血液凈化治療患者血管通路使用情況分析
發(fā)布時間：2019-07-01 17:58
【摘要】：研究一維持性血液透析患者血管通路使用情況分析目的:明確我們中心血液透析患者首次和目前血管通路使用情況及影響因素。方法:2015年7月~2015年12月維持性血液患者納入研究。資料收集來自于本中心透析患者登記本、海泰電子資料庫、血液透析記錄單以及問卷調(diào)查。收集的資料包括:年齡、性別、開始進(jìn)入血液透析基線資料、原發(fā)病、透析齡及合并癥(包括糖尿病、高血壓)等。無滌綸套導(dǎo)管和帶隧道帶Cuff導(dǎo)管置管部位、留置時間、并發(fā)癥等。自體或移植動靜脈內(nèi)瘺情況,包括內(nèi)瘺建立部位、成熟時間、使用壽命及并發(fā)癥等。此外,收集血管通路變更情況及患者實(shí)驗(yàn)室檢查結(jié)果等。結(jié)果:294例患者,男性189例(64.3%),女性105例(35.7%),年齡53.2±15.1歲(15~87歲),透析齡6.2(0.3~32)年。原發(fā)病以原發(fā)性腎小球腎炎為主。首次透析血管通路動靜脈內(nèi)瘺56例(19.0%),無滌綸套導(dǎo)管235例(79.9%)。首次血液透析未使用內(nèi)瘺的主要原因:就診時即診斷尿毒癥占55.9%,無人告知占23.0%。目前血管通路動靜脈內(nèi)瘺占91.8%,帶隧道帶Cuff導(dǎo)管占6.12%。年齡在65歲以上患者動靜脈內(nèi)瘺使用率開始減少,導(dǎo)管使用率增加。透析齡小于2年患者,帶隧道帶Cuff導(dǎo)管使用率最高,透析齡20年以上者血管通路均為動靜脈內(nèi)瘺。無論是無滌綸套導(dǎo)管,還是長期帶隧道帶Cuff導(dǎo)管置管部位主要以頸內(nèi)靜脈為主,感染發(fā)生率較低,分別為1.09/1000導(dǎo)管日和2.03/1000導(dǎo)管日。自體動靜脈內(nèi)瘺部位主要以左橈動脈-頭靜脈為主(75.4%),首選端端吻合。首次透析開始前和開始后內(nèi)瘺手術(shù)成功者,除在內(nèi)瘺成熟時間上存在差別外,在性別、年齡、手術(shù)部位、血流量、內(nèi)瘺使用壽命上均無明顯統(tǒng)計(jì)學(xué)差異。動靜脈內(nèi)瘺早期并發(fā)癥主要是術(shù)后血栓形成,晚期并發(fā)癥主要包括內(nèi)瘺堵塞、動脈瘤樣擴(kuò)張或動脈瘤形成、血流量不足以及肢體水腫等。2例肢體水腫患者右側(cè)鎖骨下靜脈與上腔靜脈交界處狹窄,經(jīng)球囊擴(kuò)張及放置血管支架后,血管再通、肢體水腫消失。移植物動靜脈內(nèi)瘺使用較低,僅1例患者。結(jié)論:通過橫斷面調(diào)查明確在我們中心首次血液透析血管通路以無滌綸套導(dǎo)管為主,目前血管通路以動靜脈內(nèi)瘺為主。導(dǎo)管置管部位主要以頸內(nèi)靜脈為主,并且感染發(fā)生率較低。動靜脈內(nèi)瘺部位以左側(cè)橈動脈-頭靜脈為主,首選端端吻合。動靜脈內(nèi)瘺早期并發(fā)癥主要是術(shù)后血栓形成,晚期并發(fā)癥主要包括內(nèi)瘺堵塞、動脈瘤樣擴(kuò)張或動脈瘤形成、血流量不足以及肢體水腫等。遺憾的是,我們中心血液透析患者移植物動靜脈內(nèi)瘺使用較少,目前尚未普及。研究二:連續(xù)性腎臟替代治療患者血管通路使用情況分析目的:明確我們中心連續(xù)性腎臟替代治療患者血管通路使用及并發(fā)癥情況。