收稿日期:2016-10-08 修回日期:2016-11-10 出版日期:2016-12-01
通信作者: 王峥

Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration

Yannan Guo¹, Hua Ming², Xiuying Chen¹, Zheng Wang¹^,^†()

^1. Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
^2. Department of Medicine, Chengdu Hospital of Chinese People Armed Police Forces, Chengdu 610041, Sichuan Province, China

Received:2016-10-08 Revised:2016-11-10 Published:2016-12-01
Corresponding author: Zheng Wang
About author:
Corresponding author: Wang Zheng, Email: wangzheng48@126.com

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引用本文：

郭妍南, 明华, 陈秀英, 王峥. 枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用[J]. 中华妇幼临床医学杂志(电子版), 2016, 12(06): 726-730.

Yannan Guo, Hua Ming, Xiuying Chen, Zheng Wang. Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2016, 12(06): 726-730.

目的

探讨枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过(CVVH)中的应用。

方法

选择2008年5月至2016年4月，在四川大学华西第二医院住院并拟行CVVH治疗的51例脓毒症伴急性肾损伤患儿为研究对象。对其在CVVH治疗中采用枸橼酸钠抗凝。检测不同观察时间点及滤器前、后活化部分凝血活酶时间(APTT)及血清Ca^2＋浓度。观察本组患儿治疗前、后血肌酐、尿素氮、急性生理与慢性健康(APACHE)Ⅱ评分、滤器凝血情况及治疗不良反应。本研究遵循的程序符合四川大学华西第二医院人体试验委员会所制定的伦理学标准，得到该委员会批准，征得受试对象监护人的知情同意，并与之签署临床研究知情同意书。

结果

①本组患儿治疗前与治疗结束后0.5 h APTT水平比较，差异无统计学意义(t＝－1.06，P>0.05)；治疗2、4、8 h时，患儿滤器后APTT水平均显著高于滤器前，并且差异有统计学意义(t＝－28.30、－7.14、－26.11，P<0.001)。②本组患儿治疗结束后0.5 h血清Ca^2＋浓度较治疗前显著降低，并且差异有统计学意义(t＝4.63，P<0.05)；治疗2、4、8 h时，患儿滤器后血清Ca^2＋浓度显著低于滤器前，差异也有统计学意义(t＝6.00、7.47、13.90，P<0.05)。③治疗后患儿血清肌酐、尿素氮及APACHEⅡ评分均较治疗前明显下降，差异有统计学意义(t＝3.03、4.10、3.16，P<0.05)。④本研究无1例患儿发生3级滤器凝血和治疗不良反应。

结论

枸橼酸抗凝技术在儿童CVVH治疗中能有效发挥抗凝作用，治疗不良反应小，临床使用较安全。

关键词: 抗凝药, 柠檬酸, 肾替代疗法, 活化部分凝血活酶时间, 儿童

Objective

To explore the clinical application of sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration(CVVH).

Methods

From May 2008 to April 2016, a total of 51 children from West China Second University Hospital, Sichuan University, were included into the study. Sodium citrate anticoagulation were used during CVVH. The acitivatedpartial thromboplsatin time (APTT), ionized calcium concentration of before and after filter were measured at different time points.The serum creatinine, urea nitrogen, acute physiology and chronic health evaluation(APACHE)Ⅱ scores, filter clotting and treatment adverse reaction were also observed. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of West China Second University Hospital, Sichuan University.Informed consent was obtained from each participants′parents.

Results

①There was no significant difference between before and 0.5 h after treatment in APTT levels (t=-1.06, P>0.05). The APTT levels of post-filter were prolonged significantly compared with that of pre-filter at 2, 4, 8 h during CRRT(t=-28.30, -7.14, -26.11; P<0.001). ②The ionized calcium at before treatment was higher than at 0.5 h after treatment, and the differece was significant(t=4.63, P<0.05). At 2, 4, 8 h during CRRT, ionized calcium of post-filter were decreased significantly than those of pre-filter(t=6.00, 7.47, 13.90; P<0.05). ③Compared to before treatment, the serum creatinine, urea nitrogen, APACHE Ⅱ scores after treatment were declined significantly (t=3.03, 4.10, 3.16; P<0.05). ④There were no level 3 filter clotting or treatment adverse reactions be observed.

Conclusion

Sodium citrate is clinically effective, safe and less adverse reactions in the anticoagulation of CVVH in children.

Key words: Anticoagulants, Citric acid, Renal replacement therapy, Activated partial thromboplsatin time, Child

表1 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点APTT水平比较(s, ±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	30.7±3.0	30.6±3.5	31.1±3.2
滤器后	51	48.8±4.3	53.4±6.1	52.8±4.2
t值	?	－28.30	－7.14	－26.11
P值	?	<0.001	<0.001	<0.001

表1 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点APTT水平比较(s, ±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	30.7±3.0	30.6±3.5	31.1±3.2
滤器后	51	48.8±4.3	53.4±6.1	52.8±4.2
t值	?	－28.30	－7.14	－26.11
P值	?	<0.001	<0.001	<0.001

表2 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点血清Ca^2＋浓度比较(mmol/L，±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	1.06±0.15	0.97±0.13	1.00±0.07
滤器后	51	0.46±0.08	0.47±0.04	0.44±0.03
t值	?	6.00	7.47	13.90
P值	?	<0.05	<0.05	<0.05

表2 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点血清Ca^2＋浓度比较(mmol/L，±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	1.06±0.15	0.97±0.13	1.00±0.07
滤器后	51	0.46±0.08	0.47±0.04	0.44±0.03
t值	?	6.00	7.47	13.90
P值	?	<0.05	<0.05	<0.05

表3 脓毒症伴急性肾损伤患儿CVVH治疗前、后血肌酐、尿素氮及APACHEⅡ评分比较(±s)

观察时间点	例数	肌酐(mol/L)	尿素氮(mmol/L)	APACHE Ⅱ评分(分)
治疗前	51	595.0±124.7	33.9±12.7	17.3±5.0
治疗后	51	415.0±37.9	18.4±5.9	13.5±1.4
t值	?	3.03	4.10	3.16
P值	?	<0.05	<0.05	<0.05

表3 脓毒症伴急性肾损伤患儿CVVH治疗前、后血肌酐、尿素氮及APACHEⅡ评分比较(±s)

观察时间点	例数	肌酐(mol/L)	尿素氮(mmol/L)	APACHE Ⅱ评分(分)
治疗前	51	595.0±124.7	33.9±12.7	17.3±5.0
治疗后	51	415.0±37.9	18.4±5.9	13.5±1.4
t值	?	3.03	4.10	3.16
P值	?	<0.05	<0.05	<0.05

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