日间无抗凝CRRT患者体外循环管路冲洗护理的研究

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,△P)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).③2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).④2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(t=3.745,P=0.001)、5h(t=3.355,P=0.002)及下机时(t=2.711,P=0.010)较上机时均有显著性差异,平均动脉压变化值在上机后2h(t=2.508,P=0.016)、3h(t=3.078,P=0.004)、4h(t=3.023,P=0.004)、5h(t=2.412,P=0.021)均有显著性差异,脉压在上机后2h(t=2.635,P=0.012)、3h(t=2.805,P=O.008)、4h(t=3.070,P=0.004)、5h(t=2.893,P=0.006)及下机时(t=2.254,P=0.030)有显著差异,脉压变化值在上机后1h(t=2.769,P=0.008)、2h(t=3.154,P=0.003)、3h(t=2.614,P=0.013)、4h(t=2.973,P=0.005)、5h(t=3.063,P=0.004)及下机时(t=2.672,P=0.011)较上机时均有显著性差异. 结论 生理盐水冲洗有利于减缓机器各压力值的上升,对于预防5h以上CRRT体外循环管路的凝血有一定的作用.有高危出血风险的急性或慢性肾功能衰竭患者行无抗凝CRRT过程中,对于合并心血管疾病的患者需慎用生理盐水冲洗.%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 (△P) 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 lh (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 hours in all patients in the two groups.CRRT treatment was terminated in 5 patients (one case in saline flushes group and 4 cases in no-rinse group) due to high pressure limit alarm.The rest of the patients completed continuous veno-venous hemofiltration (CVVH) for 6～ 1 0h following doctor's advice.Compared between the two groups,there were significant differences in systolic pressure changes at lh (t=2.845,P=0.007),2h (t=3.353,P=0.002),3h (t=3.367,P=0.002),4h (t=3.745,P=0.001),5h (t=3.355,P=0.002) and at the end of CRRT (t=2.711,P=0.010),significant differences in mean arterial blood pressure changes at 2h (t=2.508,P=0.016),3h (t=3.078,P=0.004),4h (t=3.023,P=0.004),5h (t=2.412,P=0.021),significant differences in pulse pressure values at 2h (t=2.635,P=0.012),3h (t=2.805,P=0.008),4h (t=3.070,P=0.004),5h (t=2.893,P=0.006) and at the end of CRRT (t=2.254,P=0.030),and significant differences in pulse pressure changes at lh (t=2.769,P=0.008),2h (t=3.154,P=0.003),3h (t=2.614,P=0.013),4h (t=2.973,P=0.005),5h (t=3.063,P=0.004) and at the end of CRRT (t=2.672,P=0.011).Conclusion Physiological saline irrigation is conducive to slow down the rise of pressure value in the machine and to prevent blood coagulation in extracorporeal circuit in CRRT for more than 5h.Patients with acute or chronic renal failure with high risk of bleeding associated with cardiovascular disease should be treated with saline irrigation without anticoagulation during CRRT.