46.7%枸橼酸钠用于血液透析患者长期留置导管封管

目的 探讨46.7%枸橼酸钠溶液应用于长期留置导管行血液透析患者封管的效果.方法 尿毒症维持透析长期留置导管患者61例,随机分为枸橼酸钠组(31例)和肝素组(30例).枸橼酸钠组每次透析结束后以46.7%枸橼酸钠溶液接管腔容量封管,肝素组以肝素钠溶液(2 mg/ml)封管,均连续使用6个月,比较两组导管功能、导管相关感染情况和药物不良反应.结果 枸橼酸钠组导管功能不良和导管感染发生率显著低于肝素组(P<0.05,P<0.01).枸橼酸钠组28例次(1.79%)用药后出现口唇麻木症状,8例次给予钙荆后缓解,余自行缓解.结论 血液透析患者长期留置导管应用46.7%枸橼酸钠溶液封管能提高导管通畅率、降低导管相关感染率,不良反应轻微,适合长期使用.     

46．7％枸橼酸钠用于血液透析患者长期留置导管封管

目的探讨46．7％枸橼酸钠溶液应用于长期留置导管行血液透析患者封管的效果。方法尿毒症维持透析长期留置导管患者61例,随机分为枸橼酸钠组（31例）和肝素组（30例）。枸橼酸钠组每次透析结束后以46．7％枸橼酸钠溶液按管腔容量封管,肝素组以肝素钠溶液（2mg／m1）封管,均连续使用6个月,比较两组导管功能、导管相关感染情况和药物不良反应。结果枸橼酸钠组导管功能不良和导管感染发生率显著低于肝素组（P〈0．05,P〈0．01）。枸橼酸钠组28例次（1．79％）用药后出现口唇麻木症状,8例次给予钙剂后缓解,余自行缓解。结论血液透析患者长期留置导管应用46．7％枸橼酸钠溶液封管能提高导管通畅率、降低导管相关感染率。不良反应轻微,适合长期使用。     

4％枸橼酸钠与肝素钠在血液透析长期导管封管中的效果比较

目的 比较4％枸橼酸钠与肝素钠溶液在血液透析长期导管封管中的临床效果.方法 选取2015年1月至2019年5月在我院应用长期导管行血液透析的患者60例,按照随机数字表法随机分为对照组与试验组,每组各30例.对照组患者一周三次肝素钠溶液封管,试验组患者一周三次4％枸橼酸钠溶液封管,连续使用3个月.对比两组患者导管应用相关...     

长期留置管在维持性血液透析患者的应用与随访

建立稳定、可靠的血管通路是患者进行血液透析（血透）的基本保证。临时性中心静脉插管简便、易于掌握,但保留时间短、并发症较多,对于需要长久留置导管的患者就不适应,因此,具有涤纶套的双腔留置导管就应运而生。文献检索国内至今仅见个别报道［１,２］。我们报告近２年多使用长期留置导管２７例及随访情况。 一、资料和方法 １．病例：我科从１９９８年１２月～２００１年１月,行永久性带涤纶套导管留置术２７例,男１３例,女１４例,年龄３０～８１ｌ岁（５８±１９）;这些患者大都做过多次内疹术、腹膜透析或人造血管搭桥,无法…     

留置导管长期血液透析的应用

目的 介绍长期留置血液透析（下称血透）导管的置入方法、透析效果以及并发症。方法 采取带皮下隧道长期留置导管置入术建立血透通路15例,观察其透析效果与并发症的发生情况。结果 15根长期留置血透导管共使用2820d,平均每根留置时间188d,其透析效果优于人造血管和临时性血透导管,但不及动静脉内瘘。长期留置血透导管常见的并发症为血流不畅和感染。经干预均可控制。结论 长期留置血透导管对于老年人、心功能不全或造瘘困难者是较好的选择,其透析效果较好,并发症较少。     

