局部枸橼酸抗凝时影响重症患者连续性肾脏替代治疗时间的相关因素分析
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摘要
目的分析局部枸橼酸抗凝时影响重症患者连续性肾脏替代治疗(CRRT)时间的相关因素。方法回顾性分析2016年1—10月入住西安交通大学第一附属医院重症医学科使用枸橼酸抗凝行CRRT治疗的重症患者的相关资料,比较治疗前及治疗后相关生化指标的变化,通过单因素及多因素回归分析影响治疗时间的相关因素。结果共纳入27例患者(男13例、女14例),平均年龄(59±18)岁,共行CRRT治疗63次,平均治疗时间(47±25)h,下机时的跨膜压(281±120)cmH_2O(1 cmH2O=0.098 kPa)。治疗后血尿素氮、血肌酐低于治疗前,pH值高于治疗前[(9±5)mmol/L比(12±7)mmol/L、(128±95)μmol/L比(162±126)μmol/L、(7.43±0. 09)比(7. 41±0. 09)],差异均有统计学意义(均P<0. 05)。单因素线性回归分析发现护士工作年限(B=14. 721,95%置信区间:2. 214～27. 229,P=0. 022)、治疗前的Na~+(B=-1.089,95%置信区间:-2.151～-0.027,P=0.045)、凝血酶时间(B=2.942,95%置信区间:0.085～5.799,P=0.044)与治疗时间存在相关性。进一步多因素线性回归分析发现护士工作年限与治疗时间存在正相关性(B=15.330,95%置信区间:3.063～27.598,P=0.015)。结论局部枸橼酸抗凝时护士工作年限对CRRT时间有影响.与CRRT治疗时间存在正相关性。
Objective To analyze the influence factors of the duration time of continuous renal replacement therapy( CRRT) with regional citrate anticoagulation in critical patients. Methods Clinical records of critical patients who had CRRT using regional citrate anticoagulation from January to October 2016 in the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed. Changes of biochemical indicators were analyzed before and after treatment. Influence factors of the duration time of CRRT were analyzed by univariate and multivariate regression. Results Twenty-seven patients(13 males and 14 females) were included; the mean age was(59 ± 18) years. Sixty-three times of CRRT were performed; the mean therapy time was(47 ± 25) h; the mean transmembrane pressure at the end of therapy was(281 ± 120) cmH_2 O. After treatment, urea nitrogen and serum creatinine were lower and pH value was higher than those before treatment [(9 ± 5) mmol/L vs(12 ±7)mmol/L,(128±95)μmol/L vs(162±126)μmol/L,(7.43±0.09) vs(7.41± 0.09)](P<0.05).Univariate regression showed that work experience of nurse( B = 14.721, 95% confidence interval: 2.214-27.229, P=0.022), serum sodium(B =-1.089, 95% confidence interval:-2.151 to-0.027, P = 0.045)and thrombin time(B = 2. 942, 95% confidence interval: 0.085-5. 799, P =0.044) were related to the duration time of CRRT. Multivariate regression showed that work experience of nurse was positively related to the duration time of CRRT(B = 15. 330, 95% confidence interval: 3.063-27.598, P= 0.015). Conclusion In patients undergoing CRRT with regional citrate anticoagulation, the work experience of nurse shows a positive relation with the duration of therapy.
Objective To analyze the influence factors of the duration time of continuous renal replacement therapy( CRRT) with regional citrate anticoagulation in critical patients. Methods Clinical records of critical patients who had CRRT using regional citrate anticoagulation from January to October 2016 in the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed. Changes of biochemical indicators were analyzed before and after treatment. Influence factors of the duration time of CRRT were analyzed by univariate and multivariate regression. Results Twenty-seven patients(13 males and 14 females) were included; the mean age was(59 ± 18) years. Sixty-three times of CRRT were performed; the mean therapy time was(47 ± 25) h; the mean transmembrane pressure at the end of therapy was(281 ± 120) cmH_2 O. After treatment, urea nitrogen and serum creatinine were lower and pH value was higher than those before treatment [(9 ± 5) mmol/L vs(12 ±7)mmol/L,(128±95)μmol/L vs(162±126)μmol/L,(7.43±0.09) vs(7.41± 0.09)](P<0.05).Univariate regression showed that work experience of nurse( B = 14.721, 95% confidence interval: 2.214-27.229, P=0.022), serum sodium(B =-1.089, 95% confidence interval:-2.151 to-0.027, P = 0.045)and thrombin time(B = 2. 942, 95% confidence interval: 0.085-5. 799, P =0.044) were related to the duration time of CRRT. Multivariate regression showed that work experience of nurse was positively related to the duration time of CRRT(B = 15. 330, 95% confidence interval: 3.063-27.598, P= 0.015). Conclusion In patients undergoing CRRT with regional citrate anticoagulation, the work experience of nurse shows a positive relation with the duration of therapy.
