血浆置换和MARS人工肝临床疗效与护理对策构建

发布时间：2018-05-12 05:54

本文选题：肝衰竭 + 终末期肝病　；参考：《山东大学》2014年硕士论文

【摘要】：研究背景与目的肝衰竭是多种因素引起的严重肝脏损害,导致其合成、解毒、排泄和生物转化等功能发生严重障碍或失代偿,出现以凝血功能障碍、黄疸、肝性脑病、腹水等为主要表现的一组临床症候群。其治疗主要包括内科综合治疗、人工肝支持治疗及肝移植。人工肝支持系统能替代肝脏解毒功能,清除体内毒性物质,改善内环境,为肝移植或肝细胞再生赢得时间。血浆置换和MARS是目前应用最广泛的人工肝技术,但两者的有效性和安全性缺乏深入的对照研究,特别是对不同的人工肝技术如何采取有针对性的护理缺少系统研究。人工肝治疗操作主要由护士完成,护理人员在人工肝治疗过程中扮演着重要角色。护理人员掌握熟练的操作规程,做好治疗前对患者的评估、术中的配合与病情观察、术后的护理是人工肝治疗得以顺利进行和成功的保证。所以,认真总结经验,探索合理的护理方案,所以如何根据不同人工肝技术的特点有针对性地构建护理对策,以最大程度地减少副作用或并发症、提高人工肝的治疗水平是非常必要的。方法本研究为回顾性对照研究。对2009年1月～2013年6月在我院接受人工肝治疗且资料相对完整的病例进行疗效、费用、病死率、死亡原因、副作用、并发症等方面进行多层次分析。研究对象为150例慢性乙型肝炎并肝衰竭的患者。肝衰竭的诊断符合《肝衰竭诊治指南(2012年版)》的诊断标准。根据不同的人工肝治疗,分A组和B组。A组为单用血浆置换组,共62例,其中男45例,女17例,平均年龄43.5±11.2岁；B组为血浆置换和MARS联合组,共88例,其中男60例,女28例,平均年龄42.6±12.4岁。B组中又将接受血浆置换的称为B1组,接受MARS治疗的称为B2组。人工肝治疗标准：血清总胆红素水平大于350μmol/L,且每日总胆红素上升幅度大于17.1μ mol/L, PTA小于40%；停止人工肝治疗标准：患者血清总胆红素小于200μ mol/L,每天上升幅度10μ mol/L, PTA大于60%；最低出院标准：患者消化道症状明显改善,无肝性脑病、肝肾综合症、感染、消化道出血等重要并发症,总胆红素小于100μ mol/L, PTA大于70%。护理措施包括术前护理,如患者的心理护理、环境及物品的准备、病员的准备(如备皮)和机器及管道准备；术中护理包括严格执行无菌操作、密切观察生命体征变化、注意观察仪器运行情况和抗凝血的护理；术后护理包括术后观察不良反应、股静脉置管的护理和饮食指导等。观察项目为,分析比较A组和B组的总体疗效、并发症和死亡原因；对存活患者的住院天数、人工肝治疗费用以及总医疗费用进行比较分析；分析比较A组患者每次血浆置换后、B1组患者每次血浆置换后以及B2组患者每次MARS后的血常规、肝功生化指标的变化以及并发症的发生情况。统计学处理,均数间比较采用方差分析或t检验,率的比较采用x2检验。当P＜0.05视为有统计学差异。结果在接受人工肝治疗前A组和B组患者,肝功能各项指标均显著异常并达到重型肝炎的诊断标准,两组各项肝能功指标均无显著性差异(P＞0.05)。生化学指标中,两组患者血钠水平均有不同程度下降,其余指标无明显异常,两组生化学指标无显著差异(P＞0.05)。经人工肝治疗后,两组死亡例数无显著差异(P＞0.05),A组和B组病死率分别为35.5%和36.4%,提示总体疗效两组相同(P＞0.05),但直接死因两组略有差异,A组因肾衰死亡的比率明显高于B组(12.9.0%vs2.3%,P＜O.05),其他死因两组无显著差异。主要并发症中,A组新发肝性脑病发生率明显高于B组(35.5%vs19.3%,P＜0.05),其他并发症两组无显著差异。对两组经治疗而存活的患者进行住院天数和医疗费用分析显示,B组患者住院天数略长于A组,但无统计学差异。人工肝费用和总医疗费用B组均显著高于A组(P＜0.01),主要差别在MARS治疗费用高昂。分析比较A组患者每次血浆置换前后、B组患者每次血浆置换前后、以及B组患者每次MARS治疗前后的肝功、生化指标以及血常规变化。无论是A组的血浆置换还是B2组的血浆置换,总胆红素的下降幅度均显著大于MARS治疗(P0.01),PTA的上升幅度也显著高于MARS治疗(P0.01), ALT、血氨和总胆固醇水平的变化各组无显著差异(P0.05)。各组人工肝治疗后对外周血白细胞的影响无统计学差异,但MARS治疗后红细胞和血小板的下降幅度均大于A组的血浆置换和B2组的血浆置换(p0.01)。ARS治疗组对钠、钾、氯以及尿素氮和肌酐的复常率均显著高于A组的血浆置换和B2组的血浆置换(P＜0.01)。对各组的主要不良反应包括鼻腔出血、牙龈出血、消化道出血、插管局部出血、皮疹、畏寒寒战、四肢发麻等进行分析比较,MARS治疗组的鼻腔出血和牙龈出血明显多于A组的血浆置换和B2组的血浆置换(P＜0.05),而皮疹、畏寒寒战和四肢发麻等不良反应显著少于A组的血浆置换和B2组的血浆置换(P＜0.05)。结论人工肝技术能明显地提高肝功能衰竭患者的存活率,单独血浆置换和血浆置换联合MARS治疗疗效相同。死亡因素中,单独血浆置换组肾功能衰竭较多,心功能衰竭、肝性脑病、感染、多器官功能衰竭两组无显著差异；血浆置换联合MARS治疗费用明显高于单独血浆置换治疗,主要原因为MARS材料费高昂；在并发症中血浆置换组以新发肝性脑病较为突出,其他并发症包括肝肾综合症、消化道出血、感染等,两组无显著差异；在不良反应或副作用中,血浆置换发热、皮疹、寒战等过敏现象较多,其次是口周和四肢发麻；MARS治疗更多见局部出血情况,包括鼻腔、牙龈出血,插管部位皮肤出血,以及消化道出血等；针对血浆置换和MARS治疗的不同特点,有针对性的构建护理对策对提高临床疗效具有重要意义。这些护理对策应包括人工肝支持治疗中心的管理、严格控制感染、严密观察并发症和不良反应并及时处理、对患者进行良好的健康教育。
[Abstract]:Research background and purpose
Liver failure is a serious liver damage caused by a variety of factors, resulting in severe impairment or decompensation of its functions such as synthesis, detoxification, excretion and biotransformation, and a group of clinical syndromes mainly manifested as coagulation dysfunction, jaundice, hepatic encephalopathy, and ascites. The treatment and treatment mainly include comprehensive medical treatment, artificial liver support and treatment. Liver transplantation. Artificial liver support system can replace the function of liver detoxification, remove toxic substances in the body, improve the internal environment, and win the time for liver transplantation or liver cell regeneration. Plasma exchange and MARS are the most widely used artificial liver techniques, but the effectiveness and safety of the two are lack of a deep control study, especially for different artificial liver techniques. The operation of artificial liver is