4％枸橼酸钠溶液在中心静脉置管血液透析患者中的应用

目的观察4％枸橼酸钠封管液在临时性中心静脉置管血液透析患者中的应用。方法将61例维持性血液透析患者随机分为2组,即4%枸橼酸钠封管组30例,肝素钠封管组31例。每次透析结束后,对2组患者分别以4％枸橼酸钠和肝素钠封管,均连续使用5周。评价2组患者导管相关的出血、感染和导管功能不良情况。结果①4％枸橼酸钠封管组导管相关的出血事件发生率较肝素钠封管组低,差异有统计学意义（P〈0．05）。②4％枸橼酸钠封管组有1例次出现透析中发热,但导管液和血液细菌培养均为阴性,肝素钠封管组有1例患者出现透析中发热,导管液培养为金黄色葡萄球菌阳性,血培养为阴性。③2组患者导管功能不良发生率无显著差异（P〉0．05）。结论对于临时性中心静脉置管的血液透析患者,4％枸橼酸钠封管液可作为常规肝素钠封管液的替代。     

定期尿激酶封管治疗血液透析长期留置导管功能不良疗效分析

血液透析是治疗急、慢性肾功能衰竭的有效方法,随着透析装置及技术的进步,血液透析越来越多的应用于急、慢性肾功能衰竭.中心静脉留置导管是血液透析患者透析治疗常用的血管通路,该导管的通畅往往是保证维持性血液透析患者安全、有效的重要前提之一,但透析导管常因为栓塞、感染等严重的并发症而丧失功能终至拔管.近一半的透析导管会在置管1年内丧失功能[1-2],而其中约2/3的原因就是因为导管栓塞[3].有研究提出定期对永久性中心静脉导管给予尿激酶溶栓治疗[4-5],我院对永久性长期颈内静脉留置导管透析的患者应用尿激酶稀释液封管,分别作导管功能和透析充分性的评价,现报道如下.     

双腔留置导管在血液透析中的应用

自1987年以来,我院应用双腔留置导管建立血液通路,对43例急、慢性肾功能衰竭患者进行269次血液透析,效果满意,现报告如下.1 资料与方法1.1 一般资料43例中,男36例,女7例;年龄21～65岁.共进行269次血液透析.1.2 透析方法局麻下,在腹股沟韧带下2cm处紧贴股动脉内侧以45°角进针.穿刺成功后即可抽到暗红色静脉     

Citrate lock versus heparin lock for the prevention of catheter related infections in hemodialysis patients with tunneled catheters: a Meta-analysis of randomized controlled trials

ObjectiveTo study whether citrate lock is superior to heparin lock in the prevention of catheter related infections, bleeding complications and catheter malfunctions among hemodialysis patients with tunneled catheters. MethodsBy searching in Pubmed, the Cochrane Library, EMBASE, Ovid, WanFang, VIP, CNKI and CBM databases as well as related journals, qualified randomized controlled trials were included in a Meta - analysis using Revman 5.0 and STATA 10.0 software. The endpoints included catheter related infection, bleeding complication, thrombolytic treatment, catheter removal for malfunction, catheter thrombosis and all - cause death. ResultsFifteen randomized controlled trials were included with 1621 patients involved. Eight studies compared citrate alone with heparin lock, while 7 trials focused on citrate in combination with other antimicrobials. Pooled analysis demonstrated that incidence of catheter related infections in patients receiving citrate lock decreased by 47% compared with those on heparin (RR=0.53, 95%CI 0.36-0.77, P＜0.01). Subgroup analysis by types of citrate lock indicated that all combined lock solutions of citrate and other antimicrobials (citrate + gentamicin, citrate + taurolidine, citrate + methylene blue + methylparaben + propylparaben) were superior to heparin lock in preventing catheter-related infections (P＝0.01, 0.04, 0.01, respectively); citrate alone seemed to reduce catheter-related infection risk (RR＝0.68), but no statistically significant difference was observed (95%CI 0.38-1.21, P＝0.19). There were fewer patients with bleeding complications in citrate group (RR＝0.53, 95%CI 0.34-0.84, P＜0.01), while citrate showed no advantage over heparin lock in terms of thrombolytic treatment (P＝0.93), catheter removal for malfunction (P＝0.35), catheter thrombosis (P＝0.64) and all - cause death (P＝0.35). ConclusionsFor hemodialysis patients with tunneled catheters, combined lock solutions of citrate and other antimicrobials, rather than citrate alone, are superior to heparin in preventing catheter related infections. Citrate locks are associated with less bleeding complications, and are comparable to heparin in the maintenance of catheter patency.     