方法:2014年4月~2014年10月,收集本中心連續(xù)性腎臟替代治療患者的資料,包括人口學(xué)資料、原發(fā)病、收治科室、血壓、心率、SOFA評分、APACHE II評分、有無使用免疫抑制劑、有無機(jī)械通氣、連續(xù)性腎臟替代治療方式、血管通路選擇、無滌綸套導(dǎo)管置管部位、置管時間、血流量,有無重新置管、重新置管部位、重新置管后導(dǎo)管使用時間、導(dǎo)管護(hù)理、導(dǎo)管累計(jì)使用時間、導(dǎo)管功能失功及導(dǎo)管感染等。此外,還收集患者血管通路變更情況及實(shí)驗(yàn)室檢查結(jié)果等。結(jié)果:292例患者符合條件入選本研究。其中,男性175例(59.9%),女性117例(40.1%),年齡50.8±18.6歲(12~94歲)。CRRT患者以AKI、MODS以及SIRS患者為主。血管通路:280例患者選擇無滌綸套導(dǎo)管,所占比例為95.9%,11例患者使用動靜脈內(nèi)瘺僅占3.77%,1例患者使用長期帶滌綸套帶隧道導(dǎo)管。無滌綸套導(dǎo)管置管部位主要為右側(cè)頸內(nèi)靜脈(54.3%),其次為右側(cè)股靜脈(30.7%)和左側(cè)股靜脈(13.2%)。其中,內(nèi)科和急診科患者置管部位主要是右側(cè)頸內(nèi)靜脈,外科患者主要是右側(cè)和左側(cè)股靜脈;此外,CRRT方式,連續(xù)性靜脈靜脈血液濾過患者置管部位以股靜脈為主,連續(xù)性靜脈靜脈血液透析以右側(cè)頸內(nèi)靜脈為主。32例患者(11.4%),在CRRT治療過程中需要重新置管,共計(jì)51次,平均重新置管1.59±0.98次,最高重新置管次數(shù)4次。重新置管原因主要為感染和導(dǎo)管功能失功;重新置管部位以左側(cè)股靜脈為主(52.9%),重新置管部位與首次置管部位相同者僅占21.6%。導(dǎo)管功能失功,占全部患者的7.14%,占全部置管總數(shù)的11.8%,導(dǎo)管功能失功的中位時間5天,平均使用時間8.95天,原因主要為導(dǎo)管內(nèi)血栓(17.9%)和導(dǎo)管血流量不足(82.1%),多因素分析導(dǎo)管功能失功的主要風(fēng)險因素為CRRT累計(jì)時間和血Hb水平。此外,導(dǎo)管感染發(fā)生的平均時間為置管后10.7天,導(dǎo)管感染發(fā)生率為7.19/1000導(dǎo)管日,導(dǎo)管感染發(fā)生率股靜脈高于頸內(nèi)靜脈,外科患者高于內(nèi)科患者。影響導(dǎo)管感染的主要因素是導(dǎo)管累計(jì)使用時間和血清ALB水平。結(jié)論:通過橫斷面調(diào)查發(fā)現(xiàn)我們中心CRRT治療患者血管通路主要選擇無滌綸套導(dǎo)管,置管部位以右側(cè)頸內(nèi)靜脈為主,部分患者需要重新置管。導(dǎo)管功能失功主要風(fēng)險因素是CRRT累計(jì)時間和血Hb水平。導(dǎo)管感染發(fā)生的平均時間為置管后10.7天,導(dǎo)管感染發(fā)生率為7.19/1000導(dǎo)管日。影響導(dǎo)管感染的主要因素是導(dǎo)管累計(jì)使用時間和血清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.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R692.5
本文編號：2508688
[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.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R692.5
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