血液净化治疗患者血管通路使用情况分析

发布时间：2019-07-01 17:58

【摘要】：研究一维持性血液透析患者血管通路使用情况分析目的:明确我们中心血液透析患者首次和目前血管通路使用情况及影响因素。方法:2015年7月~2015年12月维持性血液患者纳入研究。资料收集来自于本中心透析患者登记本、海泰电子资料库、血液透析记录单以及问卷调查。收集的资料包括:年龄、性别、开始进入血液透析基线资料、原发病、透析龄及合并症(包括糖尿病、高血压)等。无涤纶套导管和带隧道带Cuff导管置管部位、留置时间、并发症等。自体或移植动静脉内瘘情况,包括内瘘建立部位、成熟时间、使用寿命及并发症等。此外,收集血管通路变更情况及患者实验室检查结果等。结果:294例患者,男性189例(64.3%),女性105例(35.7%),年龄53.2±15.1岁(15~87岁),透析龄6.2(0.3~32)年。原发病以原发性肾小球肾炎为主。首次透析血管通路动静脉内瘘56例(19.0%),无涤纶套导管235例(79.9%)。首次血液透析未使用内瘘的主要原因:就诊时即诊断尿毒症占55.9%,无人告知占23.0%。目前血管通路动静脉内瘘占91.8%,带隧道带Cuff导管占6.12%。年龄在65岁以上患者动静脉内瘘使用率开始减少,导管使用率增加。透析龄小于2年患者,带隧道带Cuff导管使用率最高,透析龄20年以上者血管通路均为动静脉内瘘。无论是无涤纶套导管,还是长期带隧道带Cuff导管置管部位主要以颈内静脉为主,感染发生率较低,分别为1.09/1000导管日和2.03/1000导管日。自体动静脉内瘘部位主要以左桡动脉-头静脉为主(75.4%),首选端端吻合。首次透析开始前和开始后内瘘手术成功者,除在内瘘成熟时间上存在差别外,在性别、年龄、手术部位、血流量、内瘘使用寿命上均无明显统计学差异。动静脉内瘘早期并发症主要是术后血栓形成,晚期并发症主要包括内瘘堵塞、动脉瘤样扩张或动脉瘤形成、血流量不足以及肢体水肿等。2例肢体水肿患者右侧锁骨下静脉与上腔静脉交界处狭窄,经球囊扩张及放置血管支架后,血管再通、肢体水肿消失。移植物动静脉内瘘使用较低,仅1例患者。结论:通过横断面调查明确在我们中心首次血液透析血管通路以无涤纶套导管为主,目前血管通路以动静脉内瘘为主。导管置管部位主要以颈内静脉为主,并且感染发生率较低。动静脉内瘘部位以左侧桡动脉-头静脉为主,首选端端吻合。动静脉内瘘早期并发症主要是术后血栓形成,晚期并发症主要包括内瘘堵塞、动脉瘤样扩张或动脉瘤形成、血流量不足以及肢体水肿等。遗憾的是,我们中心血液透析患者移植物动静脉内瘘使用较少,目前尚未普及。研究二:连续性肾脏替代治疗患者血管通路使用情况分析目的:明确我们中心连续性肾脏替代治疗患者血管通路使用及并发症情况。方法:2014年4月~2014年10月,收集本中心连续性肾脏替代治疗患者的资料,包括人口学资料、原发病、收治科室、血压、心率、SOFA评分、APACHE II评分、有无使用免疫抑制剂、有无机械通气、连续性肾脏替代治疗方式、血管通路选择、无涤纶套导管置管部位、置管时间、血流量,有无重新置管、重新置管部位、重新置管后导管使用时间、导管护理、导管累计使用时间、导管功能失功及导管感染等。此外,还收集患者血管通路变更情况及实验室检查结果等。结果:292例患者符合条件入选本研究。其中,男性175例(59.9%),女性117例(40.1%),年龄50.8±18.6岁(12~94岁)。CRRT患者以AKI、MODS以及SIRS患者为主。血管通路:280例患者选择无涤纶套导管,所占比例为95.9%,11例患者使用动静脉内瘘仅占3.77%,1例患者使用长期带涤纶套带隧道导管。无涤纶套导管置管部位主要为右侧颈内静脉(54.3%),其次为右侧股静脉(30.7%)和左侧股静脉(13.2%)。其中,内科和急诊科患者置管部位主要是右侧颈内静脉,外科患者主要是右侧和左侧股静脉;此外,CRRT方式,连续性静脉静脉血液滤过患者置管部位以股静脉为主,连续性静脉静脉血液透析以右侧颈内静脉为主。32例患者(11.4%),在CRRT治疗过程中需要重新置管,共计51次,平均重新置管1.59±0.98次,最高重新置管次数4次。重新置管原因主要为感染和导管功能失功;重新置管部位以左侧股静脉为主(52.9%),重新置管部位与首次置管部位相同者仅占21.6%。导管功能失功,占全部患者的7.14%,占全部置管总数的11.8%,导管功能失功的中位时间5天,平均使用时间8.95天,原因主要为导管内血栓(17.9%)和导管血流量不足(82.1%),多因素分析导管功能失功的主要风险因素为CRRT累计时间和血Hb水平。此外,导管感染发生的平均时间为置管后10.7天,导管感染发生率为7.19/1000导管日,导管感染发生率股静脉高于颈内静脉,外科患者高于内科患者。影响导管感染的主要因素是导管累计使用时间和血清ALB水平。结论:通过横断面调查发现我们中心CRRT治疗患者血管通路主要选择无涤纶套导管,置管部位以右侧颈内静脉为主,部分患者需要重新置管。导管功能失功主要风险因素是CRRT累计时间和血Hb水平。导管感染发生的平均时间为置管后10.7天,导管感染发生率为7.19/1000导管日。影响导管感染的主要因素是导管累计使用时间和血清ALB水平。
[Abstract]:The purpose of the study on the use of vascular access in a maintenance hemodialysis patient is to identify the first and present use of vascular access in our central hemodialysis patients and the factors affecting them. Method: The maintenance hemodialysis patients were included in the study from July 2015 to December 2015. The data collected from this central dialysis patient's registry, the Haitai electronic database, the hemodialysis record sheet, and the questionnaire. The data collected included age, sex, baseline data from the beginning to the hemodialysis, the original onset, the dialysis age, and the comorbidities, including diabetes, hypertension, and the like. No polyester jacket catheter and catheter with cuff catheter with tunnel, retention time, complication, etc. Autologous or grafted arteriovenous contraindications, including the establishment site, the mature time, the service life and the complications, etc. In addition, the change of the vascular access and the results of the patient's laboratory tests were collected. Results: There were 294 patients,189 (64.3%),105 (35.7%), 53.2-15.1 (15-87), and 6.2 (0.3-32) years. The primary glomerular nephritis is the main disease. In the first time,56 cases (19.0%) and 235 cases (79.9%) of the vascular access were treated. The primary reason for the first hemodialysis not to be used was: the diagnosis of uremia was 55.9% at the time of the visit, and no one was informed of 23.0%. In the present, 91.8% of the vascular access and the Cuff catheter with the tunnel account for 6.12%. In patients with age over 65 years of age, the rate of use of vascular access was reduced and the rate of catheter usage increased. In patients with dialysis age less than 2 years, the use rate of Cuff catheter with tunnel was the highest, and the vascular access of over 20 years of dialysis was the inside of the artery and vein. There were mainly internal jugular vein and internal jugular vein, and the incidence of infection was low, 1.09/1000 catheter days and 2.03/1000 catheter days, respectively. The main part of the internal jugular vein of the vein was mainly the left inferior artery-head vein (75.4%), and the first-choice end-end anastomosis. There was no significant difference in sex, age, operation site, blood flow and internal life of the first time before and after the first dialysis. The early complications of the early complications of the AVMs are the postoperative thrombosis, and the late complications mainly include internal occlusion, aneurysm-like expansion or aneurysm formation, insufficient blood flow, and limb edema. After the balloon was expanded and the stent was placed, the vessel was recanalized and the edema of the limb disappeared. The use of the graft and arterio-venous system was low, with only one patient. Conclusion: Through the cross-sectional investigation, the first hemodialysis vascular access in our center is dominated by the non-polyester sleeve catheter, and the current vascular access is mainly in the vein of the vein. The catheter insertion site was mainly internal jugular vein, and the incidence of infection was lower. The site of the vein of the arteriovenous is the main artery-head vein of the left side, and the preferred end is in good agreement. The early complications of the early complications of the arteriovenous malformation are the postoperative thrombosis, and the late complications mainly include internal occlusion, aneurysm-like expansion or aneurysm formation, insufficient blood flow, and limb edema. Unfortunately, in our central hemodialysis patients, the use of graft and vein is less, and is not yet available. Objective: To study the vascular access and complications of continuous renal replacement therapy in patients with continuous renal replacement therapy. Method: From April 2014 to October 2014, the data of the continuous renal replacement therapy in this center was collected, including the demographic data, the original incidence, the department, the blood pressure, the heart rate, the SOFA score, the APACHE II score, the presence or absence of the immunosuppressants, the presence or absence of mechanical ventilation, The method of continuous renal replacement therapy, the selection of the vascular access, the location of the catheter in the non-polyester sleeve catheter, the time of the catheter insertion, the blood flow, the presence or absence of the