枸橼酸钠与阿加曲班在血液透析患者抗凝治疗中的效果比较

目的 比较枸橼酸钠与阿加曲班在血液透析患者抗凝治疗中的疗效及安全性.方法 12例存在出血倾向的血液透析患者采用数字表法随机分为2组,每组6例.阿加曲班组予2.5mg/h阿加曲班泵入,提前半小时停泵;枸橼酸钠组予4％枸橼酸钠200 ml/h动脉端泵入,维持至透析结束.透析过程中观察患者有无不适症状(包括发热、头痛、恶心、口唇发麻、手足抽搐、心室颤动或停搏)、心率、血压;监测透析中静脉压、动脉压变化.透析前、后检测患者外周血凝血酶原时间(PT)、活化部分凝血酶时间(APTT)、离子(钾、钠、钙、磷)浓度、血气分析(pH值)情况.透析结束后观察透析器、动静脉壶凝血及患者出血情况,透析器凝血分为3度,Ⅰ°为透析器＜ 1/3出现凝血;Ⅱ°为透析器1/3 ～ 2/3出现凝血;Ⅲ°为透析器＞2/3出现凝血、动静脉壶根据有无血凝块监测.结果 (1)阿加曲班组1例出现头痛症状,其他无明显不适症状出现;透析中心率、血压、透析中动脉压及静脉压两组比较差异无统计学意义.(2)两组透析前PT、APT、PH、BE及离子钾、钠、钙、磷无明显差异;透析后阿加曲班组PT及APTT较透析前及枸橼酸组均明显延长,差异有统计学意义(P＜0.05).与透析前相比,透析后两组pH值及离子钙显著增高,离子钾、磷均显著下降,差异有统计学意义(P＜0.05);透析后枸橼酸钠组与阿加曲班组pH值及离子钾、钠、钙、磷无明显变化,差异无统计学意义.(3)透析结束后,枸橼酸钠组有1例出现透析器Ⅰ°凝血,无动静脉血凝块;阿加曲班组透析器有3例出现Ⅰ°凝血、1例出现Ⅱ°凝血、2例出现动静脉血凝块,两组比较差异无统计学意义.枸橼酸钠组患者透析后无出血倾向,阿加曲班组4例出现出血倾向,其中2例为伤口渗血、2例为原有出血加重,两组比较差异有统计学意义(P＜0.05).结论 阿加曲班与枸橼酸抗凝均是安全、可行的方法,且易于掌握,两者相比,枸橼酸不增加透析后的出血风险,是更为理想的血液透析抗凝方法.     

380例次长期深静脉留置导管临床应用的生存分析

目的提高对长期静脉留职导管的置管、使用、护理的认识，延长其使用寿命。方法随访本院血液净化中心患者380例次深静脉置管并长期留置的情况和并发症，记录导管使用终点。应用Kaplan-Meier法绘制导管使用寿命的生存曲线，计算中位生存时间。log-rank检验比较导管使用寿命的差异。分析评价置管方法、感染发生率、导管退出原因及透析充分性。结果导管静脉入路途径包括颈内、颈外、锁骨下及股静脉。3种静脉入路中位生存时间分别为颈内（31．0±2．8）月，颈外（30．0±4．0）月，锁骨下（19．0±2．9）月。log-rank生存曲线检验结果显示，颈内与锁骨下进路比较差异有统计学意义（P〈0．05）。导管使用终点113例次，其中患者死亡60例（53．1％），感染14例（12．4％），导管功能不良13例（11．5％），肾移植13例（11．5％），内瘘2例（1．8％），导管意外拉脱7例（6．2％），导管破损4例（3．5％）。导管内感染61例次，隧道感染2例次。结论长期留置导管首选颈内静脉入路，其次为颈外静脉入路。导管终点以患者死亡、感染及导管功能不良占绝大多数。     

