Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China.
BMC Anesthesiol. 2021 Mar 30;21(1):96. doi: 10.1186/s12871-021-01319-4.
The cumbersome program and the shortage of commercial solution hindered the regular application of regional citrate anticoagulation (RCA). It is urgent to simplify the protocol using only commercial preparations. The aim of this study was to explore the feasibility and efficacy of the modified protocol for continuous veno-venous hemofiltration (CVVH) in unselected critically ill patients.
A prospective cohort study was conducted in 66 patients who received a new protocol combining fixed citrate concentration with modified algorithm for supplements (i.e., fixed protocol), and compared the efficacy, safety and convenience for this group to a historical control group with a traditional protocol (n = 64), where citrate was titrated according to the circuit ionized calcium concentration (i.e., titrated protocol). The convenience was defined as the demand for monitoring test and dose adjustment of any supplement.
The filter lifespan was 63.2 ± 16.1 h in the fixed group and 51.9 ± 17.7 h in the titrated group, respectively. Kaplan-Meier survival analysis demonstrated longer circuit lifetime for fixed group (log-rank, p = 0.026). The incidence of circuit clotting was lower in the fixed protocol (15.2% vs. 29.7% in the titrated protocol, p = 0.047). Moreover, compared with the titrated group, patients with fixed protocol had less demand for monitoring test and dose adjustment of any supplement (the number of times per person per day) (3.3 [IQR 2.3-4.5] vs. 5.7 [IQR 3.3-6.9], p = 0.001 and 1.9 [IQR 0.5-2.7] vs. 6.3 [IQR 4.2-7.9], p < 0.001; respectively). No new onset bleeding complications occurred in all patients. The overall incidence of suspected citrate accumulation was 4.6% and there was no difference between the two groups (p = 0.969), yet a lower rate of metabolic alkalosis was found in the fixed group (3.0% vs. 14.1%, p = 0.024).
Our modified fixed citrate concentration protocol is feasible, safe and effective to enhance the circuit lifespan and the convenience of implementation while maintaining a similar safety when compared to the traditional protocol. Using only commercial preparations may be helpful for widespread application of RCA.
Clinicaltrials.gov. NCT02663960 . Registered 26 January 2016.
繁琐的方案和商业解决方案的短缺阻碍了局部枸橼酸抗凝（RCA）的常规应用。急需使用仅有的商业制剂来简化方案。本研究旨在探索改良的连续静脉-静脉血液滤过（CVVH）方案在未经选择的危重症患者中的可行性和疗效。
对 66 例接受新方案（即固定方案）的患者进行前瞻性队列研究，该方案将固定浓度的枸橼酸与改良的补充算法相结合，将其疗效、安全性和便利性与传统方案（即滴定方案）的历史对照患者（n=64）进行比较，其中枸橼酸根据回路离子钙浓度进行滴定。便利性定义为监测测试和任何补充剂量调整的需求。
固定组的滤器寿命为 63.2±16.1 h，滴定组为 51.9±17.7 h。Kaplan-Meier 生存分析显示固定组的回路寿命更长（对数秩检验，p=0.026）。固定方案的回路凝血发生率较低（固定方案 15.2%，滴定方案 29.7%，p=0.047）。此外，与滴定组相比，固定方案组的监测测试和任何补充剂量调整的需求较少（每人每天的次数）（3.3[IQR 2.3-4.5] vs. 5.7[IQR 3.3-6.9]，p=0.001；1.9[IQR 0.5-2.7] vs. 6.3[IQR 4.2-7.9]，p<0.001）。所有患者均未发生新发出血并发症。疑似枸橼酸盐蓄积的总发生率为 4.6%，两组间无差异（p=0.969），但固定组代谢性碱中毒发生率较低（3.0%vs. 14.1%，p=0.024）。
与传统方案相比，我们改良的固定枸橼酸浓度方案具有可行性、安全性和有效性，可以延长回路寿命，提高实施便利性，同时保持相似的安全性。仅使用商业制剂可能有助于 RCA 的广泛应用。
Clinicaltrials.gov。NCT02663960。2016 年 1 月 26 日注册。
