Yuav Ua Li Cas Anticoagulate hauv Nruam Raum Hloov Kho

Kev kho lub raum tsis tu ncua (CRRT) yog siv dav hauv kev kho mob tseem ceeb. Ntshav coagulation nyob rau hauv extracorporeal ncig yog ib qho teeb meem tseem ceeb ntawm CRRT. Anticoagulants tuaj yeem tiv thaiv cov ntshav coagulation hauv extracorporeal ncig zoo, tab sis kev tiv thaiv ntau dhau tuaj yeem ua rau los ntshav. Yog li ntawd, qhov zoo tshaj plaws anticoagulant ntsuas yuav tsum yooj yim rau kev siv thiab saib xyuas, thiab muaj kev cuam tshuam tsawg dua thiab muaj txiaj ntsig zoo dua.

Nyem rau cistanche phelypaea rau mob raum

Cov pab pawg kws tshaj lij ntawm Nephrology ceg ntawm Tuam Tshoj Medical Association tsis ntev los no tau tshaj tawm thawj tsab ntawm "Cov Lus Qhia rau Kev Tswj Xyuas Kev Tiv Thaiv Kev Tiv Thaiv Kev Kho Mob Nruam Raum Hloov Kho", ua rau CRRT anticoagulation kev lag luam cov qauv ua raws.

CRRT anticoagulation kev soj ntsuam thiab saib xyuas

CRRT Anticoagulant Management Guidelines Group tau muab ib lub tswv yim: ua ntej CRRT, nws raug nquahu kom cov neeg mob yuav tsum ua tib zoo tshuaj xyuas cov txiaj ntsig thiab kev pheej hmoo ntawm kev tiv thaiv coagulant, thiab tom qab ntawd txiav txim siab hom thiab txoj kev siv tshuaj tiv thaiv coagulant, thiab hloov kho cov tshuaj tiv thaiv kab mob raws li tus neeg mob tus mob. . Kho cov tshuaj anticoagulation regimen. Rau cov neeg mob uas tsis muaj ntshav los ntshav thiab coagulation mob, thiab tsis tau txais kev kho mob anticoagulant, nws raug nquahu kom siv cov tshuaj anticoagulant thaum CRRT.

Thaum ua CRRT, lub regional citrate anticoagulation yog pom zoo siv es tsis txhob ntawm heparin, tsuav yog tus neeg mob tsis muaj contraindications rau citrate siv. Yog tias tus neeg mob muaj contraindications rau kev siv citrate thiab tsis muaj kev pheej hmoo los ntshav, nws raug nquahu kom siv cov tshuaj heparin uas tsis muaj zog lossis tsis muaj molecular hnyav heparin es tsis txhob siv lwm cov tshuaj rau kev tiv thaiv. Qhov kev pom zoo no yog ua raws li xyoo 2012 rau Kev Txhim Kho Kev Txhim Kho Ntiaj Teb Lub Koom Haum (KDIGO) cov lus qhia rau cov lus pom zoo los tiv thaiv coagulation ntawm CRRT rau mob raum raug mob. Rau cov neeg mob uas muaj heparin-txog thrombocytopenia (HIT), nws raug nquahu kom tsis txhob siv cov tshuaj heparin, thiab nws raug nquahu kom siv cov tshuaj tiv thaiv kab mob thrombosis (xws li argatroban lossis lepirudin) lossis lwm yam Xa inhibitors (xws li danaparin lossis fondaparinux), es. dua li lwm cov tshuaj tiv thaiv coagulants lossis heparin-dawb anticoagulants.

Cov neeg mob uas muaj daim siab cirrhosis lossis daim siab tsis ua haujlwm tuaj yeem txiav txim siab siv cov tshuaj tiv thaiv hauv cheeb tsam citrate hauv kev saib xyuas ze, thiab cov kev kho mob pom zoo yog txuas ntxiv venovenous hemodialysis (CVVHD) lossis nruam venovenous hemodiafiltration (CVVHDF).