1500例临时静脉留置导管透析的临床分析

目的探讨临时静脉内留置导管透析的血管选择、透析效果、并发症、影响因素及处理。方法静脉置管后观察导管血流量、留置时间、尿素清除指数（Kt／V）、再循环、血液流变学指标、并发症及其影响因素。结果颈内静脉、锁骨下静脉、股静脉是留置导管静脉常选静脉。1500例静脉留置导管总体使用良好，透析充分，Kt／V平均1．20±0．35；导管再循环率低为（10．5±2．5）％；留置导管常见的并发症依次为血流量不足、栓塞、感染、导管脱落等。大多数能通过调整导管位置、导管内溶栓及抗感染等处理改善；5例反复发生栓塞者血纤维蛋白原显著升高；导管尖端位于右心房者与上腔静脉者比较，前者具有更好的血流量、再循环率低[（285±50．5）ml／minVS（205±45．5）ml／mim（8±3．5）％VS（12±4．5）％，（P〈0．05）]；导管腔内高浓度肝素与低浓度肝素比较，前者导管留置时间明显延长（P〈0．05），检塞发生率减少（P〈0．05）。结论临时静脉内留置导管透析血流量充分，透析疗效确切。留置导管常见的并发症有血流量不足、栓塞、感染等，绝大多数能通过处理矫正。导管尖端位置、导管腔肝素浓度、血液粘度等对导管成活、血流量不足、栓塞有重要影响。     

Survival of analysis of older patients with external iliac vein tunneled cuffed catheters on maintenance hemodialysis

Objective To investigate the survival of older patients with iliac vein tunneled cuffed catheters on maintenance hemodialysis. Methods A total of 70 older patients with external iliac vein tunneled cuffed catheters on maintenace hemodialysis were included in this study, there were 94 patients with internal jugular vein tunneled cuffed catheters as control group. The baseline anthropometric and 1aboratory parameters were measured. The catheter dysfunction and catheter related complications were documented. Results There were lower survival rate and catheter survival in the external iliac vein group compared with internal jugular vein group（χ2=13.714, P＜0.01;χ2=13.093, P＜0.01）. Compared with internal jugular vein group, there was lower rate of catheter infection in external iliac vein group(χ2=9.416, P＜0.01); In addition, there were higher rate of cardiovascular disease(CVD) events and catheter dysfunction among patients in external iliac vein group (χ2=7.492, P＜0.01;χ2=5.912, P＜0.05). Furthermore, the incidence of catheter dysfunction and cardiovascular disease events were the independent risk factors of mortality for older patients with iliac vein tunneled cuffed catheters on maintenance hemodialysis by Cox regression model. Conclusions Patients with iliac vein tunneled cuffed catheters have a shorter survival time. Those with catheter dysfunction or cardiovascular disease events are in higher risk of mortality．     

血液透析双腔导管肝素封管液浓度的随机对照研究

目的 观察规律血液透析患者采用不同浓度肝素液进行颈内静脉留置双腔导管封管时对患者凝血功能、出血倾向、导管血栓形成等的影响,探讨合理的封管浓度。 方法 90例颈内静脉留置双腔导管作为维持性血液透析血管通路的患者根据不平衡指数最小分配原则随机分为3组（均n=30）,分别采用不同浓度肝素钠溶液进行封管。A组：纯肝素钠封管（6250 U/ml）;B组：中浓度肝素钠（1040 U/ml）+生理盐水溶液;C组：低浓度肝素钠（625 U/ml）+生理盐水溶液。测定封管后短期凝血功能,监测出血倾向、通路血栓形成情况、感染情况及血小板变化。 结果 A组在封管后30 min时凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）等凝血功能指标均较基础值显著延长（P < 0.01）,在4 h后仍显著高于基础值（P < 0.05）,但24 h后PT、TT恢复至基础水平（P > 0.05）,APTT仍显著超过基础值（P < 0.05）。B组患者封管30 min后仅APTT显著超过基础值（P < 0.05）,且在4 h后恢复至基础水平（P > 0.05）。C组患者封管后PT、APTT和TT与基础值比较,差异均无统计学意义（P > 0.05）。观察期内,A组患者出血事件发生率显著高于B、C组（26.7% 比10%、0,P < 0.05）;C组血栓事件显著高于A、B组（23.3% 比0、10%,P < 0.05）。C组出现1例可疑导管相关感染。A组出现2例血小板中度减少。 结论 中等浓度肝素钠溶液进行颈内静脉留置双腔导管封管不良反应较少,可用于大多数患者。有高凝倾向的患者更适合采用高浓度肝素液;有出血倾向的患者可以用低浓度肝素钠溶液封管。     

Thrombosis of tunneled-cuffed hemodialysis catheters: treatment with high-dose urokinase lock therapy

