柠檬酸体外抗凝集束化护理在严重烧伤患者连续性肾脏替代治疗中的应用效果

黎宁; 陈华玲; 李茂君; 罗高兴; 袁志强

doi:10.3760/cma.j.cn501120-20201201-00511

柠檬酸体外抗凝集束化护理在严重烧伤患者连续性肾脏替代治疗中的应用效果

doi: 10.3760/cma.j.cn501120-20201201-00511

陆军军医大学（第三军医大学）第一附属医院全军烧伤研究所，创伤、烧伤与复合伤国家重点实验室，重庆　　400038

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袁志强，Email：cqburn@aliyun.com

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出版历程
- 收稿日期: 2020-12-01

Application effects of bundle nursing of citric acid extracorporeal anticoagulation on continuous renal replacement therapy of severe burn patients

State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing 400038, China

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Corresponding author: Yuan Zhiqiang, Email: cqburn@aliyun.com

摘要

摘要: 目的探讨柠檬酸体外抗凝集束化护理在严重烧伤患者连续性肾脏替代治疗（CRRT）中的应用效果。方法采用非随机对照研究方法。将陆军军医大学（第三军医大学）第一附属医院2017年1—12月收治的符合入选标准的46例严重烧伤行CRRT柠檬酸体外抗凝常规护理的患者纳入常规护理组［男30例、女16例，年龄42.0（38.7，47.0）岁，共进行201次CRRT］，将该单位2018年1—12月收治的符合入选标准的48例严重烧伤行CRRT柠檬酸体外抗凝集束化护理的患者纳入集束化护理组［男32例、女16例，年龄41.0（36.0，46.0）岁，共进行164次CRRT］。统计2组所有患者住重症监护病房（ICU）时间、住ICU治疗总费用、CRRT费用、非计划结束治疗情况、因手术结束治疗情况（计算非计划结束治疗率、因手术结束治疗率）、一次性使用血液透析滤过器及配套管路滤器（下称滤器）使用时间>24 h次数、CRRT次数、滤器寿命；针对2组患者中从首次治疗开始连续接受3 d及以上CRRT者，统计首次治疗前（以下简称治疗前）与首次治疗3 d后（以下简称治疗3 d后）凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、国际标准化比值（INR）、总钙、离子钙（计算治疗前后总钙、离子钙差值）、肌酐、尿素、β ₂微球蛋白、胱抑素C、血小板计数、平均动脉压、pH值、氧合指数、碳酸氢根、乳酸水平；统计2组所有患者住院期间发生治疗相关并发症情况。对数据行独立样本 t检验、Mann-Whitney U检验、 χ ² 检验。结果与常规护理组比较，集束化护理组患者住ICU时间明显缩短（ Z=-4.71， P<0.01），住ICU治疗总费用明显减少（ t=-1.39， P<0.01），CRRT费用无明显变化（ P>0.05），非计划结束治疗率、因手术结束治疗率均明显降低（ χ ² 值分别为12.20、17.83， P<0.01），滤器使用时间>24 h次数明显增加（ Z=-5.93， P<0.01），CRRT次数明显减少（ Z=-4.75， P<0.01），滤器寿命明显延长（ Z=-9.24， P<0.01）。集束化护理组31例患者、常规护理组28例患者从首次治疗开始连续接受了3 d及以上的CRRT。治疗前，集束化护理组患者PT、APTT、INR分别为24.10（16.08，39.20）s、38.81（32.32，45.50）s、1.17（1.12，1.19），与常规护理组患者的31.75（22.99，40.96）s、41.82（35.05，48.06）s、1.15（1.11，1.19）相近（ P>0.05）；2组患者总钙、离子钙水平相近（ P>0.05）。治疗3 d后，集束化护理组与常规护理组患者PT、APTT、INR分别为29.06（20.11，39.46）s、35.25（30.06，40.28）s、1.13（1.09，1.17）与36.51（26.64，42.92）s、39.89（34.81，46.62）s、1.14（1.10，1.18），均与治疗前相近（ P>0.05）；常规护理组患者离子钙水平较治疗前明显升高（ Z=-2.08， P<0.05），集束化护理组患者总钙、离子钙水平均较治疗前明显升高（ Z值分别为-3.55、-3.69， P<0.01）；集束化护理组患者APTT明显短于常规护理组（ Z=-2.29， P<0.05），总钙水平明显高于常规护理组（ Z=-2.26， P<0.05）。集束化护理组患者治疗前后总钙差值明显高于常规护理组（ Z=-3.15， P<0.01），2组患者治疗前后离子钙差值相近（ P>0.05）。治疗前，集束化护理组患者β ₂微球蛋白水平明显高于常规护理组（ Z=-2.84， P<0.01），血小板计数明显低于常规护理组（ Z=-2.44， P<0.05）；2组患者肌酐、尿素、胱抑素C、平均动脉压、pH值、氧合指数、碳酸氢根及乳酸水平相近（ P>0.05）。治疗3 d后，集束化护理组患者肌酐、尿素、β ₂微球蛋白、胱抑素C、pH值、碳酸氢根及乳酸水平均较治疗前明显下降（ Z值分别为-2.10、-2.90、-3.11、-2.02、-2.34、-2.63、-2.84， P<0.05或 P<0.01），血小板计数、氧合指数、平均动脉压均较治疗前明显升高（ Z值分别为-6.65、-2.40， t=-9.97， P<0.05或 P<0.01）；常规护理组患者肌酐、尿素、β ₂微球蛋白、胱抑素C、血小板计数、pH值、碳酸氢根及乳酸水平均较治疗前明显下降（ Z值分别为-5.32、-2.31、-2.41、-2.21、-3.68、-2.93、-2.20、-2.31， P<0.05或 P<0.01），氧合指数、平均动脉压均较治疗前明显升高（ Z=-5.59， t=-7.74， P<0.01）。治疗3 d后，集束化护理组患者肌酐、胱抑素C、血小板计数、氧合指数、碳酸氢根、平均动脉压水平均明显高于常规护理组（ Z值分别为-2.93、-1.99、-6.39、-2.09、-2.52， t=-3.28， P<0.05或 P<0.01），尿素、β ₂微球蛋白、pH值及乳酸水平均明显低于常规护理组（ Z值分别为-3.87、-2.58、-4.24、-2.75， P<0.05或 P<0.01）。住院期间，2组患者均未发生治疗相关性出血事件、与柠檬酸治疗相关的高钠血症。集束化护理组1例患者总钙与离子钙比值>2.5，但无柠檬酸蓄积中毒表现；1例患者发生低离子钙血症、1例患者发生严重代谢性碱中毒。常规护理组5例患者发生低离子钙血症，2例患者发生严重代谢性碱中毒。结论在严重烧伤患者CRRT中实行柠檬酸体外抗凝集束化护理缩短了患者住ICU时间，减少了住ICU治疗总费用以及治疗相关并发症的发生，减轻了患者经济负担，提高了治疗连续性和质量。
- 烧伤 /
- 柠檬酸 /
- 护理 /
- 集束化 /
- 连续性肾脏替代治疗
