董玉鳳
【摘要】目的:探討對(duì)于高危出血患者血液透析中使用枸櫞酸鈉抗凝的應(yīng)用效果。方法:選取2021年1月—2022年10月收治的100例血液透析高危出血患者為研究對(duì)象,所有患者均給予枸櫞酸鈉抗凝,將受試者進(jìn)行隨機(jī)分組,各50例,對(duì)照組患者給予常規(guī)護(hù)理,研究組患者則給予全面護(hù)理,對(duì)比兩組患者透析前后各電解質(zhì)水平與pH值變化、腎功能與凝血功能變化及不良反應(yīng)發(fā)生率。結(jié)果:透析前兩組患者各電解質(zhì)水平比較無(wú)差異(P>0.05),透析后研究組患者血鈉、血鈣水平及pH值均高于對(duì)照組(P<0.05),血氯與血鉀水平比較無(wú)差異(P>0.05);透析后兩組患者血Scr及BUN水平較透析前均降低(P<0.05),且兩組之間相比無(wú)差異(P>0.05),兩組患者治療前后ACT相比均無(wú)差異(P>0.05);研究組患者全身抽搐、肌肉痙攣、口唇周圍發(fā)麻及堿中毒的發(fā)生率均顯著低于對(duì)照組,組間相比無(wú)差異(P<0.05)。結(jié)論:對(duì)于高危出血患者血液透析枸櫞酸鈉抗凝中實(shí)施全面護(hù)理可有效改善血清電解質(zhì)水平,降低出血風(fēng)險(xiǎn)及不良反應(yīng)發(fā)生率,確保透析效果。
【關(guān)鍵詞】枸櫞酸鈉抗凝;血液透析;高危出血;電解質(zhì);不良反應(yīng)
Nursing study of sodium citrate anticoagulation in hemodialysis of patients with high risk bleeding
DONG Yufeng
The First Peoples Hospital of Xining, Xining, Qinghai 810000, China
【Abstract】Objective: To investigate the effect of sodium citrate anticoagulation in hemodialysis for patients with high risk of bleeding. Methods: A total of 100 patients with high risk bleeding on hemodialysis admitted from January 2021 to October 2022 were selected as the research objects. All patients were given sodium citrate anticoagulation, and the subjects were randomly divided into two groups, 50 cases in each group. The control group was given routine care, while the study group was given comprehensive care. The changes of electrolyte level and pH value, renal function and coagulation function, and the incidence of adverse reactions were compared between the two groups before and after dialysis. Results: Before dialysis, there was no significant difference in the electrolyte levels between the two groups(P>0.05). After dialysis, the serum sodium, calcium and pH levels in the study group were significantly higher than those in the control group(P<0.05), and there was no significant difference in the serum chloride and potassium levels(P>0.05). After dialysis, the levels of Scr and BUN in the two groups were significantly lower than those before dialysis(P<0.05), and there was no significant difference between the two groups(P>0.05), and there was no significant difference between the ACT before and after treatment in the two groups (P>0.05). The incidence of convulsions, muscle spasms, numbness around the mouth and lip and alkalosis in the study group were significantly lower than those in the control group, and there were statistical differences between the two groups(P<0.05). Conclusion: Comprehensive nursing in sodium citrate anticoagulation in hemodialysis for patients with high-risk bleeding can effectively improve serum electrolyte level, reduce the risk of bleeding and the incidence of adverse reactions, and ensure the effect of dialysis.
【Key Words】Sodium citrate anticoagulation; Hemodialysis; High risk bleeding; The electrolyte; Adverse reactions
