CN117442803A - 血膜预充在预防血液透析滤过早期并发症的应用 - Google Patents
血膜预充在预防血液透析滤过早期并发症的应用 Download PDFInfo
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Abstract
本发明公开了血膜预充在预防血液透析滤过早期并发症的应用,通过在HDF中使用患者的自体血密闭预充循环后再进行HDF治疗,从而改善透析膜的相容性,达到预防患者在HDF发生过敏反应的效果,降低患者的透析风险,且不增加出血及体外凝血的现象。
Description
【技术领域】
本发明属于血液透析滤过技术领域,涉及血膜预充在预防血液透析滤过早期并发症的应用。
【背景技术】
慢性肾功能衰竭是临床常见疾病,近年来发病率逐渐升高,血液透析(HD)是慢性肾功能衰竭患者肾脏替代治疗方式之一。它通过将体内血液引流至体外,经一个由无数根空心纤维组成的透析器中,血液与含机体浓度相似的电解质溶液(透析液)在一根根空心纤维内外,通过弥散、超滤、吸附和对流原理进行物质交换,清除体内的代谢废物、维持电解质和酸碱平衡;同时清除体内过多的水分,并将经过净化的血液回输的整个过程,血液透析使许多肾病患者得以长期存活。由于普通的血液透析不能将中分子毒素清除彻底,且还会诱导产生新的毒素,发生并发症现象较多,从而降低了患者的生存质量,使患者的死亡率提升。
血液透析滤过(HDF)是在血液透析的基础上,采用高通透性的透析滤过膜,提高清除率,从血中滤出大量含毒素的体液,同时输入等量置换液的一种特殊的血液净化方法,是血液透析和血液滤过的有机结合,目的就是增加对大、中、小分子毒素的清除,在改善患者的生活质量,提高生存率方面有明显的优势,但是用于体外循环的管道和透析膜等常导致患者产生过敏反应。
透析过敏反应临床分为两类:
A型反应(过敏反应型);主要发病机制为快速的变态反应,常于透析开始后5min内发生,少数迟至透析开始后30min。依据反应轻重可表现为皮肤瘙痒、荨麻疹、咳嗽、流鼻涕、腹痛、腹泻,甚至呼吸困难、休克、死亡等。
B型反应:常见于透析开始后20-60min出现,其发作程度较轻,多表现为胸痛背痛。
HDF过敏反应的发生率不高,但发生时会给患者造成严重的不适和痛苦,影响治疗的正常进行,部分患者和家属因过敏反应产生严重的心理负担,从而对HDF产生负面情绪。造成透析过敏反应的原因大概可以分成几类:一是透析器膜的生物相容性差以及体外循环材料的生物相容性差;二是对透析器的消毒剂过敏;三是透析液污染以及机器消毒不合格;四是过敏体质(如高嗜酸细胞血症)以及药物敏感;五是假性透析器过敏。
过敏反应是血液透析滤过(HDF)常见的早期并发症,不仅增加患者的痛苦,使患者无法顺利完成HDF治疗,而且影响患者的透析质量,从而加重患者和家属的心理负担。长期以来,如何减少透析过程中的并发症,保证患者医疗安全,是维持性血液透析患者、家属及广大医护工作者关注的问题。
【发明内容】
针对现有技术中过敏反应是血液透析滤过(HDF)常见的早期并发症,增加患者的痛苦,使患者无法顺利完成HDF治疗的问题,本发明提供了血膜预充在预防血液透析滤过早期并发症的应用,通过在HDF中使用患者的自体血密闭预充循环后再进行HDF治疗,从而改善透析膜的相容性,达到预防患者在HDF发生过敏反应的效果,降低患者的透析风险,且不增加出血及体外凝血的现象。
本发明的目的通过以下技术方案来实现:
通过采用血膜预充在HDF治疗的应用,注意观察HDF治疗中患者的血压波动,呼吸的改变,心率的变化等,还有过敏反应出现的轻重,出现的时间,用药后症状是否缓解;在患者进行HDF时先按HDF的操作流程进行血滤器和管路的常规在线预充后,再使用患者自体血进行密闭式循管和跨膜超滤10min,可以让患者少量血液提前与透析膜充分接触,引发血/膜反应,使补体充分适化,减少对中性粒细胞的激活、活化的粒细胞对血管内皮的粘附及细胞因子的释放,并且能在透析膜内形成一层自身蛋白膜,从而改善透析器的生物相容性,最终预防透析过敏反应的发生,提高患者的透析质量。
血膜预充在预防血液透析滤过早期并发症的应用,包括以下步骤:
