血液透析双腔导管肝素封管液浓度的随机对照研究

A randomized controlled trial on the heparin lock concentration of hemodialysis intra-jugular vein dual lumen catheter

目的观察规律血液透析患者采用不同浓度肝素液进行颈内静脉留置双腔导管封管时对患者凝血功能、出血倾向、导管血栓形成等的影响，探讨合理的封管浓度。方法90例颈内静脉留置双腔导管作为维持性血液透析血管通路的患者根据不平衡指数最小分配原则随机分为3组（均n=30），分别采用不同浓度肝素钠溶液进行封管。A组：纯肝素钠封管（6250U／ml）；B组：中浓度肝素钠（1040U／ml）＋生理盐水溶液；C组：低浓度肝素钠（625U／ml）＋生理盐水溶液。测定封管后短期凝血功能，监测出血倾向、通路血栓形成情况、感染情况及血小板变化。结果A组在封管后30min时凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）等凝血功能指标均较基础值显著延长（P〈0．01），在4h后仍显著高于基础值（P〈0．05），但24h后PT、TT恢复至基础水平（P〉0．05），APTT仍显著超过基础值（P〈0.05）。B组患者封管30min后仅APTT显著超过基础值（P〈0．05），且在4h后恢复至基础水平（P〉0．05）。C组患者封管后门、APTT和TT与基础值比较，差异均无统计学意义（P〉0．05）。观察期内，A组患者出血事件发生率显著高于B、C组（26．7％比10％、0，P〈0．05）；C组血栓事件显著高于A、B组（23．3％比0、10％，P〈0．05）。C组出现1例可疑导管相关感染。A组出现2例血小板中度减少。结论中等浓度肝素钠溶液进行颈内静脉留置双腔导管封管不良反应较少，可用于大多数患者。有高凝倾向的患者更适合采用高浓度肝素液；有出血倾向的患者可以用低浓度肝素钠溶液封管。

Objective To explore the effects of intra-jugular vein dual lumen catheter lock heparin in different concentrations on the coagulation function, hemorrhagic tendency and catheter thrombosis risk in hemodialysis patients, and to investigate the reasonable lock heparin concentration. Method Ninety end stage renal disease （ESRD） patients receiving regular hemodialysis were enrolled and randomly assigned into 3 groups（n=30）： Group A （pure heparin lock solution, 6250 U/ml）, Group B （medium heparin lock solution, 1040 U/ml） and Group C （low heparin lock solution, 625 U/ml）. The coagulation indexes were determined in short term. Complications such as bleeding, thrombosis, infection and thromboeytopenia were monitored. Results Prothrombin time （PT）, activated partial thromboplastin time （AFFr） and thrombin time （TIC） were significantly prolonged in Group A （P〈0.01）; only APTF was significantly prolonged in Group B; however, no significant changes were observed in Group C, Hemorrhage risk was much higher in Group A than that in Group B and C （26,7% vs 10% and 0, P〈0.05）, Catheter thrombosis incidence was significantly higher in Group C than that in Group A and B （23.3% vs 0 and 10%, P〈0.05）. Only 1 suspected catheter related infection was found in Group C, and 2 cases of moderated thrombocytopenia in Group A. Conclusion Moderate concentration of lock heparin solution has the best balance of hemorrhagic and thrombotic risk, and should be recommended to most of regular hemodialysis patients.