ABSTRACT
【Objective】 To compare the therapeutic effects of low molecular weight heparin sodium and sodium citrate on hemodialysis(HD) patients at high risk of bleeding. 【Method】 A total of 96 patients at high risk of bleeding on maintenance hemodialysis from May 2018 to May 2020 were enrolled and divided randomly into control group(n=48) and observation group(n=48). Patients in control group received systemic anticoagulation with heparin, and patients in observation group adopted regional citrate anticoagulation of in vitro dialyzer. The indexes of prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fg), D-dimer, service time of filters and the dialysis efficiency, as well as the complication occurrences of clotting events, bleeding, metabolic alkalosis and hypocalcaemia were compared between the two groups. 【Results】 No significant difference was found in coagulation indicators (ACT, PT, Fg, APPT and D-dimer) before and after hemodialysis in observation group(P>0.05), but those in control group were prolonged significantly (P0.05). The incidence of filter clotting (0.0%), dialyzer pipeline clotting (0.0%) and bleeding (2.1%) in observation group were less than those in control group (8.3%, 6.2%, 14.6%, respectively) (P0.05). 【Conclusion】 Regional anticoagulation with citric acid in vitro is safe for patients on maintenance hemodialysis at high risk of bleeding, and can greatly prolong service time of filters, reduce bleeding and thrombocytopenia rates, bring less effects to coagulation function in vivo.
ABSTRACT
Objective To design a mathematical calculation model for better understanding and grasping the logical problem of replacement fluid and citric acid anticoagulant infusion in continuous veno-venous hemofiltration (CVVH). Methods ① Parameter definition: A, B, and T were respectively called the main part of pre-replacement fluid, 5% sodium bicarbonate solution, and 4% sodium citrate infused before filter. And a and b were respectively called the main part of post-replacement fluid, and 5% sodium bicarbonate solution infused after filter. ② Logic conversion:The liquid in back terminal (Z) was artificially divided into two parts. One (X) was the original residual plasma after filtration. The second (Y) was the part excluding the plasma, including the left part of pre-replacement fluid with sodium citrate, and the post-replacement fluid. ③The mathematical formulas of liquid volume and electrolyte concentration at X, Y and Z in unit time were listed according to the principle of CVVH and the screening coefficient of filter for different substances. ④The calculation formulas were entered into Excel form, and a mathematical calculation model was made, and a simulation calculation with examples was carried out. Results An Excel model was established by inserting the calculation formulas of volume, electrolyte, and total calcium at X, Y and Z. And it was found that the concentration of Na+, K+, Cl-, HCO3- at Y point remained unchanged only when A, B and (or) a, b was kept in same side and proportion even with the change of blood flow and other parameters without sodium citrate as anticoagulant. Once any of the parameters (such as blood flow, replacement fluid volume, etc.) were adjusted in other infusion methods (such as different ratios, different directions of the same year, etc.), the calculation results at Y would vary, and the electrolyte concentration at Z would change accordingly. A change of dilution model or parameter would result in the change of the electrolyte concentration at Y and Z with sodium citrate as anticoagulant. The concentration of total calcium scarcely changed no matter in what model and parameters. Conclusions All kinds of infusion ways could be included in the Excel model. The infusion results of all kinds of infusion matching could be intuitively evaluated. It is helpful for the medical staff to make a logical analysis and risk prediction in CVVH.
ABSTRACT
Corresponding author:Tao Shaohua,Email:tsh1987﹫sina. com [Abstract] Continuous renal replacement therapy(CRRT)has become the standard treatment for acute kidney injury or severe metabolic derangement in the pediatric intensive care unit. Anticoagulation for circuit patency is the prerequisite during CRRT operation. Regional citrate anticoagulation for CRRT is more effective and safe than systemic or regional heparin. Regional citrate anticoagulation can decrease the risk of circuit loss and filter failure;furthermore,it is safer than systemic heparin anticoagulation for the reduction of bleeding risk. Complications of citrate anticoagulation ( such as acid－base imbalance and electrolyte disturbances)can be avoided by using an appropriate protocol and regu﹣lar monitoring. Therefore,citrate should be considered as the first choice for anticoagulation during CRRT in critically ill pediatric patients,and further studies are needed to evaluate the safety and efficacy of citrate anticoagulation in the pediatric population.