S1、患者选择:选择尿毒症透析患者,随机将患者分为观察组与对照组,二组患者在年龄、身高、体重等体质方面无显著性差异(P>0.05),具有可比性;
病历入选标准:意识清楚,言语表达正常,与研究人员沟通无障碍;知情同意且得到医院伦理委员会的批准;
排除标准:血液高凝状态,危重患者认知障碍者,精神障碍,严重的心脏衰竭;
S2、观察组干预方式处理:
S2-1、透析器常规预冲,至膜内、膜外排液完成;
S2-2、患者建立体外循环通路,抽血10ml,从静脉壶注入体外循环管路,密闭式循环10min后,再做跨膜超滤10min,超滤量200ml;
S2-3、跨膜超滤结束,用生理盐水500ml冲尽管路内循环的残余血液;
S2-4、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S2-5、常规引血,引血过程及透析4小时内严密观察患者反应;
S2-6、如有过敏,按照透析器A、B型反应对症处理,A型反应,必要时要弃血;
S3、对照组干预方式处理:
S3-1、透析器常规预冲,至膜内、膜外排液完成;
S3-2、患者建立体外循环通路;
S3-3、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S3-4、常规引血,引血过程及透析4小时内严密观察患者反应;
S3-5、如有过敏,按照透析器A、B型反应对症处理,必要时要弃血;
S4、观察指标:
对比观察组和对照组的两组患者在使用血膜预充的方法后,在治疗过程中和治疗后是否现血液透析滤过过敏反应;
S5、评价方法:
患者在进行常规HDF治理4h,观察患者在治疗过程中是否出现气促,心率改变,分别测定每次透析前,透析中1、2、3h及透析后前臂血压值,并进行比较分析:
S5-1、观察两组患者血液滤过透析早期并发症,过敏反应发生的情况:
A型反应:常发生在透析5-30min,主要表现为焦虑不安、血压下降、恶心呕吐等,少数严重患者可伴有意识丧失、呼吸困难、甚至心跳骤停;
B型反应:常发生在透析开始1h内,主要表现为胸痛、背痛、瘙痒、荨麻疹、咳嗽、喷嚏、鼻过敏、眼部水肿、恶心、呕吐、腹痛及腹泻等症状;
S5-2、低血压的评定标准:计算平均动脉压(MAP=舒张压下降≥30mmHg)者,则认为有症状性低血压发生,所有观察对象当日透析前后均停用常规口服降压药物,以排除药物干扰因素;
S5-3、心率的稳定性的对比:对照组的患者心率波动范围大小与观察组的患者心率波动范围的大小,成人正常心率60-100次/分;
S5-4、呼吸频率的改变,成人正常呼吸16-20次/分;
S5-5、通过生化数据血红蛋白的对比,对照组与观察组的患者血红蛋白无显著性差异(P>0.05);
S6、统计学方法:
选择SPSS20.00软件进行数据记录、统计学分析,两组间比较采用t检验;
计数资料采用χ2检验;
对比患者进行血膜预充后各项指标的变化以及两组间数据对比,观察有无统计学差异,以及进行效果分析。
本发明中:
步骤S4所述的过敏反应,是指高血压、低血压、呼吸急促、呕吐、全身瘙痒、治疗后浑身无力感等。血液滤过透析治疗过程中存在多种过敏反应,与多种因素有关,严重者可以影响患者的治疗及预后,导致严重的后果,威胁患者的生命,预防过敏反应有助于改善患者的治疗效果。
步骤S4所述的过敏反应,预防对策包括:
(1)定期检测透析液,严格遵守血液透析标准操作规程相关规定,定期检测透析液成分,定期更换细菌过滤器,治疗结束后严格进行机器消毒,确保透析液各项指标均达标,不含致敏原,阻断血液透析滤过过敏反应的途径;
(2)选择合适的预充方式,充分预充血滤器及血路管,患者对透析膜材料反应各有不同,选择合适的血滤器,对考虑因透析膜材料过敏的患者采用血膜预充,HDF均采用在线预冲,预冲量1000ml以上,超滤500ml,充分预充透析器及血路管,尽量减少透析器的血路管的残留物;
(3)排除药物过敏,排除抗凝剂及其他药物引起的过敏反应。
和现有技术相比,本发明具有如下优点:
1、本发明所述的血膜预充在预防血液透析滤过早期并发症的应用,为了减少和预防透析过敏反应的发生,本申请运用患者自体血液先预充血滤器和管路,能有效地减少和预防透析过敏反应的发生,主要原因是:(1)停止了含致敏因子的血液回输,减少抗原对机体的再刺激;(2)血浆蛋白被吸附在透析膜表面,阻止了血液与透析膜的直接接触,使补体激活减少,改善透析膜生物相容性,从而减轻过敏反应的发生;同时有部分致敏因子在闭路循环过程中,通过透析机的透析与滤过清除,而起到减少免疫反应的作用。本申请的应用是创造性的方法,集科学、实用,高效于一体,与同类相比具有经济性,实用性,可适用于乡、镇、市、省等各级医院,有较广阔的市场需求。
2、本发明所述的血膜预充在预防血液透析滤过早期并发症的应用,创新点如下:
(1)使用血膜循管能改善透析器的生物相容性,明显降低透析过敏反应的发生,经过血膜循管仍发生透析过敏反应的患者症状和体征较轻,临床处理比较简单,可以减轻患者的痛苦,提高透析效果和患者的生存质量;
(2)避免患者在HDF治疗过程中发生过敏反应后会产生焦虑、恐惧等情绪,导致精神压力较重,畏惧治疗;
(3)在透析过敏反应发生时,我们最常用的药物就是地塞米松磷酸钠注射液,地塞米松磷酸钠注射液是一种糖皮质激素,糖皮质激素的药理作用十分广泛,能调控机体糖类、蛋白质、脂肪类物质代谢,并能调节钠、钾、水代谢过程。在临床中应用亦十分广泛,主要用于抗炎、抗休克、抗毒与免疫抑制,由于其药理作用较广泛,因而在获得治疗作用的同时,也会带来不少药物不良反应,使用糖皮质激素可减弱机体防御疾病的能力,有利于细菌、真菌的繁殖及扩散,可能诱发和加重感染。
【具体实施方式】
以下结合实施例对本发明的具体实施方式做进一步说明。
实施例:
血膜预充在预防血液透析滤过早期并发症的应用:
S1、患者选择:选择我科2020年12月-2023年12月在我科治疗的尿毒症患者60例,随机将患者分为观察组与对照组各30例,二组患者在年龄、身高、体重等体质方面无显著性差异(P>0.05),具有可比性;
病历入选标准:意识清楚,言语表达正常,与研究人员沟通无障碍;知情同意且得到医院伦理委员会的批准;
排除标准:血液高凝状态,危重患者认知障碍者,精神障碍,严重的心脏衰竭;
S2、观察组干预方式处理:
S2-1、透析器常规预冲,至膜内、膜外排液完成;
S2-2、患者建立体外循环通路,抽血10ml,从静脉壶注入体外循环管路,密闭式循环10min后,再做跨膜超滤10min,超滤量200ml;
S2-3、跨膜超滤结束,用生理盐水500ml冲尽管路内循环的残余血液;
S2-4、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S2-5、常规引血,引血过程及透析4小时内严密观察患者反应;
S2-6、如有过敏,按照透析器A、B型反应对症处理,A型反应,必要时要弃血;
S3、对照组干预方式处理:
S3-1、透析器常规预冲,至膜内、膜外排液完成;
S3-2、患者建立体外循环通路;
S3-3、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S3-4、常规引血,引血过程及透析4小时内严密观察患者反应;
S3-5、如有过敏,按照透析器A、B型反应对症处理,必要时要弃血;
S4、观察指标:
对比观察组和对照组的两组患者在使用血膜预充的方法后,在治疗过程中和治疗后是否现透过敏反应;所述的过敏反应,是指高血压、低血压、呼吸急促、呕吐、全身瘙痒、治疗后浑身无力感等;
过敏反应,预防对策包括:
(1)定期检测透析液,严格遵守血液透析标准操作规程相关规定,定期检测透析液成分,定期更换细菌过滤器,治疗结束后严格进行机器消毒,确保透析液各项指标均达标,不含致敏原,阻断血液透析滤过过敏反应的途径;
(2)选择合适的预充方式,充分预充血滤器及血路管,患者对透析膜材料反应各有不同,选择合适的血滤器,对考虑因透析膜材料过敏的患者采用血膜预充,HDF均采用在线预冲,预冲量1000ml以上,超滤500ml,充分预充透析器及血路管,尽量减少透析器的血路管的残留物;
(3)排除药物过敏,排除抗凝剂及其他药物引起的过敏反应;
S5、评价方法:
患者在进行常规HDF治理4h,观察患者在治疗过程中是否出现气促,心率改变,分别测定每次透析前,透析中1、2、3h及透析后前臂血压值,并进行比较分析:
S5-1、观察两组患者血液滤过透析早期并发症,过敏反应发生的情况:
