日间无抗凝CRRT患者体外循环管路冲洗护理的研究  

The research on flush methods for preventing coagulation and clot formation during continuous renal replacement therapy without anticoagulation

作　　者：郭宏晶[1] 李莉[2] 向晶[3] 马志芳[3] 张杰[3] 黄静[3] 耿赫兵 王艳[4] 孟庆义[5] 朱秀勤[1] 王建荣[4] 

机构地区：[1]解放军总医院内科临床部护理办,北京100853 [2]解放军总医院南楼临床部检验科,北京100853 [3]解放军总医院内科临床部肾脏病科,北京100853 [4]解放军总医院护理部,北京100853 [5]解放军总医院门诊部急诊科,北京100853

出　　处：《中国血液净化》2017年第9期635-642,共8页Chinese Journal of Blood Purification

基　　金：中国人民解放军总医院科研基金项目;编号:13KMM10

摘　　要：目的探索生理盐水冲洗与免冲洗两种方法对有高危出血风险行日间无抗凝连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)时患者凝血指标、循环情况及机器各压力值的影响。方法将有高危出血风险行无抗凝CRRT治疗的患者随机分为生理盐水冲洗组和免冲洗组,在上机过程不同时间点采集血标本,测定凝血酶原片段(prothrombinfragment 1+2,PF1+2)和β-血小板球蛋白(β-Thromboglobulin,β-TG)的变化,记录机器跨膜压(transmembrane pressure,TMP)、滤器前压(filter pressure,PBE)和滤器压力下降值(filter pressure decrease value,ΔP)及患者心率、血压的变化。结果 (1)生理盐水冲洗组与免冲洗组相比,患者PF1+2和β-TG的变化无显著差异。(2)免冲洗组跨膜压在上机后3h(t=3.813,P<0.001)、4h(t=4.230,P<0.001)及下机时(t=7.014,P<0.001)较上机时增加,且有显著差异;生理盐水组跨膜压在上机后4h(t=3.296,P=0.002)及下机时(t=3.930,P<0.001)较上机时增加,且有显著差异。两组患者所用机器不同时间滤器前压变化值在上机后1h(u=3.056,P=0.002)、2h(u=2.788,P=0.005)、3h(u=2.009,P=0.045)及下机时(u=2.201,P=0.043)有显著差异。免冲洗组滤器压力下降值在上机后1h(t=2.738,P=0.009)、2h(t=3.590,P<0.001)、3h(t=4.771,P<0.001)、4h(t=4.754,P<0.001)及下机时(t=5.144,P<0.001)均较上机时增加,且有显著差异;生理盐水冲洗组滤器压力下降值在上机后3h(t=3.013,P=0.005)、4h(t=3.020,P=0.005)及下机时(t=3.814,P=0.001)均较上机时增加,且有显著差异。2组滤器压力下降值变化值在下机时有显著差异(u=2.155,P=0.031)。(3)2组患者因压力高限报警下机时间均在5h以上,生理盐水冲洗组例数(1例)少于免冲洗组(4例),其余患者均根据医嘱完成了6~10h的连续性静脉静脉血液滤过(continuous veno-venous hemofiltration,CVVH)。(4)2组患者不同时间收缩压变化值在上机后1h(t=2.845,P=0.007)、2h(t=3.353,P=0.002)、3h(t=3.367,P=0.002)、4h(Objectives To investigate the effects on blood coagulation, circulation status and filter life in critically ill patients with high bleeding risk requiring continuous renal replacement therapy （CRRT） without anticoagulation. Methods Patients with high risk of bleeding requiring CRRT without anticoagulation in the ICU were randomly divided into saline flushes group and no-rinse group. Levels of prothrombin fragment 1＋2 （PF1＋2） and β-thromboglobulin （β-TG） were measured, and the transmembrane pressure （TMP）, pressure before the filter （PBE） and filter pressure decrease value （ΔP） were observed. Changes of heart rate and blood pressure were monitored during CRRT. Results There was no significant difference in the levels of PF1＋2 and β-TG between saline flushes group and no-rinse group. In no-rinse group the TMP at 3h （t=3.813, P〈0.001）, 4h （t=4.230, P〈0.001） and at the end of CRRT （t=7.014, P〈0.001） were significantly higher than that at the start of CRRT. In saline flushes group, the TMP at 4h （t=3.296, P=0.002） and at the end of CRRT （t=3.930, P〈0.001） were significantly higher than that at the start of CRRT. Filter pressure in the two groups showed significant differences after 1h （u=3.056, P=0.002）, 2h （u=2.788, P=0.005）, 3h （u=2.009, P=0.045） and at the end of CRRT （u=2.201, P=0.043）. In no- rinse group the filter pressure decrease value at 1h （t=2.738, P=0.009）, 2h （t=3.590, P〈0.001）, 3h （t=4.771, P〈0.001）, 4h （t=4.754, P〈0.001） and at the end of CRRT （t=5.144, P〈0.001） were significantly higher than that at the start of CRRT. In saline flushes group, the filter pressure decrease value at 3h （t=3.013, P=0.005）, 4h （t=3.020, P=0.005） and at the end of CRRT （t=3.814, P=0.001） were significantly higher than that at the start of CRRT. Filter pressure decrease value in the two groups showed significant differences at the end of CRRT （u=2.155, P=0.031）. The CRRT treatment time were more than 5

关 键 词：持续肾脏替代治疗 生理盐水冲洗 抗凝 凝血 护理 

分 类 号：R459.5[医药卫生—治疗学]