中国血液净化

中国血液净化 ›› 2025, Vol. 24 ›› Issue (08): 689-694.doi: 10.3969/j.issn.1671-4091.2025.08.014

• 护理研究 • 上一篇    下一篇

闭式循环肝素化安装预冲5步法在血液灌流联合血液透析体外循环凝血观察中的应用研究

王 颖   胡雅茹   梁俊卿   杨洪杰   高月英    陈 薇   孙桂芝   高雅君   唐娜娜   朱宸瑶   朱 丽   甘良英  左 力
  

  1. 100044 北京，1北京大学人民医院肾内科
  • 收稿日期:2025-02-25 修回日期:2025-04-13 出版日期:2025-08-12 发布日期:2025-08-12
  • 通讯作者: 朱丽 E-mail:zhuli3714@126.com
  • 基金资助:
    北京大学人民医院研究与发展基金(RDL 2022-09)

Study on the application of the closed-loop heparinized five-step installation and priming method in monitoring extracorporeal circulation coagulation during hemoperfusion combined with hemodialysis

WANG Ying, HU Ya-ru, LIANG Jun-qing, YANG Hong-jie, GAO Yue-ying, CHEN Wei, SUN Gui-zhi, GAO Ya-jun, TANG Na-na, ZHU Chen-yao, ZHU Li, GAN Liang-ying, ZUO Li   

  1. Department of Nephrology, Peking University People’s Hospital, Beijing 100044, China
  • Received:2025-02-25 Revised:2025-04-13 Online:2025-08-12 Published:2025-08-12
  • Contact: 100044 北京，1北京大学人民医院肾内科 E-mail:zhuli3714@126.com

摘要： 目的  基于应用新型灌流器HP110(北京中科太康科技有限公司，中国)实施血液灌流(hemoperfusion,HP)联合血液透析(hemodialysis,HD)治疗的肝素化方案改进；构建HP+HD体外循环凝血发生率相关护理质量指标、HP+HD安装预冲护理操作查检表，为新型灌流器的肝素化方案选择以及护理质量控制提供参考依据。 方法  以2024年6月—11月在北京大学人民医院血液透析中心进行规律血液灌流联合血液透析，并应用肝素类抗凝剂(普通肝素或低分子肝素)的维持性血液透析(maintenance hemodialysis，MHD)患者作为研究对象。项目起始阶段(2024年6月1日—8月8日)应用动态肝素化安装预冲，改进阶段(2024年8月9日—11月30日)应用闭式循环肝素化安装预冲5步法，均采用一体化连接管路。构建：①HP+HD肝素化安装预冲操作流程；②HP+HD体外循环凝血发生率护理质量指标；③HP+HD安装预冲护理操作查检表，并进行操作质控。 结果  共纳入MHD患者52例，其中男性33例，女性19例，年龄34～77岁，平均(56.8±10.2)岁。共观察HP+HD治疗677例次，起始阶段(242例次)、改进阶段(435例次)：两阶段Ⅱ级及以上体外循环凝血发生率分别为9.5%、0(P＜0.001)，其中Ⅲ级体外循环凝血发生率分别为2.07%、0(P＜0.001)，以及同一患者2次凝血发生率分别为26.09%、0；两阶段护理操作质控评分比较无统计学差异(t=0.708，P=0.482)。应用闭式循环方案后患者凝血指标[凝血酶原时间：(10.2±0.8)s；活化部分凝血活酶时间：(30.6±3.0)s；纤维蛋白原：(314.0±57.2)mg/dl]均在正常范围内；单次HP+HD治疗可节约生理盐水1000 ml、肝素钠12 500 IU，节省经济成本15.16元，本研究闭式循环时间比现有文献减少5 min，节约护理工作时间。 结论  基于新型灌流器(HP110)使用2种肝素化安装预冲方案对照提示：应用“闭式循环肝素化安装预冲5步法”在降低体外循环凝血发生率、减少肝素和生理盐水使用剂量方面相较于动态肝素化法具有优势；应用护理质量指标“Ⅱ、Ⅲ级体外循环凝血发生率”“同一患者2次凝血发生率”及《HP+HD安装预冲查检表》作为HP+HD安装预冲护理操作的质量评价工具敏感有效。

关键词: 肝素化方案, 体外循环凝血, 护理质量管理, 血液灌流联合血液透析

Abstract: Objective To determine the optimal heparinization protocol for hemoperfusion combined with hemodialysis (HP+HD) using a novel perfusion device (HP110) and to establish quality control tools for HP+HD therapy, including HP+HD installation and priming checklist and nursing quality indicators relating to the incidence of extracorporeal circulation coagulation, so as to provide a reference for clinical nursing quality control.  Methods This study enrolled maintenance hemodialysis (MHD) patients undergoing regular HP+HD therapy using heparin-based anticoagulants (unfractionated heparin or low molecular weight heparin) at Peking University People’s Hospital from June to November 2024. The study was divided into two phases: the initial phase (dynamic heparinization for installation and priming) and the improvement phase (closed-loop heparinization 5-step method for installation and priming). A project management team was established to develop the heparinization protocol, the HP+HD installation and priming checklist, and the nursing quality indicators relating to extracorporeal circulation coagulation.  Results   A total of 52 MHD patients were included (33 males and 19 females), aged 34～77 years (mean 56.8±10.2 years). Among 677 HP+HD treatments, 242 were conducted in the initial phase and 435 were in the improvement phase. During the initial phase and the improvement phase, the rates of extracorporeal circulation coagulation of grade II or more were 9.5% (23 treatments) and 0% (P＜0.001) respectively, and the rates of extracorporeal circulation coagulation of grade Ⅲ were 2.07% (5 treatments) and 0% (P＜0.001) respectively. The rate of recurrent coagulation in the same patient was 26.09% (6/23 treatments) in the initial phase. Monthly quality control score for nursing procedures showed no significant differences between the two phases (t=0.708; P=0.482). In the 435 treatments in the improvement phase, prothrombin time (10.2±0.8s), activated partial thromboplastin time (30.6±3.0s) and fibrinogen (314.0±57.2 mg/dl) were in the normal ranges, a total of 1000 mL normal saline and 12 500 IU of heparin (costed 15.16 RMB yuan) could be saved in a single HP+HD treatment, and the manipulation time was 5 minutes less than that reported in the literature.  Conclusion  The use of the closed-loop 5-step method for heparinization during HP+HD installation and priming significantly reduced the incidence of extracorporeal circulation coagulation and optimized the use of heparin and saline compared to the dynamic heparinization method. The nursing quality indicators, including the rates of grade Ⅱ and Ⅲ extracorporeal circulation coagulation and recurrent coagulation in the same patient, and the HP+HD installation and priming checklist are sensitive and effective tools for evaluating nursing quality of HP+HD installation and priming.

Key words: Heparinization protocol, Extracorporeal circulation coagulation, Nursing quality control; , Hemoperfusion combined with hemodialysis

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