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枸橼酸

枸橼酸抗凝方法及机制综述(很全)

PediatrNephrol(2014)29:1625–1631DOI10.1007/s00467-014-2770-2

ORIGINALARTICLE

RegionalcitrateanticoagulationforpediatricCRRT

usingintegratedcitratesoftwareandphysiologicalsodiumconcentrationsolutions

Jean-MichelLiet&EmmaAllain-Launay&

BénédicteGaillard-LeRoux&FrançoisBarrière&

AlexisChenouard&Jean-MarcDejode&NicolasJoram

Received:27September2013/Revised:7January2014/Accepted:22January2014/Publishedonline:15February2014#IPNA2014

Abstract

BackgroundIncontinuousrenalreplacementtherapy(CRRT),regionalcitrateanticoagulationoffersanattractivealternativetoheparinization,especiallyforchildrenwithahighbleedingrisk.

MethodsWereportonanewmanagementapproachtoCRRTusingintegratedcitratesoftwareandphysiologicalsodiumconcentrationsolutions.Convectivefiltrationwasperformedwithpre-filtercitrateanticoagulationusingan18mmol/Lcitratesolutionandapost-filterreplacementfluid.Thecitrateflowratewasautomaticallyadjustedtothebloodflowratebymeansofintegratedcitratesoftware.Similarly,calciumwasautomaticallyinfusedintochildrentomaintaintheirbloodcalciumlevelswithinnormalrange.

ResultsElevenCRRTsessionswereperformed(330h)insevencriticallyillchildrenaged3–15years(extremevalues15–66kg).Diseasecategoriesincludedsepsiswithmultiorgandysfunction(n=2)andhemolyticuremicsyndrome(n=5).Medianeffluentdosewas2.1(extremevalues1.7–3.3)L/h/1.73m2.Nosessionhadtobestoppedbecauseofmetaboliccomplications.Calciumlevels,bothinthecircuitsandinthecirculatingbloodofthechildren,remainedstableandsecure.ConclusionsRegionalcitrateanticoagulationcanbeusedinchildrenwithabodyweightof>15kgusingintegratedcitratesoftwareandcommerciallyavailablesolutionswith

physiologicalsodiumconcentrationsinasafe,effectiveandconvenientprocedure.

KeywordsContinuousvenovenoushemofiltration.Children.Citrateanticoagulation.Acutekidneyinjury.

Continuousrenalreplacementtherapy.Pediatricintensivecare

Introduction

Incontinuousrenalreplacementtherapy(CRRT),regionalcitrateanticoagulationoffersanattractivealternativetoheparinization,especiallyinpatientswithahighbleedingrisksincetheydonothavetobeanticoagulated[1–4].Inthistherapeuticmodality,anticoagulationoccursonlyintheextra-corporealcircuitthroughtheinfusionofcitratewhichchelatesionizedcalcium,resultinginverylowcalcemia.Bloodcalci-umlevelsandbloodcoagulationfactorsarerestoredafterthehemofilterbeforereturningtothechild.ManyNorthAmeri-canpediatricintensivecareunits(PICU)haveadoptedregion-alcitrateanticoagulation[5–9],butthistechniquehasprovendifficulttoimplementinunitswherethenursetochildratiois1to2andwhereongoingsupportfromnephrologycannotbeconsidered.Amongthedifficultieslinkedtotheimplementa-tionofthistechniquearethemeticulousadjustmentofcitrateandcalciumperfusionstothebloodflowrate,aswellasthelackofcommerciallyavailablephysiologicalfluidsandthecomplexityofvariousprotocolsusingmanydifferentsolutesandstrategies.

Wereporthereontheimplementationofregionalcitrateanticoagulationincontinuousvenovenoushemofiltration(CVVH)inauniversity-affiliated12-bedPICUusingintegrat-edcitratesoftware,commerciallyavailablesolutionscontain-ingphysiologicalsodiumconcentrationsandsimplifiedprocedures.

J.<M.Liet(*)B.Gaillard-LeRouxF.BarrièreA.ChenouardJ.<M.Dejode:N.Joram

UnitédeRéanimationPédiatrique,PôleFemme-Enfant-Adolescent,Centrehospitalieruniversitaire(CHU)deNantes,38BoulevardJean-Monnet,44093Nantes,Francee-mail:jeanmichel.liet@chu-nantes.fr

E.Allain-Launay

UnitédeNéphrologiePédiatrique,CliniqueMédicalePédiatrique,PôleFemme-Enfant-Adolescent,CHUofNantes,Nantes,France

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