Herrera-Gutiérrez M E, Seller-Pérez G, Lebrón-Gallardo M, De La Cruz-Cortés J P, González-Correa J A
Servicio de Cuidados Críticos y Urgencias, Complejo Hospitalario Hospital Universitario Carlos Haya, Málaga, España.
Med Intensiva. 2006 Oct;30(7):314-21. doi: 10.1016/s0210-5691(06)74536-3.
At present, there is no consensus on the best anticoagulant regimen for the maintenance of extrarenal clearance circuits (RRTC). We present our experience with the isolated use of epoprostenol in patients at risk of bleeding or associated to non-fractionated heparin (nFH) in patients with problems of early coagulation of the filters.
Prospective study of cohorts on all the RRTC filters used in our service since 1994.
Forty-two-bed polyvalent ICU in a tertiary hospital.
Anticoagulation was administered in prefilter perfusion, at doses of 5-7 U/kg/hour for nFH or 4-5 ng/kg/min for epoprostenol. The combined use was done with equal doses of epoprostenol and nFH at 2,5 U/kg/hour. VARIABLES OF MAIN INTEREST: We analyzed the duration of each filter, reason for removing the filter, existence of coagulopathy, platelet count, appearance of bleeding, anticoagulant used and dose.
We analyzed the use of 2,322 filters (66,957 hours) in 389 patients, 54% of whom had a clot. nFH was used in 74% of the filters for a median of 39 hours (interquartile range: 19-75), epoprostenol in 6% for 32 hours (interquartile range: 17-48) and combined therapy in 4% for 27 hours (interquartile range: 19-41). In the epoprostenol group, we detected a decrease in blood pressure in only two filters that became normal when the dose was decreased. The filters that were initially anticoagulated with nFH had a 14-hour survival as a median versus 27 hours in combined therapy (p < 0.001). In absence of coagulopathy or thrombopenia, we observed mild bleeding in 8%, moderate in 1% and serious in 1% in the 1,170 filters treated with nFH. We only observed mild bleeding in 3% in 66 filters with epoprostenol.
Isolated epoprostenol in patients at risk of bleeding provided a similar duration of the filters to nFH, decreasing the risk of bleeding. The use of epoprostenol plus low dose nFH significantly increases their duration in patients with early coagulation.
目前，对于维持肾外清除回路（RRTC）的最佳抗凝方案尚无共识。我们介绍了在有出血风险的患者中单独使用依前列醇的经验，以及在滤器早期凝血问题患者中与普通肝素（nFH）联合使用的经验。
对自1994年以来我们科室使用的所有RRTC滤器进行队列前瞻性研究。
一家三级医院的42张床位的综合重症监护病房。
在滤器前灌注中进行抗凝，nFH的剂量为5 - 7 U/kg/小时，依前列醇的剂量为4 - 5 ng/kg/分钟。联合使用时，依前列醇和nFH的剂量均为2.5 U/kg/小时。主要关注变量：我们分析了每个滤器的使用时长、滤器移除原因、是否存在凝血病、血小板计数、出血情况、使用的抗凝剂及其剂量。
我们分析了389例患者中2322个滤器的使用情况（共66957小时），其中54%的滤器出现了凝血。74%的滤器使用了nFH，中位使用时长为39小时（四分位间距：19 - 75）；6%的滤器使用了依前列醇，时长为32小时（四分位间距：17 - 48）；4%的滤器采用联合治疗，时长为27小时（四分位间距：19 - 41）。在依前列醇组中，仅在两个滤器中检测到血压下降，降低剂量后血压恢复正常。最初用nFH抗凝的滤器中位存活时长为14小时，而联合治疗组为27小时（p < 0.001）。在无凝血病或血小板减少症的情况下，在1170个使用nFH治疗的滤器中，我们观察到8%出现轻度出血，1%出现中度出血，1%出现严重出血。在66个使用依前列醇的滤器中，仅3%出现轻度出血。
在有出血风险的患者中单独使用依前列醇，滤器的使用时长与nFH相似，且降低了出血风险。在早期凝血患者中，使用依前列醇加低剂量nFH可显著延长滤器使用时长。
