The Department of Intensive Care Medicine of Hengshui Fifth Hospital successfully treated a patient with uremia complicated by acute cerebral hemorrhage.
Patients with uremia require regular hemodialysis and heparin anticoagulation** during dialysis. If a patient with uremia has intracerebral hemorrhage, normal dialysis is required without heparin anticoagulation**, as heparin anticoagulation** increases the risk of bleeding. What to do?
Recently, the Department of Intensive Care Medicine of Hengshui Fifth Hospital successfully treated a patient with uremia complicated by acute cerebral hemorrhage using sodium citrate anticoagulation continuous renal replacement** technology.
The patient, a 68-year-old female, was admitted to the hospital with "slurred speech and 2-hour impairment of right limb movement". He had a history of hypertension, diabetes and renal insufficiency in the past, and was on hemodialysis 3 times a week at the Provincial Medical University due to edema and oliguria half a month ago. The emergency head CT of the five hospitals showed cerebral hemorrhage in the left basal ganglia and radiating coronal area. Admission diagnosis: cerebral hemorrhage in the left basal ganglia, grade 3 hypertension, chronic renal insufficiency, uremia, renal anemia, membranous nephropathy, hypoproteinemia type 2 diabetes mellitus, diabetic nephropathy. The patient has oliguria, the urine output is only 220ml a day, the second day of cerebral hemorrhage is the day of dialysis for the patient, dialysis needs to be anticoagulated with heparin, and anticoagulation with heparin in the acute phase of intracerebral hemorrhage will increase the risk of bleeding.
Anticoagulation with sodium citrate is the preferred anticoagulation** regimen in critically ill patients who require CRRT and are accompanied by bleeding or bleeding tendency. The anticoagulation principle of sodium citrate is related to ionized calcium, which reduces the concentration of Ca2+ in the blood, which is the mechanism of action of sodium citrate anticoagulation, which has the advantages of not easy bleeding, stable and long-lasting anticoagulation effect, long filter pipeline life, convenient anticoagulation monitoring, and increased biocompatibility. The safety of the free calcium reaction in the peripheral blood, the effectiveness of the free calcium reaction after the filter, the medical team of the intensive care medicine department has mastered the monitoring of blood calcium before and after filtration, and can carefully adjust the parameters, which has been carried out smoothly.
After the patient was transferred to our department, local citrate anticoagulant CRRT** was used for four times, and the dialysis time was up to 45 hours, during the dialysis period, the patient's vital signs were stable, and there was no obvious coagulation in the pipeline and filter, and a good anticoagulant effect was obtained. After dialysis, the blood and kidney function were significantly improved, the electrolytes were basically normal, and there was no rebleeding in the head CT, and the condition improved.
1.Indications for citrate anticoagulation.
1. Active bleeding or high-risk bleeding tendency. (1) Recent surgery and trauma; (2) bleeding tendency; (3) severe mucosal ulcers; (4) intracranial injury; (5) uremic pericarditis; (6) Severe diabetic retinopathy; (7) hypertensive crisis; (8) Uncontrollable coagulopathy.
2. Heparin-induced thrombocytopenia (HIT) and thrombosis.
3. Hypercalcemia.
2.Contraindications to citrate anticoagulation.
1.Severe liver failure, severe cirrhosis.
2.Severe circulatory collapse, and/or tissue hypoperfusion.
3.Restriction of citrate metabolism (septic shock, lactic acidosis).
CRRT technology has brought more life to critically ill patients. The development of citrate anticoagulation technology has made blood purification more widely used in high-risk patients who need kidney replacement** and have bleeding!
Breaking through this bottleneck, blood purification** is no longer limited by the anticoagulation method, which increases the rescue success rate of such patients. The Department of Intensive Care Medicine of Hengshui Fifth Hospital will continue to carry out the clinical application of citrate anticoagulation technology to escort critically ill patients and regain the sunshine of life!
Liu Yanhong, Department of Critical Care Medicine, Hengshui Fifth People's Hospital