顺血流穿刺法对维持性血液透析患者动静脉内瘘使用初期的影响

目的探讨维持性血液透析（maintenance hemodialysis，MHD）患者自体动静脉内瘘使用初期的最佳穿刺方法。方法将64例自体动静脉内瘘术后6～8周的MHD患者按随机数表法分为对照组和实验组。2组动脉出路选择距离吻合口3em以上的内瘘远心端，对照组32例选用传统穿刺法，即逆血流穿刺法；实验组32例采用顺血流穿刺法，2组静脉回路均为顺血流穿刺。观察内瘘最初4次使用情况，比较2组一次穿刺成功率、血肿发生率、血流量不足发生率及拔针后压迫止血时间，同时比较尿素氮下降率（urear reduction rare，URR）及单室模型尿素清除指数（singl—poolKt／V，spKt／V）。结果64例患者，每例行血液透析4次，2组分别记录血液透析128例次（32例×4次）、内瘘穿刺256例次（动脉出路穿刺128例次＋静脉回路穿刺128例次）。实验组动脉出路一次穿刺成功率为99．22％（127例次，127／128）显著高于对照组92．97％（119例次，119／128）（P〈O．01），血肿发生率为2．34％（3例次，3／128）低于对照组8．59％（11例次，11／128）（P〈0．05），拔针后压迫止血时间（17．63±1．91）min-]显著少于对照组（19．61±1．84）mini（P〈0．01）。实验组和对照组静脉回路一次穿刺成功率分别为99．22％（127例次，127／128）和96．88％（124例次，124／128）、透析血流量不足发生率分别为6．25％（8例次，8／128）和7．03％（9例次，9／128）；URR分别为（65．23％±2．93％）和（65．32％±2．41％）、spKt／V分别为（1．20±0．18）和（1．21±0．11），2组比较，差异无统计学意义（P〉O．05）。结论自体动静脉内瘘使用初期采用顺血流穿刺法，不影响透析血流量及透析充分性，可提高动脉出路穿刺成功率、减少血肿发生、缩短拔针后内瘘压迫止血时间，配合相关护理措施，可减少内瘘相关并发症、保护内瘘成熟，可能延长内瘘使用寿命。

A new fistula puncture method for initially used native arteriovenous fistula

Objective To discuss the optimal fistula puncture method for native arteriovenous fistula used initially in the patients subject to maintenance hemodialysis （MHD）. Methods Sixty-four patients were divided into two groups randomly 6-8 weeks after radial-cephaliz native arteriovenous fis- tula operation. Thirty-two patients in control group were subjected to the traditional fistula puncture method.- inserting the arterial needle with the contrary direction of the blood flow in the distal fistula vein 3 cm from the anastomosis,and 32 patients in test group to a different puncture method： just in- serting the arterial needle with the same direction of the blood flow. The same puncture method of ve- nous needles was done on all patients. The success rate of puncture, the incidence of hematoma, the in- cidence of low blood-flow in dialysis and the bleeding time after withdrawing the needle between the two groups of the first 4 times of dialysis were compared. After the 4th dialysis, the adequacy of dialy- sis was calculated and compared in the two groups, including urea reduction rate （URR） and single- pool Kt/V （spKt/V）. Results All the patients were subjected to hemodialysis 4 times, including 128 cases for hemodialysis, and 256 cases for fistula puncture （128 cases for arterial puncture, and 128 cases for venipuncture）. In test group, the first puncture success rate of arterial puncture was 99. 22% （127 cases, 127/128）, significantly higher than that in control group（92. 97%, 119/128）（ P〈0. 01）. The incidence of hemotoma in test group was 2. 34% （3 cases, 3/128）, significantly lower than in con- trol group （8. 59 %, 11/128） （P〈0. 05）. The bleeding time in test group was （ 17. 63 ± 1.91 ） min, sig- nificantly shorter than in control group （19. 61 ± 1.84 min,P〈0. 05）. The first puncture success rate of venipuncture in test and control groups was 99. 22% （127 cases,127/128） and 96. 88% （124 cases, 124/128,P〉0. 05） respectively. The incidence of low blood-flow in test and control groups was 6. 25% （8 cases,8/128） and 7. 03% （9 cases,9/128,P〉0. 05） respectively. The URR in test and con- trol groups was （65. 23%± 2. 93%） and （65.32% ± 2. 41%） respectively（P〉0. 05）. The spKt/V in test and control groups was （1.20 ± 0. 18） and （1.21 ± 0. 11） respectively（P〉0. 05）. Conclusions For the initially used arteriovenous fistula, puncture with the same direction of the blood-flow will in- crease the success rate of puncture, reduce the incidence of hemotoma at the puncture point and shorten the bleeding time after withdrawing the needle. Cooperating with relevant nursing interventions, it will reduce fistula-related complications, protect fistula maturation, and may prolong the life of the native arteriovenous fistula.