A型反应:常发生在透析5-30min,主要表现为焦虑不安、血压下降、恶心呕吐等,少数严重患者可伴有意识丧失、呼吸困难、甚至心跳骤停;
B型反应:常发生在透析开始1h内,主要表现为胸痛、背痛、瘙痒、荨麻疹、咳嗽、喷嚏、鼻过敏、眼部水肿、恶心、呕吐、腹痛及腹泻等症状;
S5-2、低血压的评定标准:计算平均动脉压(MAP=舒张压下降≥30mmHg)者,则认为有症状性低血压发生,所有观察对象当日透析前后均停用常规口服降压药物,以排除药物干扰因素;
S5-3、心率的稳定性的对比:对照组的患者心率波动范围大小与观察组的患者心率波动范围的大小,成人正常心率60-100次/分;
S5-4、呼吸频率的改变,成人正常呼吸16-20次/分;
S5-5、通过生化数据血红蛋白的对比,对照组与观察组的患者血红蛋白无显著性差异(P>0.05);
S6、统计学方法:
选择SPSS20.00软件进行数据记录、统计学分析,两组间比较采用t检验;
计数资料采用χ2检验;
对比患者进行血膜预充后各项指标的变化以及两组间数据对比,观察有无统计学差异,以及进行效果分析。
表1:患者资料
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结果及讨论:
1、完成了60例尿毒症患者行HDF病例研究,观察组:在HDF治疗中使用常规在线预充后,再使用患者自体血循环预充血滤器及其循环管路,跨膜超滤的方法。对照组:在HDF治疗中使用常规在线预充的方法。比较两组患者在预防HDF治疗中早期并发症的治疗效果。用自体血循环预充血滤器的方法在预防和减少在HDF治疗中的早期并发症(过敏反应、高血压、低血压、呼吸急促、呕吐、全身瘙痒、治疗后浑身无力感等),使得HDF治疗能顺利地完成,提高HDF的疗效,有效地保证患者的透析质量,使得肾病患者减轻治疗的痛苦,提高患者的生存质量,提高患者及家属的满意度,提升专科护理质量。
2、临床数据均有原始记录,结果准确完整。数据资料进行统计学处理,以P<0.05为差异有统计学意义。
3、本申请所述的血膜预充在预防血液透析滤过早期并发症的应用,技术关键在于:患者在HDF治疗过程中发生过敏反应后会产生焦虑、恐惧等情绪,精神压力较重,担心再次治疗时会发生过敏反应,畏惧治疗,对疾病的治疗感到无望及担心。透析过敏反应由于其发生快,如果不及时诊断与处理,会危及患者生命,因此预防和减少透析过敏反应尤其重要。申请人在患者进行HDF时先遵循常规HDF操作规程的方法对使用的血滤器和管路进行常规预充后,再使用患者自体血进行密闭式循管10min,可以让患者少量血液与透析膜充分接触,引发血/膜反应,使补体充分适化,减少对中性粒细胞的激活、活化的粒细胞对血管内皮的粘附及细胞因子的释放,并且能在透析膜内形成以层自身蛋白膜,从而改善透析器的生物相容性,预防血液透析滤过过敏反应的发生。
4、本申请所述的血膜预充在预防血液透析滤过早期并发症的应用,该研究为临床找到了在HDF治疗中减少和预防血液透析滤过的早期并发症的干预方法,从而最大限度地减少患者的痛苦,提高其生活质量及对生活增加信心,也可以减少护理人员的工作压力,而且还提高了患者对护理工作的满意度。因此,采用血膜预充技术具有广阔的推广前景,值得在各医院血液透析室推广应用。
参考文献:
叶媛黄佳玉江信炎.血液透析滤过17例过敏反应的原因分析及对策,中国中西医结合肾病杂志2015年12月第16卷第12期CJITWN,December2015,Vol.16,No.12
吴卓君,黄永娟,黎爱群.自体血循管预防血透病人首次使用综合征的疗效分析,国际医药卫生导报2014年第20卷第7期IMHGN,April 2014,Vol.20No.7
邹丽芳,刘舒清.针对性护理在预防血液透析滤过并发症中的应用,医疗装备2019年10月第32卷第19期Medical Equipment,October.2019,Vol.32,No.19
陈莹.3种透析模式预防血液透析中低血压的临床效果研究,医药卫生科技,10.19613/j.cnki.1671-3141.2018.57.066
张娜.血液透析滤过过敏反应的原因及对策分析,人人健康,1004-597X(2018)12-0032-02