Hauv zos citrate anticoagulation CRRT

Hauv zos citrate anticoagulation, ob qho calcium ion concentrations yuav tsum tau saib xyuas: calcium ion concentration hauv extracorporeal ncig tuaj yeem tswj hwm ntawm 025-0.40 mmol / L kom ua tiav cov nyhuv anticoagulant hauv zos; Calcium ion concentration nyob rau hauv lub cev yog tswj nyob rau hauv ib txwm physiological ntau yam ntawm 1.1-1.3 mmol / L.

During local citrate anticoagulation, the serum total calcium level should be monitored at least once a day. If the ratio of serum total calcium to calcium ion is >2.1, the possibility of citrate accumulation should be considered; if the ratio is >2.5, citrate accumulation should be highly suspected. It is recommended to stop using local citrate anticoagulation and switch to other anticoagulation methods. For hyperlactatemia (>4 mmol / L), lub regional citrate anticoagulation tsis pom zoo. Nws raug nquahu kom siv lub txaj pw sai sai ntshav kuaj ntshav txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau txhawm rau nws nws nws yuav tsum tau ua tib zoo saib xyuas qhov ntsuas ntawm cov pa roj carbon dioxide. thiab nws yog ib qho tsim nyog los teem lub hom phiaj sib txawv raws li kev kho mob anticoagulation nyhuv. phiaj tus nqi.

Saib xyuas cov calcium ion ntau hauv lub cev tom qab lub lim rau thawj 2 teev, thiab tom qab ntawd ua haujlwm dynamic saib xyuas txhua 6 mus rau 8 teev tom qab stabilization; rau cov neeg mob uas muaj kev pheej hmoo ntawm citrate tsub zuj zuj, lub sijhawm saib xyuas tuaj yeem ua kom luv. Cov ntshav nyob rau hauv cov kab mob extracorporeal ua ntej lub lim tuaj yeem sau rau kev txiav txim siab ntawm pH tus nqi thiab electrolyte concentration; Txawm li cas los xij, thaum lub qhov hluav taws xob thiab qhov chaw nres nkoj ntawm ob lub lumen catheter rov qab txuas nrog cov kab hluav taws xob ntxiv, nws raug nquahu kom ncaj qha mus sau cov ntshav peripheral.

It is recommended to use traditional calcium-free replacement fluid, but calcium-containing replacement fluid can also be used. When local citric acid anticoagulation is used, if the replacement solution prefilled with citric acid is used, it is recommended to use pre-diluted supplementation. It is recommended to use a 4% sodium citrate anticoagulant solution, and ACD-A blood preservation solution can also be used; for blood glucose >10 mmol / L, ACD-A cov tshuaj tiv thaiv ntshav tsis pom zoo.

Nws raug nquahu kom siv CVVHDF thiab CVVHD hom kev kho mob. Yog siv CVVH, qhov pom feem yuav tsum tau tswj los ntawm 25 feem pua ​​​​rau 30 feem pua. Thaum siv 1.5 mmol / L calcium uas muaj cov kua hloov pauv, calcium ion supplementation tseem yuav tsum tau nyob rau hauv lub peripheral lossis extracorporeal ncig Circuit Court, thiab thawj zaug calcium ion supplementation tus nqi yog pom zoo kom 1.0 mmol / h / L.

Systemic anticoagulation CRRT

Thaum unfractionated heparin siv los ua cov tshuaj tiv thaiv coagulant, thawj koob tshuaj pom zoo yog 2000-3000 IU (30-40 IU/kg), thiab cov tshuaj noj yog 5-10 IU/kg/h. Nws raug nquahu kom saib xyuas lub sijhawm ua haujlwm ib feem ntawm thromboplastin (APTT), nrog lub hom phiaj ntawm kev tswj hwm APTT rau 1.2-1.5 npaug ntawm tus nqi hauv qab lossis ncav cuag 45-60 s.