Abstract: Objective To explore the application effects of bundle nursing of citric acid extracorporeal anticoagulation on continuous renal replacement therapy (CRRT) of severe burn patients. Methods A non-randomized controlled study was conducted. Forty-six patients who met the inclusion criteria and received regular nursing of citric acid extracorporeal anticoagulation during CRRT in the First Affiliated Hospital of Army Medical University (the Third Military Medical University) from January to December 2017 were included in regular nursing group (30 males and 16 females, aged 42.0 (38.7,47.0) years, with 201 times of CRRT performed), and 48 patients who met the inclusion criteria and received bundle nursing of citric acid extracorporeal anticoagulation during CRRT in the same hospital from January to December 2018 were included in bundle nursing group (32 males and 16 females, aged 41.0 (36.0,46.0) years, with 164 times of CRRT performed). The clinical data of all the patients in the two groups were recorded, including the length of intensive care unit (ICU) stay, total cost of treatment in ICU, cost of CRRT, unplanned ending of treatment, ending of treatment due to operation (with the rates of unplanned ending of treatment and ending of treatment due to operation calculated), times of disposable hemodialysis filter and supporting pipeline filter (hereinafter referred to as filter) with use time>24 h, times of CRRT, and lifetime of filter. For the patients in both groups who continuously received CRRT for 3 days or more from the first treatment, the prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), total calcium, ionic calcium (with the difference of total calcium or ionic calcium between before and after treatment calculated), creatinine, urea, β ₂ microglobulin, cystatin C, platelet count, mean arterial pressure, pH value, oxygenation index, bicarbonate radical, and lactic acid levels before the first treatment (hereinafter referred to as before treatment) and 3 days after the first treatment (hereinafter referred to as after 3 days of treatment). The treatment-related complications of all patients in the two groups were recorded during hospitalization. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. Results Compared with those in regular nursing group, the length of ICU stay was significantly shortened ( Z=-4.71, P<0.01), the total cost of treatment in ICU was significantly reduced ( t=-1.39, P<0.01), the cost of CRRT had no significant change ( P>0.05), the rates of unplanned ending of treatment and ending of treatment due to operation were both significantly decreased (with χ ² ^{values of 12.20 and 17.83, respectively, P<0.01), the times of filter service time>24 h was increased significantly ( Z=-5.93, P<0.01), the times of CRRT were significantly reduced ( Z=-4.75, P<0.01), and the filter service life was significantly prolonged ( Z=-9.24, P<0.01) among patients in bundle nursing group. Thirty-one patients in bundle nursing group and 28 patients in regular nursing group continuously received CRRT for 3 days or more from the first treatment. Before treatment, PT, APTT, and INR of patients in bundle nursing group were 24.10 (16.08, 39.20) s, 38.81 (32.32, 45.50) s, and 1.17 (1.12, 1.19), respectively, similar to 31.75 (22.99, 40.96) s, 41.82 (35.05, 48.06) s, and 1.15 (1.11, 1.19) of patients in regular nursing group ( P>0.05); the levels of total calcium and ionic calcium of patients in the two groups were similar ( P>0.05). After 3 days of treatment, PT, APTT, and INR of patients in bundle nursing group and regular nursing group were 29.06 (20.11, 39.46) s, 35.25 (30.06, 40.28) s, 1.13 (1.09, 1.17) and 36.51 (26.64, 42.92) s, 39.89 (34.81, 46.62) s, 1.14 (1.10, 1.18), respectively, similar to those before treatment ( P>0.05); the level of ionic calcium of patients in regular nursing group was significantly higher than that before treatment ( Z=-2.08, P<0.05); the levels of total calcium and ionic calcium of patients in bundle nursing group were both significantly higher than those before treatment (with Z values