回顾性分析反渗水残余氯超标对维持性血液透析患者的影响

目的探讨血液透析室反渗水残余氯超标的原因以及对维持性血液透析(HD)患者的影响。方法将南通市第二人民医院(以下简称南通二院)2005年1月、3月、4月及5月36例HD患者血红细胞计数(RBC)、血红蛋白(Hb)和血细胞比容(Hct)进行比较,观察各参数的变化;将南通市第六人民医院(以下简称南通六院)2010年12月份、2011年1月份、2月份24例HD患者RBC、Hb和Hct进行比较,观察各参数的变化;观察2008年南通二院新水处理机安装后反渗水残余氯测定结果以及增装活性炭罐后残余氯测定结果。结果 2005年2～3月,南通二院HD患者集体出现Hb、RBC、Hct下降,并伴有心悸、胸闷、乏力、透析低血压和心律失常等临床症状;Hb下降速度较快(P0.01);更换同量的进口椰壳活性炭无效,Hb继续下降(P0.05);增加活性炭容量后,病情未再恶化,贫血症状逐步改善,Hb逐渐上升(P0.01)。2006年2～3月份同样出现类似情况,更换活性炭后患者贫血症状逐渐缓解;2008年7月,南通二院新购入40床双级水处理系统,安装后采用比色法监测即发现残余氯超标(0.5mg/L),增装一个活性炭罐后,残余氯控制在允许范围内(0.5mg/L),投放使用后未出现集体贫血事件的发生。2011年1月南通六院新建血液透析室患者透析1个月后,发现所有患者均出现血常规的变化,血红蛋白下降(P0.05);透析2个月后血红蛋白进一步下降(P0.05),大部分患者有临床症状;增加一个同型号炭罐,1个月后血红蛋白均上升(P0.01),临床症状改善。结论 HD患者集体溶血事件易发生在春季,且Hb下降速度较快,每月平均可下降20～30g/L;这些溶血事件与水处理反渗水残余氯超标有关;活性炭对残余氯的吸附能力主要与活性炭数量有关,与其种类关系不大;目前通用的水处理系统中标准配置活性炭对残余氯的吸附能力不足易致残余氯超标,引起维持性血液透析患者出现集体急性溶血事件。

Retrospective analysis on influence of reverse osmosis water residual chlorine exceeding the standard to maintenance hemodialysis patients

Objective To explore the causes of the overproof of reverse osmosis water residual chlorine of hemodialysis room and its influence to maintenance hemodialysis（HD）patients.Methods Comparison was made on 36 HD patients in 2005 January,March,April and May from Nantong Second People＇s Hospital（referred Nantong Second Hospital）,the number of red blood cells（RBC）,hemoglobin（Hb）and red blood cell volume（Hct）were observed;Comparison was made on 24 HD patients in 2010 December,2011January and February from Nantong Sixth People＇s Hospital,the number of RBC,Hb and Hct were observed.;Observation was made on the installation of reverse osmosis water residual chlorine determination results and filled with activated carbon tank of Nantong Second Hospital in 2008 after taking the new water processor.Results Hb,RBC,Hct in HD patients from Nantong Second Hospital were decreased,accompanied by palpitations,chest,tightness,fatigue,dialysis hypotension and arrhythmia;Hb decreased faster（P〈0.01）;Replaced the same amounts of import coconut shell activated carbon were invalid,Hb continued to decline（P〈0.05）;The illness did not get worse after increasing capacity of activated carbon,anemia symptoms gradually improved,Hb increased（P〈0.01）.In 2006Feb-Mar,this situation appeared again,anemia symptoms gradually eased after replacing activated carbon;In 2008 July,Nantong Second Hospital bought new 40 bed hospital acquired two-stage water treatment system,after the installation of the colorimetric method was used to monitor residual chlorine exceed the standard（〉0.5mg/L）,after adding a canister,residual chlorine was controlled in the permissible range（〈0.5mg/L）,the collective solution events did not happen after it was put to use.After dialysis 1month in new hemodialysis room of Nantong Sixth Hospital,all patients showed blood routine change,Hb decreased（P〈0.05）;dialysis 2months later,a further decline in Hb was observed（P〈0.05）,most of the patients had clinical symptoms;added s