當(dāng)患者處于終末期腎臟疾病時(shí),往往需要進(jìn)行腎臟替代療法,其中血液透析為一種應(yīng)用率較高且最有效的治療方法,其機(jī)理是利用體外透析器的彌散、對(duì)流、超濾、吸附等功能清除血液中的代謝廢物,先將體內(nèi)血液引流到體外透析器中,再將已經(jīng)清除了代謝廢物的血液重新輸回體內(nèi),而合理的抗凝是保證血液透析順利進(jìn)行的基礎(chǔ)[1]。臨床上關(guān)于抗凝劑的使用,低分子肝素應(yīng)用率最高,但常用于已發(fā)生出血的透析患者,若應(yīng)用于高危出血患者中則會(huì)增加出血并發(fā)癥的發(fā)生風(fēng)險(xiǎn)[2]。枸櫞酸鈉是一種新型的抗凝劑,其發(fā)揮抗凝作用主要是由于枸櫞酸根離子結(jié)合血液中的鈣離子形成枸緣酸鈣,枸櫞酸鈣可溶解但不容易解離,使得游離鈣離子水平較低,繼而凝血過(guò)程被阻攔,達(dá)到抗凝效果,該藥物應(yīng)用于高危出血患者血液透析中,具有優(yōu)勢(shì)[3-4]。因此,本文收集血液透析高危出血患者100例,探討枸櫞酸鈉抗凝的應(yīng)用效果,現(xiàn)進(jìn)行如下報(bào)道。
1.1 一般資料
收集血液透析高危出血患者100例,病例納入時(shí)間2021年1月—2022年10月。納入標(biāo)準(zhǔn):①所有患者均有體內(nèi)活動(dòng)性出血或存在高危出血風(fēng)險(xiǎn);②年齡18~80歲;③血管通路為動(dòng)靜脈自體內(nèi)瘺;④認(rèn)知功能正常;⑤依從性佳;⑥既往病史資料均有記載;⑦患者充分知情后自愿參與本次研究。排除標(biāo)準(zhǔn):①枸緣酸鈉過(guò)敏;②精神認(rèn)知障礙;③低血壓;④肝功能衰竭;⑤合并全身嚴(yán)重感染性疾?。虎弈∈芳安荒芘浜媳敬窝芯空?。
將受試者進(jìn)行隨機(jī)分組,各50例。對(duì)照組,男28例,女22例,年齡40~80歲,平均年齡(61.73±3.74)歲,疾病類型:慢性腎小球腎炎10例,糖尿病腎病12例,多囊腎8例,高血壓腎病11例,腎病綜合征9例;研究組,男27例,女23例,年齡42~78歲,平均年齡(61.38±3.68)歲,疾病類型:慢性腎小球腎炎12例,糖尿病腎病9例,多囊腎6例,高血壓腎病10例,腎病綜合征13例。兩組患者在上述基本資料信息方面無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),可進(jìn)行比較。
1.2 方法
所有患者均選擇金寶血液透析機(jī)和4008血液透析機(jī),及百特中空纖維透析器或德國(guó)費(fèi)森Fresenius中空纖維透析器,透析液為碳酸氫鹽透析液。透析液流量為500mL/min,血流量為200~250mL/min,透析液溫度為36℃~37℃。枸緣酸鈉抗凝劑(四川南格爾生物科技有限公司,國(guó)藥準(zhǔn)字H20058912)抗凝,枸緣酸鈉抗凝給藥從動(dòng)脈端進(jìn)入,且枸櫞酸的流速與血流速一致,如枸櫞酸200 mL/min抗凝,血泵流速也為200 mL/min,靜脈端也給予少量枸櫞酸抗凝,與動(dòng)脈端的比值是1:5,透析期間若疑有凝血傾向,可用生理鹽水進(jìn)行沖管。
以上述治療為前提,對(duì)照組實(shí)施常規(guī)護(hù)理,主要為密切監(jiān)測(cè)患者的生命體征、透析情況及抗凝效果,確保血液透析的有效性及安全性。
研究組實(shí)施全面護(hù)理,具體為:(1)心理護(hù)理及健康宣教:強(qiáng)化與患者之間的溝通,全面評(píng)估患者心理狀況,耐心且詳細(xì)的向其講述血液透析治療的方法、步驟、相關(guān)注意事項(xiàng)、出血癥狀及應(yīng)對(duì)措施等,對(duì)患者不理解的地方耐心解答,減輕其心理負(fù)擔(dān),同時(shí)對(duì)患者進(jìn)行心理疏導(dǎo),增加其治療信心。(2)血液透析前準(zhǔn)備:透析前根據(jù)患者的具體病情、水腫情況、體重及身體狀況確定超濾量,準(zhǔn)確評(píng)估患者的出血傾向及凝血功能,監(jiān)測(cè)靜脈端與動(dòng)脈端的ACT并設(shè)定枸緣酸鈉的量,分析動(dòng)脈血?dú)狻⒀杏坞x鈣的濃度以及跨膜壓以便透析時(shí)及時(shí)調(diào)整枸緣酸鈉的輸注速度。(3)透析時(shí)護(hù)理:透析時(shí)嚴(yán)密監(jiān)測(cè)患者的臨床癥狀、生命體征及心電圖,若出現(xiàn)抽搐、唇麻等癥狀需及時(shí)補(bǔ)充鈣劑。觀察患者靜脈壓、透析器顏色變化,一旦發(fā)現(xiàn)透析器變黑、變暗需使用生理鹽水沖洗以清除血凝塊。(4)預(yù)防不良事件:枸緣酸鈉抗凝時(shí)患者易出現(xiàn)堿中毒傾向,因此護(hù)理中需密切監(jiān)測(cè)患者臨床癥狀以及時(shí)調(diào)整枸緣酸鈉用量,同時(shí)確保血管通路通暢,建立動(dòng)脈內(nèi)瘺,預(yù)防血栓形成。
1.3 觀察指標(biāo)
在透析前及透析結(jié)束時(shí)均于動(dòng)脈端檢測(cè)兩組患者血鈉、血鉀、血鈣、血氯水平及pH值,在患者保持空腹時(shí),透析前后均采集血液樣本5 mL,將其置于EDTA真空抗凝管中,靜置30 min后離心分離出上層清液,選擇GE AU5800型生化分析儀,采用堿性苦味酸法測(cè)定肌酐(Scr)水平,采用紫外速率法測(cè)定尿素氮(BUN)水平,并記錄兩組患者透析前后的激活凝血時(shí)間(ACT),統(tǒng)計(jì)兩組患者透析后不良反應(yīng)發(fā)生情況。
1.4 統(tǒng)計(jì)學(xué)方法
采用SPSS 19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析。計(jì)數(shù)資料采用(%)表示,進(jìn)行χ2檢驗(yàn),計(jì)量資料采用(χ±s) 表示,進(jìn)行t檢驗(yàn),P<0.05為差異具有統(tǒng)計(jì)學(xué)意義。
2.1 各電解質(zhì)水平變化
透析前兩組患者各電解質(zhì)水平比較無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),透析后研究組患者血鈉、血鈣水平及pH值均顯著高于對(duì)照組(P<0.05),血氯與血鉀水平比較無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),見表1。
2.2 腎功能與凝血功能變化
透析后兩組患者血Scr及BUN水平較透析前均明顯降低(P<0.05),且兩組之間相比無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),兩組患者治療前后ACT相比均無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05),見表2。