上述说明是针对本发明较佳可行实施例的详细说明,但实施例并非用以限定本发明的专利申请范围,凡本发明所提示的技术精神下所完成的同等变化或修饰变更,均应属于本发明所涵盖专利范围。
Claims (3)
1.血膜预充在预防血液透析滤过早期并发症的应用,其特征在于:包括以下步骤:
S1、患者选择:选择尿毒症透析患者,随机将患者分为观察组与对照组,二组患者在年龄、身高、体重体质方面无显著性差异P>0.05,具有可比性;
病历入选标准:意识清楚,言语表达正常,与研究人员沟通无障碍;知情同意且得到医院伦理委员会的批准;
排除标准:血液高凝状态,危重患者认知障碍者,精神障碍,严重的心脏衰竭;
S2、观察组干预方式处理:
S2-1、透析器常规预冲,至膜内、膜外排液完成;
S2-2、患者建立体外循环通路,抽血10ml,从静脉壶注入体外循环管路,密闭式循环10min后,再做跨膜超滤10min,超滤量200ml;
S2-3、跨膜超滤结束,用生理盐水500ml冲尽管路内循环的残余血液;
S2-4、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S2-5、常规引血,引血过程及透析4小时内严密观察患者反应;
S2-6、如有过敏,按照透析器A、B型反应对症处理,A型反应,必要时要弃血;
S3、对照组干预方式处理:
S3-1、透析器常规预冲,至膜内、膜外排液完成;
S3-2、患者建立体外循环通路;
S3-3、治疗盘内地塞米松5mg备用,备好氧气及其他抢救物品;
S3-4、常规引血,引血过程及透析4小时内严密观察患者反应;
S3-5、如有过敏,按照透析器A、B型反应对症处理,必要时要弃血;
S4、观察指标:
对比观察组和对照组的两组患者在使用血膜预充的方法后,在治疗过程中和治疗后是否出现血液透析滤过过敏反应;
S5、评价方法:
患者在进行常规HDF治理4h,观察患者在治疗过程中是否出现气促,心率改变,分别测定每次透析前,透析中1、2、3h及透析后前臂血压值,并进行比较分析:
S5-1、观察两组患者血液滤过透析早期并发症,过敏反应发生的情况:
A型反应:常发生在透析5-30min,主要表现为焦虑不安、血压下降、恶心呕吐,少数严重患者可伴有意识丧失、呼吸困难、甚至心跳骤停;
B型反应:常发生在透析开始1h内,主要表现为胸痛、背痛、瘙痒、荨麻疹、咳嗽、喷嚏、鼻过敏、眼部水肿、恶心、呕吐、腹痛及腹泻等症状;
S5-2、低血压的评定标准:计算平均动脉压MAP=舒张压下降≥30mmHg者,则认为有症状性低血压发生,所有观察对象当日透析前后均停用常规口服降压药物,以排除药物干扰因素;
S5-3、心率的稳定性的对比:对照组的患者心率波动范围大小与观察组的患者心率波动范围的大小,成人正常心率60-100次/分;
S5-4、呼吸频率的改变,成人正常呼吸16-20次/分;
S5-5、通过生化数据血红蛋白的对比,对照组与观察组的患者血红蛋白无显著性差异(P>0.05);
S6、统计学方法:
选择SPSS20.00软件进行数据记录、统计学分析,两组间比较采用t检验;
计数资料采用χ2检验;
对比患者进行血膜预充后各项指标的变化以及两组间数据对比,观察有无统计学差异,以及进行效果分析。
2.根据权利要求1所述的血膜预充在预防血液透析滤过早期并发症的应用,其特征在于:步骤S4所述的过敏反应,是指高血压、低血压、呼吸急促、呕吐、全身瘙痒、治疗后浑身无力感。
3.根据权利要求1所述的血膜预充在预防血液透析滤过早期并发症的应用,其特征在于:步骤S4所述的过敏反应,预防对策包括:
(1)定期检测透析液,严格遵守血液透析标准操作规程相关规定,定期检测透析液成分,定期更换细菌过滤器,治疗结束后严格进行机器消毒,确保透析液各项指标均达标,不含致敏原,阻断血液透析滤过过敏反应的途径;
(2)选择合适的预充方式,充分预充血滤器及血路管,患者对透析膜材料反应各有不同,选择合适的血滤器,对考虑因透析膜材料过敏的患者采用血膜预充,HDF均采用在线预冲,预冲量1000ml以上,超滤500ml,充分预充透析器及血路管,尽量减少透析器的血路管的残留物;
(3)排除药物过敏,排除抗凝剂及其他药物引起的过敏反应。
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