中国血液净化

中国血液净化 ›› 2017, Vol. 16 ›› Issue (09): 635-642.doi: 10.3969/j.issn.1671-4091.2017.09.014

• 护理园地 • 上一篇    下一篇

日间无抗凝CRRT 患者体外循环管路冲洗护理的研究

郭宏晶1,李莉2,向晶3,马志芳3,张杰3,黄静3,耿赫兵1,王艳4,孟庆义5,朱秀勤1,王建荣4   

  1. 1. 解放军总医院内科临床部护理办
    2. 解放军总医院南楼临床部检验科
    3. 解放军总医院内科临床部肾脏病科
    4. 解放军总医院护理部
    5. 解放军总医院门诊部急诊科
  • 收稿日期:2016-09-23 修回日期:2017-07-01 出版日期:2017-09-12 发布日期:2017-09-12
  • 通讯作者: 王建荣 wangjianrong301@163.com E-mail:wangjianrong301@163.com
  • 基金资助:

    中国人民解放军总医院科研基金项目，编号：13KMM10

The research on flush methods for preventing coagulation and clot formation during continuous renal replacement therapy without anticoagulation

  • Received:2016-09-23 Revised:2017-07-01 Online:2017-09-12 Published:2017-09-12

PDF

557

摘要： 目的探索生理盐水冲洗与免冲洗两种方法对有高危出血风险行日间无抗凝连续性肾脏替代治疗(continuous renal replacement therapy，CRRT)时患者凝血指标、循环情况及机器各压力值的影响。方法将有高危出血风险行无抗凝CRRT 治疗的患者随机分为生理盐水冲洗组和免冲洗组，在上机过程不同时间点采集血标本，测定凝血酶原片段(prothrombinfragment 1+2，PF1+2)和β-血小板球蛋白(β-Thromboglobulin，β-TG)的变化，记录机器跨膜压(transmembrane pressure，TMP)、滤器前压(filter pressure，PBE)和滤器压力下降值(filter pressure decrease value，ΔP)及患者心率、血压的变化。结果①生理盐水冲洗组与免冲洗组相比，患者PF1+2 和β-TG 的变化无显著差异。②免冲洗组跨膜压在上机后3h(t＝3.813, P＜0.001)、4h(t＝4.230, P＜0.001)及下机时(t＝7.014, P＜0.001)较上机时增加，且有显著差异；生理盐水组跨膜压在上机后4h(t＝3.296，P＝0.002)及下机时(t＝3.930，P＜0.001)较上机时增加，且有显著差异。两组患者所用机器不同时间滤器前压变化值在上机后1h(u＝3.056，P＝0.002)、2h(u＝2.788，P＝0.005)、3h(u＝2.009，P＝0.045) 及下机时(u＝2.201，P＝0.043)有显著差异。免冲洗组滤器压力下降值在上机后1h(t＝2.738，P＝0.009)、2h(t＝3.590，P＜0.001)、3h(t＝4.771，P＜0.001)、4h(t＝4.754，P＜0.001)及下机时(t＝5.144，P＜0.001)均较上机时增加，且有显著差异；生理盐水冲洗组滤器压力下降值在上机后3h(t＝3.013, P＝0.005)、4h(t＝3.020, P＝0.005)及下机时(t＝3.814，P＝0.001)均较上机时增加，且有显著差异。2 组滤器压力下降值变化值在下机时有显著差异(u＝2.155，P＝0.031)。③2 组患者因压力高限报警下机时间均在5h 以上，生理盐水冲洗组例数(1 例)少于免冲洗组(4 例)，其余患者均根据医嘱完成了6～10h 的连续性静脉静脉血液滤过(continuous veno－venous hemofiltration，CVVH)。④2 组患者不同时间收缩压变化值在上机后1h(t＝2.845，P＝0.007)、2h(t＝3.353，P＝0.002)、3h(t＝3.367，P＝0.002)、4h(t＝3.745，P＝0.001)、5h(t＝3.355, P＝0.002)及下机时(t＝2.711，P＝0.010)较上机时均有显著性差异，平均动脉压变化值在上机后2h(t＝2.508，P＝0.016)、3h(t＝3.078，P=0.004)、4h(t＝3.023, P＝0.004)、5h(t＝2.412，P＝0.021) 均有显著性差异，脉压在上机后2h(t＝2.635，P＝0.012)、3h(t＝2.805，P＝0.008)、4h(t＝3.070, P＝0.004)、5h(t＝2.893, P＝0.006)及下机时(t＝2.254, P＝0.030)有显著差异，脉压变化值在上机后1h(t＝2.769, P＝0.008)、2h(t＝3.154, P＝0.003)、3h(t＝2.614, P＝0.013)、4h(t＝2.973, P＝0.005)、5h(t＝3.063, P＝0.004)及下机时(t＝2.672, P＝0.011)较上机时均有显著性差异。结论生理盐水冲洗有利于减缓机器各压力值的上升，对于预防5h 以上CRRT 体外循环管路的凝血有一定的作用。有高危出血风险的急性或慢性肾功能衰竭患者行无抗凝CRRT 过程中，对于合并心血管疾病的患者需慎用生理盐水冲洗。

