Schmitz M, Taskaya G, Plum J, Hennersdorf M, Sucker C, Grabensee B, Hetzel G R
Clinic for Nephrology, University Hospital, Düsseldorf, Germany.
Anaesth Intensive Care. 2007 Aug;35(4):529-35. doi: 10.1177/0310057X0703500411.
Different methods of regional anticoagulation using citrate in continuous renal replacement therapy have been described in the past. However, these procedures were usually very complex or did not reach modem requirements for effective continuous renal replacement therapy. Furthermore, little is known about long-term acid-base stability and citrate levels during the treatment. We describe a system in which citrate is used both as anticoagulant and as the sole buffer substance in continuous venovenous haemofiltration. Our citrate-containing, calcium-free substitution fluid was used in predilution mode with a constant ratio between blood flow (120 to 150 ml/min) and substitution flow (2400 to 3000 ml/hour). Anticoagulation was limited to the extracorporeal circuit. Twenty patients with acute renal failure on mechanical ventilation were treated, four for eight hours, four for 24 hours and 12 as long they needed continuous renal replacement therapy (9.6 +/- 5.0 days, range 4.0 to 39.3 days). We achieved stable acid-base and electrolyte balance in all patients. We observed no bleeding complications (patient activated clotting time 112.4 +/- 17.1 s, post-filter circuit activated clotting time 270.5 +/- 80.3 s) and achieved appropriate filter life times (48.6 +/- 13.2 h). Predilution, citrate-based substitution fluid provides both anticoagulation within the extracorporeal circuit and control of acid-base balance in critically ill patients at risk of bleeding in acute renal failure. It is easy to apply and safe. Clearance can be varied as long as a constant ratio between blood and substitution flow is maintained.
过去已经描述了在连续性肾脏替代治疗中使用柠檬酸盐进行局部抗凝的不同方法。然而，这些方法通常非常复杂，或者未达到现代有效连续性肾脏替代治疗的要求。此外，对于治疗期间的长期酸碱稳定性和柠檬酸盐水平了解甚少。我们描述了一种系统，其中柠檬酸盐在连续性静脉-静脉血液滤过中既用作抗凝剂又用作唯一的缓冲物质。我们含柠檬酸盐的无钙置换液以预稀释模式使用，血流（120至150毫升/分钟）与置换液流速（2400至3000毫升/小时）之间保持恒定比例。抗凝仅限于体外循环。对20例机械通气的急性肾衰竭患者进行了治疗，4例治疗8小时，4例治疗24小时，12例根据需要进行连续性肾脏替代治疗（9.6±5.0天，范围4.0至39.3天）。我们在所有患者中均实现了稳定的酸碱和电解质平衡。未观察到出血并发症（患者活化凝血时间为112.4±17.1秒，滤器后回路活化凝血时间为270.5±80.3秒），并获得了合适的滤器使用寿命（48.6±13.2小时）。预稀释、基于柠檬酸盐的置换液在体外循环内提供抗凝作用，并控制急性肾衰竭有出血风险的危重症患者的酸碱平衡。它易于应用且安全。只要保持血液与置换液流速之间的恒定比例，清除率就可以变化。