引文
[1]谌琦,李月红.连续性肾脏替代治疗中药物剂量的精准调整[J].临床内科杂志,2017,34(4):233-235. DOI:10.3969/j.issn. 1001-9057.2017.04.005.Chen Q, Li YH. Precise dose adjustment in continuous renal replacement therapy[J]. Journal of Clinical Internal Medicine,2017,34(4):233-235. DOI:10. 3969/j. issn. 1001-9057. 2017.04.005.
[2]余娇阳.CRRT治疗感染性急性肾损伤最佳时机探讨[J].中华全科医学,2017,15(2):246-248. DOI:10.16766/j.cnki. issn.16744152.2017.02.019.Yu JY. Best opportunity for CRRT to treat infectious acute kidney injury[J]. Chinese Journal of General Practice, 2017,15(2):246-248. DOI:10.16766/j. cnki. issn. 1674-4152.2017.02.019.
[3]李小密,阮彩霞,刘楠,等.局部柠檬酸钠抗凝在急性主动脉夹层术后并发急性肾损伤进行连续肾脏替代疗法中的应用效果[J].中国医药,2017.12(7):1018-1021. DOI:10.3760/cma. j. issn. 1673-4777.2017.07.016.Li XM, Ruan CX, Liu N, et al. Effect of regional sodium citrate anticoagulation on continuous renal replacement therapy for acute kidney injury acute aortic dissection operation[J]. China Medicine,2017,12(7):1018-1021. DOI:10. 3760/cma. j. issn. 1673-4777.2017.07.016.
[4]赵小利,刘革婷,张蕾,等.低分子肝素抗凝时影响重症患者连续性肾脏替代治疗时间的相关因素分析[J].中国医药,2018,13(5):721-724. DOI:10.3760/j. issn. 1673-4777.2018.05.022.Zhao XL, Liu GT, Zhang L, et al. Influence factors of duration of continuous renal replacement therapy with low molecular weight heparin anticoagulation in critical patients[J]. China Medicine,2018,13(5):721-724. DOI:10. 3760/j. issn. 1673-4777.2018.05.022.
[5] Tolwani A, Wille KM. Advances in continuous renal replacement therapy:citrate anticoagulation update[J]. Blood Purif, 2012,34(2):88-93. DOI:10.1159/000342378.
[6] Morabito S, Pistolesi V, Tritapepe L, et al. Regional citrate anticoagulation in CVVH:a new protocol combining citrate solution with a phosphate-containing replacement fluid[J]. Hemodial Int,2013,17(2):313-320. DOI:10. 1111/j. 1542-4758. 2012.00730.x.
[7]柯昊贤,沈玄韬,余文辉,等.肿瘤患者连续型肾脏替代治疗枸橼酸与低分子肝素抗凝效果及预后比较[J].中华重症医学电子杂志,2017,3(3):197-201.DOI:10.3877/cma.j.issn.2096-1537.2017.03.009.Ke HX, Shen XT, Yu WH, et al. Comparison of efficacy and prognosis between citrate and low molecular weight heparin in tumor patients undergoing continuous renal replacement therapy[J].Chinese Journal of Critical Care&Intensive Care Medicine(Electronic Edition), 2017,3(3):197-201. DOI:10. 3877/cma. j.issn. 2096-1537.2017.03.009.
[8] Liu C, Mao Z,Kang H, et al. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill patients:a meta-analysis with trial sequential analysis of randomized controlled trials[J]. Crit Care. 2016,20(1):144.DOI:10.1186 s13054-016-1299-0.
[9] Jackson SP, Nesbitt WS, Kulkarni S. Signaling events underlying thrombus formation[J]. J Thromb Haemost, 2003,1(7):1602-1612.
[10]吕佳璇,李月红.局部枸橼酸抗凝在连续性肾脏替代治疗中的应用[J].临床内科杂志,2017,34(4):230-232. DOI:10.3969/j. issn. 1001-9057.2017.04.004.Lyu JX, Li YH. Application of local citric acid anticoagulation in continuous renal replacement therapy[J]. Journal of Clinical Internal Medicine, 2017,34(4):230-232. DOI:10. 3969/j.issn. 1001-9057.2017.04.004.
[11] Nurmohamed SA, Jallah BP, Vervloet MG, et al. Continuous venovenous haemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency:a prospective observational study[J]. BMC Nephrol, 2013(14):89. DOI:10.1186/1471-2369-14-89.