of -3.55 and -3.69, respectively, P<0.01); compared with those in regular nursing group, APTT of patients was significantly shorter ( Z=-2.29, P<0.05), while the total calcium level of patients was significantly higher in bundle nursing group ( Z=-2.26, P<0.05). The difference of total calcium between before and after treatment of patients in bundle nursing group was significantly higher than that in regular nursing group ( Z=-3.15, P<0.01). The differences of ionic calcium between before and after treatment of patients in the two groups were similar ( P>0.05). Before treatment, the level of β ₂microglobulin of patients in bundle nursing group was significantly higher than that in regular nursing group ( Z=-2.84, P<0.01), the platelet count of patients in bundle nursing group was significantly lower than that in regular nursing group ( Z=-2.44, P<0.05), while the levels of creatinine, urea, cystatin C, mean arterial pressure, pH value, oxygenation index, bicarbonate radical, and lactic acid of patients in the two groups were similar ( P>0.05). After 3 days of treatment, the levels of creatinine, urea, β ₂ microglobulin, cystatin C, pH value, bicarbonate radical, and lactic acid of patients were all significantly lower than those before treatment (with Z values of -2.10, -2.90, -3.11, -2.02, -2.34, -2.63, and -2.84, respectively, P<0.05 or P<0.01), while the levels of platelet count, oxygenation index, and mean arterial pressure of patients were all significantly higher than those before treatment in bundle nursing group (with Z values of -6.65 and -2.40, respectively, t=-9.97, P<0.05 or P<0.01); the levels of creatinine, urea, β ₂ microglobulin, cystatin C, platelet count, pH value, bicarbonate radical, and lactic acid of patients were all significantly lower than those before treatment (with Z values of -5.32, -2.31, -2.41, -2.21, -3.68, -2.93, -2.20, and -2.31, respectively, P<0.05 or P<0.01), while the oxygenation index and mean arterial pressure of patients were both significantly higher than those before treatment in regular nursing group ( Z=-5.59, t=-7.74, P<0.01). After 3 days of treatment, compared with those in regular nursing group, the levels of creatinine, cystatin C, platelet count, oxygenation index, bicarbonate radical, and mean arterial pressure of patients were all significantly higher (with Z values of -2.93, -1.99, -6.39, -2.09, and -2.52, respectively, t=-3.28, P<0.05 or P<0.01), while the levels of urea, β ₂ microglobulin, pH value, and lactic acid of patients were all significantly lower (with Z values of -3.87, -2.58, -4.24, and -2.75, respectively, P<0.05 or P<0.01) in bundle nursing group. During hospitalization, there were no treatment-related bleeding events or hypernatremia related to citric acid treatment of patients in the two groups. The ratio of total calcium to ionic calcium in one patient in bundle nursing group was >2.5, but there was no manifestation of citric acid accumulation poisoning; 1 patient had hypoionic calcemia, and 1 patient had severe metabolic alkalosis. Five patients had hypoionic calcemia and 2 patients had severe metabolic alkalosis in regular nursing group.} Conclusions The implementation of bundle nursing of citric acid extracorporeal anticoagulation during CRRT for severe burn patients shortens the length of ICU stay, reduces the total cost of treatment in ICU and the occurrence of treatment-related complications, relieves the economic burden of patients, and improves the continuity and quality of treatment.
- Burns /
- Citric acid /
- Nursing care /
- Bundle /
- Continuous renal replacement therapy
黎宁：研究设计、数据分析、论文撰写；陈华玲：采集数据、数据分析；李茂君：数据分析；罗高兴：研究指导；袁志强：研究指导、论文修改

