380例次长期深静脉留置导管临床应用的生存分析

Survival analysis of indwelling venous catheters for permanent use in hemodialysis patients

目的提高对长期静脉留职导管的置管、使用、护理的认识，延长其使用寿命。方法随访本院血液净化中心患者380例次深静脉置管并长期留置的情况和并发症，记录导管使用终点。应用Kaplan-Meier法绘制导管使用寿命的生存曲线，计算中位生存时间。log-rank检验比较导管使用寿命的差异。分析评价置管方法、感染发生率、导管退出原因及透析充分性。结果导管静脉入路途径包括颈内、颈外、锁骨下及股静脉。3种静脉入路中位生存时间分别为颈内（31．0±2．8）月，颈外（30．0±4．0）月，锁骨下（19．0±2．9）月。log-rank生存曲线检验结果显示，颈内与锁骨下进路比较差异有统计学意义（P〈0．05）。导管使用终点113例次，其中患者死亡60例（53．1％），感染14例（12．4％），导管功能不良13例（11．5％），肾移植13例（11．5％），内瘘2例（1．8％），导管意外拉脱7例（6．2％），导管破损4例（3．5％）。导管内感染61例次，隧道感染2例次。结论长期留置导管首选颈内静脉入路，其次为颈外静脉入路。导管终点以患者死亡、感染及导管功能不良占绝大多数。

Objective To improve the cognition of long-term indwelling venous catheter in placement, management and nursing, and to prolong the use of catheter. Methods General status and complications of 380 long-term indwelling venous cuffed catheters in 355 maintenance hemodialysis patients were followed up. The reasons of ending or survival of catheters, as well as the catheter placement, infection incidence, dialysis adequacy were analyzed and evaluated retrospectively. Survival curve was analyzed by Kaplan-Meier method. Median lifetime of the catheters was calculated. Usage difference was examined with log-rank test. Results Cuffed catheters for long-term blood access were implanted in 355 cases of chronic renal failure patients, with a total of 380 implantation including 25 re-implantation. Internal jugular vein was used for the site of catheter implantation in 304 attempts, external jugular vein in 35 and subclavian vein in 40. The mean survival time of the catheter was （32.36±2.16） months （95% CI of 28.1-36.6） and the median survival time （31.0±2.3） months （95% CI of 26.5-35.5）. Median survival time of catheter locating in internal jugular vein, external jugular vein and subclavian vein was （31.0±2.8）, （30.0± 4.0） and （19.0±2.9） months respectively. The survival time of catheter locating in internal jugular vein was significantly longer as compared with that in subclavian vein by Kaplan-Meier （χ^2=4.257, P=0.039）. Ending of catheter usage was observed in 113 catheters including death of 60 cases （53.1%）, infection of 14 cases （12.4%）, successful renal transplantation of 13 cases （11.5%）,dysfunction of 13 cases （11.5%）, pull-out of 6 cases （6.2%）, catheter damage of 4 cases （3.5%） and fistula mature of 2 cases （1.8%）. Sixty-three catheter-related infections occurred, among them 21 catheters were removed. No significant difference of dialysis adequacy was found between catheter and fistula group. Conclusions The first choice of long-term indwelling catheter position is internal jugular vein. Main causes of the ending of catheter are death, infection and dysfunction.