[12] Oudemans-van Straaten HM, Ostermann M. Bench-to-bedsidereview:Citrate for continuous renal replacement therapy,from science to practice[J]. Crit Care, 2012,16(6):249. DOI:10.1186/cc11645.
[13] Ponikvar R, Gubensek J, Ponikvar JB. Citrate anticoagulation in tandem membrane plasma-exchange or immunoadsorption and hemodialysis in patients with immunological diseases and dialysisdependence[J]. Ther Apher Dial, 2016,20(3):246-250. DOI:10.1111/1744-9987.12431.
[14] Liao YJ, Zhang L, Zeng XX, et al. Citrate versus unfractionated heparin for anticoagulation in continuous renal replacement therapy[J].Chin Med J(Engl), 2013,126(7):1344-1349. DOI:10.3760/cma. j. issn. 0366-6999.20121179.
[15] De Vico P, Messino V, Tartaglione A, et al. Safe and efficacy of citrate anti-coagulation continuous renal replacement therapies in post-cardiac surgery patients with liver dysfunction[J]. Ther Apher Dial, 2015,19(3):272-278. DOI:10.1111/1744-9987.12280.
[16] Claure-Del Granado R, Macedo E, Soroko S,et al. Anticoagulation,delivered dose and outcomes in CRRT:the program to improve care in acute renal disease(PICARD)[J]. Hemodialysis Int,2014,18(3):641-649. DOI:10.1111/hdi. 12157.
[17] Schilder L, Nurmohamed SA, Bosch FH, et al. Citrate anticoagulation versus systemic heparinisation in contin uous venovenous hemofiltration in critically ill patients with acute kidney injury:a multi-center randomized clinical trial[J]. Crit Care, 2014,18(4):472. DOI:10.1186/s13054-014-0472-6.
[18] Oudemans-van Straaten HM, van Schilfgaarde M, Molenaar PJ, et al.Hemostasis during low molecular weight heparin anticoagulation for continuous venovenous hemofiltration:a randomized cross-over trial comparing two hemofiltration rates[J]. Crit Care, 2009,13(6):R193.DOI:10.1186/cc8191.
[19]郭利涛,赵小利,刘昱,等.局部柠檬酸与低分子肝素在重症患者连续型肾脏替代治疗中的抗凝效果及其影响因素分析[J].中国医药,2017,12(11):1715-1719. DOI:10. 3760/cma.j.issn. 1673-4777.2017.11. 030.Guo LT, Zhao XL, Liu Y, et al. Influence factors of anticoagulant effects of regional citrate and low molecular weight heparin on critical patients undergoing continuous renal replacement therapy[J]. China Medicine, 2017,12(11):1715-1719. DOI:10. 3760/cma. j.issn. 1673-4777.2017. 11.030.
[2]余娇阳.CRRT治疗感染性急性肾损伤最佳时机探讨[J].中华全科医学,2017,15(2):246-248. DOI:10.16766/j.cnki. issn.16744152.2017.02.019.Yu JY. Best opportunity for CRRT to treat infectious acute kidney injury[J]. Chinese Journal of General Practice, 2017,15(2):246-248. DOI:10.16766/j. cnki. issn. 1674-4152.2017.02.019.
[3]李小密,阮彩霞,刘楠,等.局部柠檬酸钠抗凝在急性主动脉夹层术后并发急性肾损伤进行连续肾脏替代疗法中的应用效果[J].中国医药,2017.12(7):1018-1021. DOI:10.3760/cma. j. issn. 1673-4777.2017.07.016.Li XM, Ruan CX, Liu N, et al. Effect of regional sodium citrate anticoagulation on continuous renal replacement therapy for acute kidney injury acute aortic dissection operation[J]. China Medicine,2017,12(7):1018-1021. DOI:10. 3760/cma. j. issn. 1673-4777.2017.07.016.
[4]赵小利,刘革婷,张蕾,等.低分子肝素抗凝时影响重症患者连续性肾脏替代治疗时间的相关因素分析[J].中国医药,2018,13(5):721-724. DOI:10.3760/j. issn. 1673-4777.2018.05.022.Zhao XL, Liu GT, Zhang L, et al. Influence factors of duration of continuous renal replacement therapy with low molecular weight heparin anticoagulation in critical patients[J]. China Medicine,2018,13(5):721-724. DOI:10. 3760/j. issn. 1673-4777.2018.05.022.
[5] Tolwani A, Wille KM. Advances in continuous renal replacement therapy:citrate anticoagulation update[J]. Blood Purif, 2012,34(2):88-93. DOI:10.1159/000342378.
[6] Morabito S, Pistolesi V, Tritapepe L, et al. Regional citrate anticoagulation in CVVH:a new protocol combining citrate solution with a phosphate-containing replacement fluid[J]. Hemodial Int,2013,17(2):313-320. DOI:10. 1111/j. 1542-4758. 2012.00730.x.
