Gabutti Luca, Marone Claudio, Colucci Giuseppe, Duchini Francesca, Schönholzer Carlo
Department of Internal Medicine, Ospedale la Carità Locarno, Locarno, Switzerland.
Intensive Care Med. 2002 Oct;28(10):1419-25. doi: 10.1007/s00134-002-1443-y. Epub 2002 Sep 6.
Feasibility and safety evaluation of regional citrate anticoagulation (RCA) versus systemic heparinization for continuous venovenous hemodiafiltration.
Combined retrospective and prospective observational study performed in a secondary multidisciplinary intensive care unit of the Ospedale Civico Lugano Switzerland.
Twelve hemodynamically unstable patients (median APACHE II score 26, interquartile range 22-29) in whom heparin was judged to be at least temporarily contraindicated. A switch from RCA (predilution setting; same iso-osmotic replacement and dialysis fluid) to heparinization or vice versa was recommended for the final evaluation; 56 dialyzers were used for RCA (1,400 h) and 39 for heparinization (1,271 h).
Median dialyzer life span was 24.2 h (interquartile range 17.4-42.3) for RCA and 42.5 h (20.6-69.1) for heparinization. Fluid control and dialysis quality were similar in the two groups and required no additional intervention. The risk of significant hypocalcemia and metabolic alkalosis was higher at the beginning of the RCA program and decreased with the further training of the staff. Seven bleeding episodes occurred with heparinization vs. three in RCA.
RCA may be a safe and useful form of anticoagulation which is more expensive than heparinization but helps to minimize bleeding risk. The risk of metabolic complications is higher at the beginning of a new RCA program. For centers lacking experienced staff we suggest reserving this technique for patients with rapid clotting of the extracorporeal circuit if treated without anticoagulation.
比较局部枸橼酸抗凝（RCA）与全身肝素化用于连续性静脉-静脉血液透析滤过的可行性和安全性。
在瑞士卢加诺市立医院的二级多学科重症监护病房进行的回顾性和前瞻性观察性联合研究。
12例血流动力学不稳定的患者（急性生理与慢性健康状况评分系统II [APACHE II]中位数为26，四分位间距为22 - 29），这些患者被判定至少暂时禁用肝素。为进行最终评估，建议从RCA（前稀释模式；等渗置换液和透析液相同）转换为肝素化，反之亦然；56个透析器用于RCA（共1400小时），39个用于肝素化（共1271小时）。
RCA组透析器中位使用寿命为24.2小时（四分位间距为17.4 - 42.3），肝素化组为42.5小时（20.6 - 69.1）。两组的液体控制和透析质量相似，无需额外干预。RCA方案开始时严重低钙血症和代谢性碱中毒的风险较高，随着工作人员进一步培训该风险降低。肝素化组发生7次出血事件，RCA组发生3次。
RCA可能是一种安全且有用的抗凝方式，虽比肝素化费用更高，但有助于将出血风险降至最低。新的RCA方案开始时代谢并发症的风险较高。对于缺乏经验丰富工作人员的中心，我们建议仅在体外循环快速凝血且未进行抗凝治疗的患者中使用该技术。