Thaum siv cov tshuaj heparinoids xws li danaparin thiab nadroparin ua cov tshuaj tiv thaiv coagulants, cov koob tshuaj thawj zaug pom zoo yog {{0}} IU/kg, thiab cov tshuaj noj yog 5 IU/kg/h. Thaum enoxaparin thiab lwm yam uas tsis muaj molecular-yuag heparins tau siv los ua cov tshuaj tiv thaiv coagulants, qhov pom zoo thawj koob tshuaj yog 30-40 IU/kg, thiab cov tshuaj noj yog 3-5 IU/kg/h. Nws raug nquahu kom saib xyuas cov tshuaj tiv thaiv coagulant Xa kev ua haujlwm, nrog rau lub hom phiaj tus nqi ntawm 0.25-0.35 IU/ml.

Thaum argatroban siv los ua cov tshuaj tiv thaiv coagulant, thawj koob tshuaj pom zoo yog {{{0}}}1-0.2 mg/kg/h, thiab noj tshuaj yog 0.1 mg/ kg/h. Rau cov neeg mob uas lub siab tsis ua haujlwm, qhov koob tshuaj txo qis rau 0.05 mg / kg / h. Nws raug nquahu kom tswj hwm APTT ncua mus rau 1.2-1.5 npaug ntawm tus nqi pib lossis ncav cuag 45- xyoo 60.

Thaum nafamostat mesylate siv los ua cov tshuaj tiv thaiv coagulant, nws tuaj yeem siv rau cov neeg mob uas muaj kev pheej hmoo los ntshav siab. Thawj koob tshuaj pom zoo yog {{0}}.1-0.5 mg/kg, thiab cov koob tshuaj tu yog 0.1-0.5 mg/kg/h. Nws raug nquahu kom tswj hwm APTT thiab txuas ntxiv mus rau qhov pib ntawm 1.2 txog 1.5 npaug ntawm tus nqi lossis ncav cuag 45 txog 60s.

Anticoagulant-dawb CRRT

Rau cov neeg mob uas muaj kev ua haujlwm tsis zoo ntawm cov coagulation hnyav, los ntshav hnyav, thiab contraindications rau kev siv cov tshuaj tiv thaiv coagulants, CRRT tsis muaj cov tshuaj tiv thaiv coagulants raug pom zoo, tab sis cov kab mob extracorporeal ncig thiab lim coagulation yuav tsum ceev faj.

Nws raug nquahu kom yaug cov raj xa dej ua ntej thiab lim nrog heparinized saline, thiab tom qab ntawd yaug cov raj xa dej nrog cov tshuaj tsis muaj heparin ib txwm siv los tiv thaiv kev mob heparinization ntawm tus neeg mob. Thaum cov neeg mob laus tau txais CRRT yam tsis muaj tshuaj tiv thaiv coagulants, nws raug nquahu kom cov ntshav ntws ntau dua 200 ml / min ntawm qhov chaw uas cov hlab ntsha nkag mus tsis muaj kev cuam tshuam.

Nws raug pom zoo tias txoj kev hloov pauv yog ua ntej dilution, thiab kev kho ua ntej ua ntej dilution tuaj yeem siv tau. Thaum lub sij hawm lim ntshav, nws tsis pom zoo kom yaug lub voj voog nrog ntsev kom tsis txhob lim coagulation. Cov kev tshawb fawb hauv tsev kuj tseem pom tau tias kev haus dej ntau zaus tsis tuaj yeem pab txhim kho kev ua haujlwm coagulation ntawm cov neeg mob, thiab tuaj yeem ua rau muaj kev pheej hmoo ntawm cov kab mob hauv cov hlab ntsha hauv cov hlab ntsha extracorporeal.

Yog xav paub ntxiv:ali.ma@wecistanche.com