长期深静脉留置双腔导管血液透析的临床应用

Application of long-term cuffed catheter in hemodialysis patients

目的 :探讨长期血液透析留置双腔导管的效果和退出原因 ,延长其使用期限。 方法 :随访血液透析患者留置导管的使用情况和并发症 ,记录导管使用终点。 结果 :①实施深静脉留置长期带涤纶环导管术 1 39例次 ,其中 1 0例次为再次置管 ;经颈内静脉入路 1 0 4例次 (成功率 98% ) ,经颈外静脉切开插管 1 3例次 (成功率 81 % ) ,经锁骨下静脉 2 2例次 (成功率 95 % )。置管成功率 1 0 0 %。②导管使用期限 :平均 (1 4 5± 1 0 4 )个月 ,使用留置导管时间分别为 :>72个月 1例 ,>36个月 7例 ,≥ 2 4个月 1 8例 ,≥ 1 2个月 37例次 ,≥ 6个月 4 2例次 ,<6个月 30例次 (大部分在继续使用 ) ,其余失访。观察导管使用终点 6 5例次 ,约占 4 6 % ,导管退出时平均使用时间 3～ 4 6 (1 0 2± 8 3)个月。退出原因 :患者死亡 4 0例 ,其余为感染拔管、导管拔脱、血流不畅和肾移植。在导管使用终点 ,90 % (5 8/ 6 5 )的导管功能良好。③导管透析充分性 :1 1 4例患者透析后尿素下降率平均 70 % ,平均Kt/V达 1 5 5。与内瘘透析患者Kt/V =1 5 0±0 33(n =30 )比较无显著差别。④导管动静脉端反接对透析效果影响 ,比较 35例导管动静脉端正接和反接 ,血流量2 0 0～ 2 5 0ml/min ,单次透析正接Kt/V =1 5 5± 0 4 3。

Objective:Long term cuffed catheter provide another access for maintenance hemodialyisis patients. In this report, we analyzed our experience with the application of cuffed tunnel catheters and the management of catheter related infections in 129 maintenance hemodialysis patients. Methodology:Cuffed catheters for long term blood access were implanted in 129 cases of chronic renal failure (CRF) patients, with a total of 139 implantation including 10 re implanted in 10 patients. Internal jugular vein were used for the site of catheter implantation in 104 attempts, subclavian vein in 22 and external jugular vein in 13. The survival and complications of each cuffed catheter implanted were followed up and recorded, including survived catheters in 1 patients for recovered fistula, 4 patients received renal transplantation and 40 patients died. 20 end points of the non survived catheters were observed . Results:The average survival of the total catheters implanted (months of effective catheter usage) was (14 5+10 4) months. Catheter survival over 72 months was observed in 1 case, in 8 cases , survival over 24 months in 18 cases, survival over 12 months in 38 cases, survival over 6 months in 42 cases, and survival below 6 months in 29 cases. The end of catheter usage was observed in 65 catheters implanted(average survival of 10 months), with 20 for technical complications. Complications resulted the ending of catheter usage included infections (in 9), pull out (in 5 ), dysfunction (in 3), cardiac complications (in 1), and catheter damages (in 2). No difference of dialysis adequacy was found between the 114 patients implanted with cuffed catheter cases(the average Kt/V was 1 55, URR was 0 7 ) and 30 patients with arterio venous fistula(Kt/V=1 50±0 33, n =30).Twenty eight catheter related infections were recorded with an average infection rate at 1.65 episode /patient year, including 9 infections demanding the removed of the catheter. The infectious agents were aerococcus staphylococcus aureus, staphylococcus epidermidis, bacillus pyocyaneus and fangus. Conclusion:Long term cuffed catheter is as effective as A V fistula for blood access in maintenance hemodialysis patients. The most frequent complication and important factor influencing survival of catheter usage is catheter related infection. Effective and long term usage of cuffed catheters in hemodialysis patients demand good catheter implanting technique and careful nursing.