关键词: 持续肾脏替代治疗, 生理盐水冲洗, 抗凝, 凝血, 护理

Abstract: Objectives To investigate the effects on blood coagulation, circulation status and filter life in critically ill patients with high bleeding risk requiring continuous renal replacement therapy (CRRT) without anticoagulation. Methods Patients with high risk of bleeding requiring CRRT without anticoagulation in the ICU were randomly divided into saline flushes group and no-rinse group. Levels of prothrombin fragment 1+2 (PF1+2) and β-thromboglobulin (β-TG) were measured, and the transmembrane pressure (TMP), pressure before the filter (PBE) and filter pressure decrease value (ΔP) were observed. Changes of heart rate and blood
pressure were monitored during CRRT. Results There was no significant difference in the levels of PF1+2 and β-TG between saline flushes group and no-rinse group. In no-rinse group the TMP at 3h (t=3.813, P＜0.001), 4h (t=4.230, P＜0.001) and at the end of CRRT (t=7.014, P＜0.001) were significantly higher than
that at the start of CRRT. In saline flushes group, the TMP at 4h (t=3.296, P=0.002) and at the end of CRRT (t=3.930, P＜0.001) were significantly higher than that at the start of CRRT. Filter pressure in the two groups showed significant differences after 1h (u=3.056, P=0.002), 2h (u=2.788, P=0.005), 3h (u=2.009, P=0.045) and at the end of CRRT (u=2.201, P=0.043). In no- rinse group the filter pressure decrease value at 1h (t=2.738, P=0.009), 2h (t=3.590, P＜0.001), 3h (t=4.771, P＜0.001), 4h (t=4.754, P＜0.001) and at the end of CRRT (t=5.144, P＜0.001) were significantly higher than that at the start of CRRT. In saline flushes group, the filter pressure decrease value at 3h (t=3.013, P=0.005), 4h (t=3.020, P=0.005) and at the end of CRRT (t=3.814, P=0.001) were significantly higher than that at the start of CRRT. Filter pressure decrease value in the two groups showed significant differences at the end of CRRT (u=2.155, P=0.031). The CRRT treatment time were more than 5 hours in all patients in the two groups. CRRT treatment was terminated in 5 patients (one case in saline flushes group and 4 cases in no-rinse group) due to high pressure limit alarm. The rest of the patients completed continuous veno-venous hemofiltration (CVVH) for 6～10h following doctor's advice. Compared between the two groups, there were significant differences in systolic pressure changes at 1h (t=2.845, P=0.007), 2h (t=3.353, P=0.002), 3h (t=3.367, P=0.002), 4h (t=3.745, P=0.001), 5h (t=3.355, P=0.002) and at the end of CRRT (t=2.711, P=0.010), significant differences in mean arterial blood pressure changes at 2h (t=2.508, P=0.016), 3h (t=3.078, P=0.004), 4h (t=3.023, P=0.004), 5h (t=2.412, P=0.021), significant differences in pulse pressure values at 2h (t=2.635, P=0.012), 3h (t=2.805, P=0.008), 4h (t=3.070, P=0.004), 5h (t=2.893, P=0.006) and at the end of CRRT (t=2.254, P= 0.030), and significant differences in pulse pressure changes at 1h (t=2.769, P=0.008), 2h (t=3.154, P=0.003), 3h (t=2.614, P=0.013), 4h (t=2.973, P=0.005), 5h (t=3.063, P=0.004) and at the end of CRRT (t=2.672, P=0.011). Conclusion Physiological saline irrigation is conducive to slow down the rise of pressure value in the machine and to prevent blood coagulation in extracorporeal circuit in CRRT for more than 5h. Patients with acute or chronic renal failure with high risk of bleeding associated with cardiovascular disease should be treated with saline irrigation without anticoagulation during CRRT.

Key words: Continuous renal replacement therapy, Saline flushes, Anticoagulation, Clotting, Nursing