catheter, the location of the re-insertion, the time of the catheter after the re-placement, the catheter care, the cumulative time of use of the catheter, Catheter function loss of work and catheter infection, etc. In addition, that change of the vascular access of the patient and the result of laboratory examination were also collected. Results:292 patients were eligible for inclusion in this study. Of these,175 males (59.9%),117 females (40.1%), and 50.8 to 18.6 years (12 to 94 years). The patients with CRRT were AKI, MODS and SIRS. Vascular access:280 patients had the choice of PET-free catheter, the proportion was 95.9%, and 11 patients used AVMs for 3.77%, and one patient used long-term polyester sleeve with tunnel. There were mainly right internal jugular vein (54.3%) and right femoral vein (30.7%) and left femoral vein (13.2%). in that case of the internal medicine department and the emergency department, the catheter site is mainly the right internal jugular vein, and the surgical patient is mainly the right and left femoral veins; in addition, the CRRT method and the continuous vein venous hemofiltration patient are mainly provided with a femoral vein, The right internal jugular vein was the main.32 patients (11.4%) had to be re-inserted in the treatment of CRRT, with a total of 51 times, an average of 1.59 and 0.98 times, and the maximum number of re-insertion times was 4 times. The reason of the re-insertion is the function of the infection and the function of the catheter; the site of the re-insertion is the main (52.9%) of the left femoral vein, and the re-insertion site only accounts for 21.6% of the same person as the first place of the catheter. The function of the catheter was lost, accounting for 7.14% of all the patients, accounting for 11.8% of the total number of the tubes, the median time of the function of the catheter was 5 days, the mean time of use was 8.95 days, the reason was that the thrombus in the catheter (17.9%) and the blood flow of the catheter were not sufficient (82.1%). The main risk factors of the multi-factor analysis of the function loss of the catheter were the cumulative time of CRRT and the level of Hb. In addition, the mean time of catheter infection was 10.7 days after the placement of the tube, the incidence of catheter infection was 7.19/1000 catheter days, the incidence of catheter infection was higher than that of the internal jugular vein, and the surgical patient was higher than that of the medical patient. The main factors that affect the catheter infection are the cumulative use time of the catheter and the serum ALB level. Conclusion: Through the cross-sectional investigation, we find that the vascular access of the central CRRT is the main choice of the non-polyester-free catheter, and the site of the catheter is the right internal jugular vein, and some patients need to be re-inserted. The main risk factors of the function failure of the catheter are the CRRT accumulation time and the blood Hb level. The mean time for catheter infection was 10.7 days after placement and the incidence of catheter infection was 7.19/1000 catheter days. The main factors that affect the catheter infection are the cumulative use time of the catheter and the serum ALB level.
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R692.5

【相似文献】