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表1 2组严重烧伤行柠檬酸体外抗凝连续性肾脏替代治疗患者一般资料比较

组别	例数	性别［例（%）］		年龄［岁， M（ Q ₁， Q ₃）］	身体质量指数［kg/m ²， M（ Q ₁， Q ₃）］	烧伤总面积（%TBSA， x ¯ ± s ）	Ⅲ度烧伤面积［%TBSA， M（ Q ₁， Q ₃）］	入院时ABSI评分［分， M（ Q ₁， Q ₃）］	吸入性损伤［例（%）］	入院时APACHEⅡ评分［分， M（ Q ₁， Q ₃）］
组别	例数	男	女	年龄［岁， M（ Q ₁， Q ₃）］	身体质量指数［kg/m ²， M（ Q ₁， Q ₃）］	烧伤总面积（%TBSA， x ¯ ± s ）	Ⅲ度烧伤面积［%TBSA， M（ Q ₁， Q ₃）］	入院时ABSI评分［分， M（ Q ₁， Q ₃）］	吸入性损伤［例（%）］	入院时APACHEⅡ评分［分， M（ Q ₁， Q ₃）］
集束化护理组	48	32（66.7）	16（33.3）	41.0（36.0，46.0）	22.8（21.3，24.2）	66±8	59.0（52.0，65.0）	11.0（10.0，12.0）	8（16.7）	17.0（16.0，18.0）
常规护理组	46	30（65.2）	16（34.8）	42.0（38.7，47.0）	23.8（21.8，24.7）	68±8	60.0（53.7，66.0）	12.0（10.0，13.0）	9（19.6）	17.0（16.0，18.0）
统计量值		χ ²=0.02		Z=-1.14	Z=-1.79	t=0.96	Z=-0.72	Z=-1.13	χ ²=0.13	Z=-1.45
P值		0.882		0.252	0.073	0.339	0.472	0.257	0.715	0.148
注：TBSA为体表总面积，ABSI为简明烧伤严重指数，APACHEⅡ为急性生理和慢性健康状况评价Ⅱ

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表2 2组严重烧伤行柠檬酸体外抗凝连续性肾脏替代治疗患者住ICU时间及相关费用比较

组别	例数	住ICU时间［d， M（ Q ₁， Q ₃）］	住ICU治疗总费用（元， x ¯ ± s ）	连续性肾脏替代治疗费用［元， M（ Q ₁， Q ₃）］
集束化护理组	48	64.0（58.0，72.0）	798 371±53 773	46 178.0（43 270.0，49 268.0）
常规护理组	46	78.0（68.0，82.0）	918 379±55 548	47 668.0（45 204.5，49 373.5）
统计量值		Z=-4.71	t=-1.39	Z=-1.42
P值		<0.001	<0.001	0.156
注：ICU为重症监护病房

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表3 2组严重烧伤行柠檬酸体外抗凝连续性肾脏替代治疗患者治疗连续性比较

组别	治疗次数	非计划结束治疗情况［次（%）］	因手术结束治疗情况［次（%）］	滤器寿命［h， M（ Q ₁， Q ₃）］
集束化护理组	164	10（6.10）	9（5.49）	32.5（20.0，39.0）
常规护理组	201	37（18.41）	42（20.90）	18.0（11.0，24.0）
统计量值		χ ² =12.20	χ ² =17.83	Z=-9.24
P值		<0.001	<0.001	<0.001
注：集束化护理组、常规护理组患者数分别为48、46例；滤器指一次性使用血液透析滤过器及配套管路滤器；1次治疗使用1个滤器