not systematically studied. The operation of artificial liver is mainly done by nurses. The nursing staff play an important role in the process of artificial liver treatment. The nursing staff master the skilled operation procedures, evaluate the patients before the treatment, cooperate with the patients in the operation and observe the condition, and the postoperative nursing is the artificial liver treatment. Therefore, it is necessary to make a careful summary of experience and to explore a reasonable nursing plan, so how to build a nursing strategy according to the characteristics of different artificial liver techniques, to reduce the side effects or complications to the maximum extent, and to improve the treatment level of artificial liver is very necessary.
Method
This study was a retrospective control study. A multilevel analysis was conducted on the efficacy, cost, fatality rate, death causes, side effects, complications and so on in the patients receiving artificial liver treatment in our hospital from January 2009 to June 2013. The subjects were 150 patients with chronic hepatitis B and liver failure. The diagnostic character of liver failure. According to the different artificial liver treatment, group A and group B.A were divided into 62 cases, including 45 males and 17 females, with an average age of 43.5 + 11.2 years. The B group was plasma exchange and MARS combined group, including 60 men and 28 women, and the average age was 42.6 + 12.4 years.B group. The total bilirubin level of serum total bilirubin was greater than 350 u mol/L, and the daily total bilirubin increased more than 17.1 mu mol/L and PTA was less than 40%, and the standard of total bilirubin was less than 200 mol/L, and the serum total cholesterol was less than 200 mu mol/L and increased by 10 u mol/L a day. The standard of serum total bilirubin was greater than 350 u mol/L, and the total bilirubin level was greater than 350 mu mol/L. PTA was greater than 60%; the minimum discharge standard: significant improvement in the symptoms of digestive tract in patients, no hepatic encephalopathy, liver and kidney syndrome, infection, gastrointestinal bleeding and other important complications, total bilirubin less than 100 mu, and PTA greater than 70%. nursing measures including preoperative care, such as patients' psychological care, preparation of environment and articles, and preparation of the sick (such as skin preparation). Machinery and pipeline preparation; intraoperative nursing included strict aseptic operation, close observation of the changes in vital signs, observation of the operation of the instrument and the nursing of anticoagulant; postoperative nursing including postoperative observation of adverse reactions, nursing of femoral vein catheterization and dietary guidance. The overall efficacy of A and B groups was analyzed and compared. The causes of disease and death, the number of days of hospitalization, the cost of artificial liver treatment and the total medical cost were compared and analyzed. The blood routine after every plasma exchange in group B1 patients after each plasma exchange, and after each MARS in group B2, the changes of biochemical index of liver function and the occurrence of complications were analyzed and compared in group A patients. Variance analysis or t test were used to compare the scores between the two groups. The x2 test was used for the comparison of the rates. When P < 0.05, the difference was statistically significant.
