维持性血液透析患者带涤纶套隧道导管肝素盐水封管效果的观察分析  

Studies on the effect of heparin saline as the catheter locking solution in maintenance hemodialysis patients with tunnel-cuffed catheters

作　　者：杨冰[1] 胡亚楠 甘良英 王伊娜[1] 朱丽 王磊[1] 蔡美顺[1] 郑姝颖[2] 刘爱春[1] 倪梦凡 左力[1] YANG Bing;HU Ya-nan;GAN Liang-ying;WANG Yi-na;ZHU Li;WANG Lei;CAI Mei-shun;ZHENG Shu-ying;LIU Ai-chun;NI Meng-fan;ZUO Li(Department of Nephrology,people's Hospital,Peking University,Beijing 100044;Department of Clinical Laboratory,Peking University People's Hospital,Beijing 100044,China)

机构地区：[1]北京大学人民医院肾内科,北京100044 [2]北京大学人民医院电镜室,北京100044

出　　处：《中国血液净化》2019年第9期639-642,共4页Chinese Journal of Blood Purification

基　　金：中国医院协会血液净化中心管理分会研究项目(CHABP201622),项目编号:2015-Z-26

摘　　要：目的评价维持性血液透析患者带涤纶套隧道导管应用肝素或肝素盐水封管的效果。方法维持性血液透析患者,由于各种原因(除外导管功能不良)拔除右颈内静脉带涤纶套隧道中心静脉导管,通过肉眼、扫描电镜对拔除导管不同部位导管内壁进行观察。结果肉眼观察,41.7%导管存在双腔完全堵塞性血栓形成,部位为自导管侧孔至导管顶端出口处,25.0%导管双侧管腔无明显血栓形成,33.3%存在单侧管腔堵塞性血栓;电镜观察,100.0%导管存在尖端及侧孔部位血栓形成,尤其侧孔、顶端切割边缘部位更明显。二分类Spearman相关分析显示导管尖端及侧孔部位血栓形成与血红蛋白水平相关(r=0.488,P=0.047),而与性别(r=0.236,P=0.362)、年龄(r=-0.113,P=0.667)、封管液是否稀释(r=0.436,P=0.080)、国际标准化比值(r=-0.339,P=0.183)、血小板(r=-0.187,P=0.473)、总胆固醇(r=0.037,P=0.887)、血钙(r=-0.188,P=0.470)、吸烟(r=0.169,P=0.517)、抗血小板药物(r=0.169,P=0.517)、糖皮质激素(r=0.169,P=0.517)、导管留置时间(r=-0.305,P=0.234)无关。将血红蛋白带入Logistic方程显著性不明显(OR=1.075,95%CI0.980~1.179,P=0.125),考虑与病例数少有关;导管其他部位电镜扫描检查,未见明显异常。16.7%发现导管内壁生物膜形成。结论导管顶端是血栓容易形成的部位,此处血栓形成与患者血红蛋白水平可能相关。Objective To evaluate the effect of heparin or heparin saline locking solution in maintenance hemodialysis (MHD) patients with tunnel-cuffed catheters. Methods After the right internal jugular vein catheters were removed in MHD patients due to various indications (except catheter dysfunction), the internal surface of different parts of the catheters were examined by electron microscopy. Results Visually, 41.7% of the catheters were completely occluded by thrombosis in the two lumens of catheters from side holes to tips of the catheters;25% of the catheters had no obvious thrombosis;33.3% were completely occluded by thrombosis in one lumen. Electron- microscopically, 100% of the catheters had thrombosis at the tips and side holes, especially obvious at the lateral holes and cutting edges of the tips. Spearman correlation analysis showed that thrombosis at the tips and lateral holes was related to hemoglobin level (r=0.488, P=0.047), but not related to gender (r=0.236, P=0.362), age (r=- 0.113, P=0.667), dilution of the locking solution (r=0.436, P=0.080), INR (r=- 0.339, P=0.183), platelet (r=- 0.187, P=0.473), total cholesterol (r=0.037, P=0.887), blood calcium (r=- 0.188, P=0.470), smoking (r=0.169, P=0.517), antiplatelet drugs (r=0.169, P=0.517), glucocorticosteroids (r=0.169, P=0.517) and catheter indwelling time (r=-0.305, P=0.234). The introducing hemoglobin level into the logistic equation had no statistically significance (OR=1.075, 95% CI 0.980~1.179, P=0.125), probably due to the insufficient number of cases. No obvious abnormalities were found in other parts of the catheters by scanning electron microscopy. Biofilm formation was found in 16.7% of the catheters. Conclusion The tip of the catheter is the site where thrombus is easily formed. The thrombosis at the tip and side hole of the catheters may relate to hemoglobin level.

关 键 词：维持性血液透析 带涤纶套隧道导管 封管液 扫描电镜 

分 类 号：R318.16[医药卫生—生物医学工程]