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表4 2组严重烧伤行柠檬酸体外抗凝连续性肾脏替代治疗患者首次治疗前后凝血指标与电解质指标比较[ M（ Q ₁， Q ₃）]

组别与时间点	例数	凝血酶原时间（s）	活化部分凝血活酶时间（s）	国际标准化比值	总钙（mmol/L）	离子钙（mmol/L）
集束化护理组	31
治疗前		24.10（16.08，39.20）	38.81（32.32，45.50）	1.17（1.12，1.19）	2.02（1.85，2.14）	1.02（0.91，1.09）
治疗3 d后		29.06（20.11，39.46）	35.25（30.06，40.28）	1.13（1.09，1.17）	2.25（2.06，2.47）	1.22（1.09，1.65）
常规护理组	28
治疗前		31.75（22.99，40.96）	41.82（35.05，48.06）	1.15（1.11，1.19）	2.02（1.86，2.13）	1.02（0.91，1.09）
治疗3 d后		36.51（26.64，42.92）	39.89（34.81，46.62）	1.14（1.10，1.18）	2.10（1.81，2.29）	1.09（1.00，1.50）
Z ₁值		-1.08	-1.34	-0.02	-0.03	-0.08
P ₁值		0.281	0.182	0.982	0.976	0.933
Z ₂值		-1.78	-2.29	-0.39	-2.26	-1.41
P ₂值		0.075	0.022	0.699	0.024	0.160
Z ₃值		-0.92	-1.58	-1.24	-3.55	-3.69
P ₃值		0.360	0.113	0.214	<0.001	<0.001
Z ₄值		-1.45	-0.57	-0.89	-1.09	-2.08
P ₄值		0.146	0.571	0.374	0.276	0.038
注： Z ₁值、 P ₁值， Z ₂值、 P ₂值分别为2组间治疗前、治疗3 d后各指标比较所得， Z ₃值、 P ₃值， Z ₄值、 P ₄值分别为集束化护理组、常规护理组组内治疗前后各指标比较所得

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表5 2组严重烧伤行柠檬酸体外抗凝连续性肾脏替代治疗患者首次治疗前后肾功能指标、平均动脉压、血小板计数及动脉血气分析指标比较

组别与时间点	例数	肌酐［µmol/L， M（ Q ₁， Q ₃）］	尿素［mmol/L， M（ Q ₁， Q ₃）］	β ₂微球蛋白［mg/L， M（ Q ₁， Q ₃）］	胱抑素C［mg/L， M（ Q ₁， Q ₃）］	血小板计数［×10 ⁹/L， M（ Q ₁， Q ₃）］
集束化护理组	31
治疗前		244.00（157.00，426.00）	19.40（10.80，30.20）	3.40（2.78，4.77）	1.76（1.14，2.10）	78.96（59.90，88.20）
治疗3 d后		178.00（155.00，242.51）	11.90（9.50，15.20）	2.79（2.29，3.16）	1.38（0.94，1.75）	178.06（125.76，250.13）
常规护理组	28
治疗前		222.90（199.65，240.73）	19.12（17.29，23.53）	2.86（2.79，2.93）	1.93（0.58，7.52）	89.71（69.82，120.40）
治疗3 d后		145.00（124.27，189.07）	16.61（14.53，20.12）	2.82（2.76，5.21）	1.12（0.61，1.43）	57.04（47.00，84.94）
统计量值 ₁		Z=-1.01	Z=-0.18	Z=-2.84	Z=-1.04	Z=-2.44
P ₁值		0.309	0.855	0.005	0.298	0.015
统计量值 ₂		Z=-2.93	Z=-3.87	Z=-2.58	Z=-1.99	Z=-6.39
P ₂值		0.003	<0.001	0.010	0.046	<0.001
统计量值 ₃		Z=-2.10	Z=-2.90	Z=-3.11	Z=-2.02	Z=-6.65
P ₃值		0.035	0.004	0.002	0.043	<0.001
统计量值 ₄		Z=-5.32	Z=-2.31	Z=-2.41	Z=-2.21	Z=-3.68
P ₄值		<0.001	0.021	0.042	0.027	<0.001
注：1 mmHg=0.133 kPa；统计量值 ₁、 P ₁值，统计量值 ₂、 P ₂值分别为2组间治疗前、治疗3 d后各指标比较所得，统计量值 ₃、 P ₃值，统计量值 ₄、 P ₄值分别为集束化护理组、常规护理组组内治疗前后各指标比较所得

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