| Objective:To explore the predictive value of indocyanine green plasma clearance combined with lactic acid on the risk of citrate accumulation in patients undergoing continuous renal replacement therapy with regional citrate anticoagulation(RCA-CRRT).Method:This study prospectively and randomly enrolled 52 patients who underwent RCA-CRRT who were hospitalized in the intensive care unit of our hospital from December 2019 to December 2020.All patients were injected with indocyanine green intravenously 2 hours before CRRT,and indocyanine green plasma disappearance rate(ICG-PDR,normal value ≥18%/min)and indocyanine green retention rate at 15minutes(ICG-R15,normal value <10%)were detected.Patients were divided into three groups according to the ICG-PDR value: group A was ICG-PDR≥18%/min,group B was 8 %≤ICG-PDR<18%,group C is ICG-PDR<8%.Monitor blood gas analysis,blood lactate,blood routine,liver and kidney function electrolytes and coagulation function 2h before CRRT,blood gas analysis and blood electrolyte 2h after CRRT,and record blood gas analysis of calcium ions in the body and pipeline during CRRT.Calculate the three groups of patients before CRRT Model for end-stage liver disease(MELD)and MELD-Na.The filter life of the three groups of patients was counted,whether there were bleeding,acid-base balance disorders,and citric acid(Total calcium/ionized calcium in the body,t Ca/i Ca)accumulation complications.Result:A total of 52 critically ill patients who underwent RCA-RCCT were included in this study.Among them,3 patients who died during CRRT or their family members requested automatic discharge but the CRRT time was less than 24 hours were excluded(1 case in group A,2 cases in group C).Finally,49 patients were selected and divided into group A 10 cases,20 cases in group B,19 cases in group C,the results are as follows:1.There was no significant difference in the average age,gender composition ratio,height,weight,body mass index,average arterial pressure,and the number of mechanically ventilated patients in the three groups;the APACHE Ⅱ scores(34.68±5.95,28.70±5.66)of group C and group B were significantly higher In group A(25.00±5.10);SOFA of group C(16.47±2.46)was significantly higher than that of group B(14.60±2.96)was significantly higher than that of group A(10.70±3.30);the number of norepinephrine users in group C was 16(84.2%)and 16 people in group B(80%)were higher than 4 people in group A(40%).Total bilirubin,aspartate aminotransferase,alanine aminotransferase,prothrombin time,international normalized ratio,prothrombin activity,blood creatinine value,blood urea nitrogen in the three groups of patients within 2 hours before CRRT There were significant differences in blood lactic acid,MELD,MELD-Na and ICG-R15(P<0.05);there were no significant differences in albumin and platelets at baseline among the three groups(P=0.625 and P=0.618).2.When analyzing the correlation between ICG-PDR and liver function laboratory indicators,it was found that ICG-PDR was strongly correlated with MELD score K=-0.705,and was moderately correlated with MELD-Na score,TBil,PT,PTA,and INR.AST is weakly correlated,not correlated with ALT,and is moderately correlated with lactic acid.3.CRRT average blood flow rate,dialysate speed,replacement fluid speed,10%calcium gluconate pumping speed,10% magnesium sulfate pumping speed,citric acid speed/blood flow rate of the three groups of patients There was no statistically significant difference in treatment duration(P≥0.05).4.The blood total calcium and ionized calcium within 2 hours before CRRT,and the blood total calcium and ionized calcium within 2 hours after the end of CRRT were not significantly different in the three groups of patients,but the total blood calcium after the end of CRRT in each group was significantly higher than that before CRRT(A Group 2.18±0.07mmol/L VS 1.87±0.26mmol/L,P=0.006;Group B2.20±0.16 mmol L VS 1.95mmol/L,P<0.001;Group C 2.23±0.20 mmol L VS1.98±0.16 mmol L,P=0.004),and the ionized calcium after CRRT in groups A and B were higher than before CRRT(Group A 1.08±0.05 VS0.96±0.14,P=0.003,Group B1.09±0.06 VS0.99±0.10,P=0.006).The PH value of patients in group B after CRRT was higher than before CRRT(7.39±0.09 VS 7.33±0.07,P=0.001).5.The median life span of the first set of filters for the three groups of patients was 47 hours in group A was 47h(95% confidence interval 36.20,57.80)VS group B52h(95% confidence interval 40.59,63.41)VS C group 44h(95% confidence interval 36.93,50.07),The difference was not statistically significant(P=0.255).6.There was no significant difference in the probability of hypoionic calcemia,hyperionocalcemia,metabolic acidosis,and metabolic alkalosis during CRRT between the three groups of patients.11 people(57.89%)of group C had citrate accumulation(total calcium/ionized calcium ≥2.5)and 4 people(20%)of group B were significantly different(P=0.036),and compared with group A(10%))There is a significant difference(P=0.036).The occurrence time of 16 patients with citrate accumulation was 5.72±6.11 h.7.Logistic regression analysis of the risk factors for citric acid accumulation found: blood lactic acid and ICG-PDR are risk factors for citric acid accumulation,and then ROC curve analysis was used to calculate that the best cut-off value of lactic acid was 5.3 mmol/L,which The area under the curve(AUC)is 0.800(95%CI: 0.642,0.958),the sensitivity is 56.3%,and the specificity is 97%;the best cut-off value of ICG-PDR is 7.15%/min,and its AUC is 0.821(95 %CI: 0.688,0.954),the sensitivity was 68.8%,and the specificity was 84.8%.Multivariate logistic regression was used to establish the ICGPDR-lactic acid regression model:(P)=0.272×lactic acid-0.176×ICGPDR-0.461,the best cutoff value was 0.695,AUC was 0.852(95%CI:0.719,0.985),and the sensitivity was 75%,the specificity is 90.9%.Conclusion:Compared with lactic acid or ICGPDR,ICGPDR combined with lactic acid has a higher predictive value for the risk of citrate accumulation in RCA-CRRT patients.For critically ill patients with ICG-PDR<7.15%/min or lactic acid>5.3mmol/L,the risk of citric acid accumulation in RCA-CRRT is significantly increased. |
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