Result
In group A and group B before the treatment of artificial liver treatment, all indexes of liver function were significantly abnormal and reached the diagnostic standard of severe hepatitis. There was no significant difference between the two groups (P > 0.05). In the biochemical indexes, the level of sodium in the two groups decreased in varying degrees, the other indexes were not obvious, and the two groups of biochemical indexes were not. Significant difference (P > 0.05). After the treatment of artificial liver, there was no significant difference in the number of deaths in the two groups (P > 0.05), the mortality rate of group A and B was 35.5% and 36.4%, respectively, indicating that the overall efficacy of the two groups was the same (P > 0.05), but the direct cause of death was slightly different, and the ratio of death to renal failure in the A group was significantly higher than that of the B group (12.9.0%vs2.3%, P < O.05), and the other two groups of the two groups did not. Among the main complications, the incidence of new hepatic encephalopathy in group A was significantly higher than that in group B (35.5%vs19.3%, P < 0.05), and there was no significant difference in other complications. The number of hospitalization days and medical costs in the two groups of patients who survived were slightly longer than those in the group A, but there was no statistical difference. The total medical cost in the B group was significantly higher than that in the A group (P < 0.01), and the major difference was high in the cost of MARS treatment. The analysis and comparison of the liver function, biochemical indexes, and blood routine changes before and after each MARS treatment in the group of A patients, before and after each plasma exchange in the A group, and in the B group before and after each MARS treatment, whether the plasma exchange in the A group or the plasma of the B2 group. The decrease of total bilirubin was significantly greater than that of MARS (P0.01), and the increase of PTA was significantly higher than that of MARS (P0.01), ALT, blood ammonia and total cholesterol levels were not significantly different in each group (P0.05). There was no statistical difference in the effect of leukocyte in peripheral blood after artificial liver treatment, but after MARS treatment, red blood cells and platelets were treated with MARS. The decrease was greater than the plasma exchange in the A group and the plasma replacement (P0.01) in group B2. The recurrent rates of sodium, potassium, chlorine, urea nitrogen and creatinine were significantly higher than those in the A group and the plasma replacement in the group B2 (P < 0.01). The major adverse reactions included nasal cavity bleeding, gingival bleeding, gastrointestinal bleeding, and intubation. The analysis and comparison of blood, rash, chill and chills, and the numbness of limbs were compared. The nasal bleeding and gingival bleeding in the MARS treatment group were significantly more than the plasma exchange in the group A and the plasma exchange in the group B2 (P < 0.05), while the adverse reactions of the rash, the cold chills and the limbs' numbness were significantly less than the plasma exchange in the A group and the plasma exchange in the group B2 (P < 0.05).
conclusion
Artificial liver technology can obviously improve the survival rate of patients with liver failure. The therapeutic effect of single plasma exchange and plasma exchange combined with MARS is the same. Among the death factors, there are more renal failure in the group of separate plasma replacement groups, no significant difference in two groups of heart failure, hepatic encephalopathy, infection, and multiple organ function failure; plasma exchange and MARS therapy The cost was significantly higher than the single plasma replacement therapy, the main reason was the high cost of MARS material; in the complications, the plasma exchange group was more prominent with new hepatic encephalopathy, other complications included liver and kidney syndrome, digestive tract bleeding, infection and so on. There were no significant differences in the two groups; in adverse reaction or side effects, plasma replacement fever, rash, shivering and so on There are more anaphylaxis, followed by the perimerent and extremities; MARS treatment is more likely to see local bleeding, including the nasal cavity, gingival bleeding, hemorrhage of the cannula, and hemorrhage of the digestive tract. In view of the different characteristics of plasma exchange and MARS treatment, the targeted construction of nursing countermeasures is of great significance to the improvement of clinical efficacy. It should include the management of artificial liver support treatment center, strict control of infection, close observation of complications and adverse reactions and timely treatment, and good health education for the patients.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R473.6

【参考文献】