Thrombosis-related malfunction of tunneled-cuffed central venous catheters (TCC) for hemodialysis (HD) currently leads to a high rate of untimely catheter removal. Urokinase (UK) therapy is used for TCC thrombosis/malfunction, but no consensus exists on the adequate dose to obtain thrombolysis. We selected 72 HD patients with TCC and a mean age and HD vintage of 74 years (range 65-87) and 36 months (range 12-61), respectively. All patients received warfarin therapy with a target international normalized ratio (INR) of 1.8-2.5. Coagulative assessment of the patients was obtained by checking the INR, activated partial thromboplastin time, fibrinogen, hemoglobin, and platelets. Sixty-five thrombotic events were recorded during a 3-year follow-up (median 0.3 events/patient/year). The patients selected were randomized into two groups according to a different thrombolytic therapy. Group A comprised 29 thrombotic events in 32 patients who received UK 25,000 IU in both arterial and venous lines of the TCC for each event. UK restored an adequate blood flow rate (BFR) for HD (≥ 250 mL/min) in 4/29 events (13.7%), whereas addition of 50,000 IU to both arterial and venous lines was required in 25/29 events (86.3%). For the same 25 events in the second HD session, a further 75,000 IU of UK was needed for each TCC lumen. Group B comprised 36 thrombotic events in 40 patients who received 100 000 IU of UK in the arterial and venous lumen of the TCC for each event. An adequate BFR was recovered in all events. In 12/36 events (33.3%), 100,000 IU UK for both lumens were needed in the second HD. In conclusion, group B patients obtained (i) a significantly better TCC patency than group A patients; (ii) a low UK administration in the following HD sessions; and (iii) no bleeding complications.     

血液透析非永久性深静脉留置导管相关性感染临床观察

目的分析血液透析患者非永久性深静脉留置导管相关性感染的相关因素、常见致病菌,并探讨其预防措施。方法分析327例血液透析患者导管留置时间、置管部位、年龄、有无合并糖尿病与感染的关系以及感染的常见致病菌和耐药情况。结果非永久性深静脉留置导管相关性感染率与导管留置时间有关,股静脉置管的感染率高于颈内静脉置管,老年、合并糖尿病患者的感染率明显高于非老年、未合并糖尿病患者。感染常见致病菌为革兰氏阳性球菌,对替考拉宁、万古霉素耐药率最低,革兰氏阴性杆菌对亚胺培南耐药率最低。结论血液透析非永久性深静脉留置导管相关性感染与置管时间、置管部位、年龄、是否合并糖尿病有关,需要早期发现,选用敏感抗生素并及时治疗。     

Survival and complications of indwelling venous catheters for permanent use in hemodialysis patients

BACKGROUND: The risk factors influencing the survival of indwelling central vein catheters and their potential complications have not been assessed in depth and on a large scale. METHODS: We investigated the general characteristics of 245 single lumen cuffed tunneled catheters and analyzed their survival by Kaplan-Meier and Cox regression analysis. Risk factors for bacteremia and thrombosis were assessed by logistic regression analysis. RESULTS: The incidence of exit-site infection, tunnel infection, bacteremia and thrombotic events was 0.35, 0.25, 1.71, and 1.94/1000 catheter days, respectively. The mean survival time per catheter was 276 days. After censoring for non catheter-related events leading to the removal of the catheter (n = 245 with 120 catheters censored and 125 events), the mean survival time of the catheter appeared to be 615 +/- 67 days (95% CI of 483-747) and the median survival time 310 +/- 50 days (95% CI of 212-408). The localization of the catheter into the right internal jugular vein results in significantly better survival as compared with other insertion sites both in Kaplan-Meier (mean survival of 650 days compared to a mean survival of 519 days, P value < 0.009) and in Cox regression analysis (relative risk of 0.537, P value < 0.001). Localization of the catheter into the right internal jugular vein seemed to increase the risk for bacteremia (relative risk of 1.798, P value of 0.063). The use of anticoagulant agents was not protective for thrombosis, although this might be due to lack of power (relative risk of 0.626, P value of 0.141). CONCLUSION: We provide evidence of a mean survival in long-term hemodialysis catheter close to 2 years with an acceptable complication rate. If a long-term hemodialysis catheter is required, it is best placed in the right internal jugular vein.