[7]柯昊贤,沈玄韬,余文辉,等.肿瘤患者连续型肾脏替代治疗枸橼酸与低分子肝素抗凝效果及预后比较[J].中华重症医学电子杂志,2017,3(3):197-201.DOI:10.3877/cma.j.issn.2096-1537.2017.03.009.Ke HX, Shen XT, Yu WH, et al. Comparison of efficacy and prognosis between citrate and low molecular weight heparin in tumor patients undergoing continuous renal replacement therapy[J].Chinese Journal of Critical Care&Intensive Care Medicine(Electronic Edition), 2017,3(3):197-201. DOI:10. 3877/cma. j.issn. 2096-1537.2017.03.009.
[8] Liu C, Mao Z,Kang H, et al. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill patients:a meta-analysis with trial sequential analysis of randomized controlled trials[J]. Crit Care. 2016,20(1):144.DOI:10.1186 s13054-016-1299-0.
[9] Jackson SP, Nesbitt WS, Kulkarni S. Signaling events underlying thrombus formation[J]. J Thromb Haemost, 2003,1(7):1602-1612.
[10]吕佳璇,李月红.局部枸橼酸抗凝在连续性肾脏替代治疗中的应用[J].临床内科杂志,2017,34(4):230-232. DOI:10.3969/j. issn. 1001-9057.2017.04.004.Lyu JX, Li YH. Application of local citric acid anticoagulation in continuous renal replacement therapy[J]. Journal of Clinical Internal Medicine, 2017,34(4):230-232. DOI:10. 3969/j.issn. 1001-9057.2017.04.004.
[11] Nurmohamed SA, Jallah BP, Vervloet MG, et al. Continuous venovenous haemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency:a prospective observational study[J]. BMC Nephrol, 2013(14):89. DOI:10.1186/1471-2369-14-89.
[12] Oudemans-van Straaten HM, Ostermann M. Bench-to-bedsidereview:Citrate for continuous renal replacement therapy,from science to practice[J]. Crit Care, 2012,16(6):249. DOI:10.1186/cc11645.
[13] Ponikvar R, Gubensek J, Ponikvar JB. Citrate anticoagulation in tandem membrane plasma-exchange or immunoadsorption and hemodialysis in patients with immunological diseases and dialysisdependence[J]. Ther Apher Dial, 2016,20(3):246-250. DOI:10.1111/1744-9987.12431.
[14] Liao YJ, Zhang L, Zeng XX, et al. Citrate versus unfractionated heparin for anticoagulation in continuous renal replacement therapy[J].Chin Med J(Engl), 2013,126(7):1344-1349. DOI:10.3760/cma. j. issn. 0366-6999.20121179.
[15] De Vico P, Messino V, Tartaglione A, et al. Safe and efficacy of citrate anti-coagulation continuous renal replacement therapies in post-cardiac surgery patients with liver dysfunction[J]. Ther Apher Dial, 2015,19(3):272-278. DOI:10.1111/1744-9987.12280.
[16] Claure-Del Granado R, Macedo E, Soroko S,et al. Anticoagulation,delivered dose and outcomes in CRRT:the program to improve care in acute renal disease(PICARD)[J]. Hemodialysis Int,2014,18(3):641-649. DOI:10.1111/hdi. 12157.
[17] Schilder L, Nurmohamed SA, Bosch FH, et al. Citrate anticoagulation versus systemic heparinisation in contin uous venovenous hemofiltration in critically ill patients with acute kidney injury:a multi-center randomized clinical trial[J]. Crit Care, 2014,18(4):472. DOI:10.1186/s13054-014-0472-6.
[18] Oudemans-van Straaten HM, van Schilfgaarde M, Molenaar PJ, et al.Hemostasis during low molecular weight heparin anticoagulation for continuous venovenous hemofiltration:a randomized cross-over trial comparing two hemofiltration rates[J]. Crit Care, 2009,13(6):R193.DOI:10.1186/cc8191.
[19]郭利涛,赵小利,刘昱,等.局部柠檬酸与低分子肝素在重症患者连续型肾脏替代治疗中的抗凝效果及其影响因素分析[J].中国医药,2017,12(11):1715-1719. DOI:10. 3760/cma.j.issn. 1673-4777.2017.11. 030.Guo LT, Zhao XL, Liu Y, et al. Influence factors of anticoagulant effects of regional citrate and low molecular weight heparin on critical patients undergoing continuous renal replacement therapy[J]. China Medicine, 2017,12(11):1715-1719. DOI:10. 3760/cma. j.issn. 1673-4777.2017. 11.030.
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