Devauchelle P, Page M, Brun P, Ber C-E, Crozon J, Baillon J-J, Allaouchiche B, Rimmelé T
Service d'anesthésie-réanimation, pavillon P réanimation, hôpital Édouard-Herriot, 5, place d'Arsonval, 69437 Lyon cedex 03, France.
Ann Fr Anesth Reanim. 2012 Jun;31(6):543-6. doi: 10.1016/j.annfar.2012.01.036. Epub 2012 Mar 30.
Regional citrate anticoagulation for continuous renal replacement therapy provides an efficient alternative to heparin as it reduces the likelihood of haemorrhage in critically ill patients with bleeding risk or coagulopathy and increases the haemofilter survival time. Liver failure is a classic contraindication of regional citrate anticoagulation since it carries the risk of citrate accumulation and its metabolic complications, although it could be attractive for this population of patients with high bleeding risk. We report three cases of continuous haemodialysis with regional citrate anticoagulation performed in patients with severe acute liver failure, without accumulation in two cases and with a suspected beginning of accumulation in the third case. For these patients, close monitoring of the total-to-ionized calcium ratio, pH and anion gap is particularly essential to control the safety of citrate infusion. Increasing effluent flow rate eliminates more calcium-bound citrate and therefore limits citrate accumulation and its consequences.
用于连续性肾脏替代治疗的局部枸橼酸抗凝法是肝素的一种有效替代方法，因为它降低了有出血风险或凝血病的重症患者出血的可能性，并延长了血液滤过器的使用寿命。肝衰竭是局部枸橼酸抗凝法的经典禁忌证，因为它存在枸橼酸蓄积及其代谢并发症的风险，尽管对于这类高出血风险的患者群体而言它可能具有吸引力。我们报告了3例在严重急性肝衰竭患者中采用局部枸橼酸抗凝法进行连续性血液透析的病例，其中2例未出现蓄积，第3例疑似开始出现蓄积。对于这些患者，密切监测总钙与离子钙比值、pH值和阴离子间隙对于控制枸橼酸输注的安全性尤为重要。提高流出液流速可消除更多与钙结合的枸橼酸，从而限制枸橼酸蓄积及其后果。
