血浆吸附序贯血浆置换人工肝模式治疗肝衰竭应用局部拘椽酸抗凝的护理

Nursing care of patients with liver failure undergoing plasma adsorption plus sequential plasma exchange artificial liver model therapy combined with regional citrate anticoagulation

目的 观察局部拘椽酸抗凝(RCA)在人工肝支持系统(ALSS)治疗肝衰竭患者中的应用效果,并总结其护理体会.方法 回顾性分析四川大学华西医院感染性疾病中心2018年6月至12月行ALSS治疗的肝衰竭患者应用RCA情况.患者在内科综合治疗基础上行双重血浆分子吸附系统(DPMAS)治疗2 h和序贯血浆置换(PE)治疗1 h,再以110 mL/h的速度泵入4%拘椽酸钠.收集患者治疗过程中动脉压(PA)、滤前压(PBE)、静脉压(PV)、跨膜压(TMP)及破膜情况等相关指标,并分析其变化;同时观察使用拘椽酸钠对患者体内离子钙水平的影响及预后.结果 140例患者行RCA-ALSS治疗731例次,其中PA<-200 mmHg(1 mmHg=0.133 kPa)11 例(1.5%),PBE≥200 mmHg 38 例(5.2%),PV≥100 mmHg 35 例(4.8%),TMP≥50 mmHg 33 例(4.5%),破膜21例(2.9%),其中2例破膜经处理后无改善给予更换分离器完成治疗.在731例次治疗中,691例次(94.5%)体外离子钙为0.2~0.4 mmol/L,其余40例次(5.5%)经调整拘椽酸钠泵速后达到该范围;698例次(95.5%)体内离子钙≥0.8 mmol/L,其余33例次(4.5%)<0.8 mmol/L,其中13例次出现低钙血症症状,体内离子钙<0.8 mmol/L者经调整拘椽酸钠和钙剂泵速后使体内离子钙≥0.8 mmol/L.140例患者在首次ALSS治疗后3个月的总体存活率为63.57%(89例).结论 ALSS治疗肝衰竭时采用RCA有一定的可行性.为保证治疗顺利完成,护理人员应及时、准确地采取针对性的操作并精心护理.

Objective To analyze the application effect of regional citrate anticoagulation(RCA)in patients with liver failure undergoing plasma adsorption plus sequential plasma exchange therapy,a pattern of artificial liver support system(ALSS)therapy,and summarize the nursing experience for such patients.Methods A retrospective analysis of RCA was performed in patients with liver failure who underwent ALSS therapy from June to December 2018 in the Center of Infectious Diseases of West China Hospital of Sichuan University.Based on comprehensive medical treatment,the patients were treated with dual plasma molecular adsorption system(DPMAS)for two hours,sequential plasma exchange(PE)for one hour,and then 4%sodium citrate was pumped at the rate of 110 mL/h.The changes of arterial pressure(PA),pre-filter pressure(PBE),venous pressure(PV),transmembrane pressure(TMP),membrane rupture situation,etc of the patients and their related indexes in the course of treatment were collected and analyzed;meanwhile,the effect of sodium citrate on the level of calcium ions in the patients and their prognosis were also observed.Results Totally RCA-ALSS was applied for 731 times in 140 patients,including 11 cases(1.5%)with an arterial pressure<-200 mmHg(1 mmHg=0.133 kPa),38 cases(5.2%)with a pre-filter pressure(PBE)≥200 mmHg,35 cases(4.8%)with a venous pressure(PV)≥100 mmHg,33 cases(4.5%)with a trans-membrane pressure(TMP)≥50 mmHg and 21 cases(2.9%)with membranes rupture,and in the cases with membranes rupture,2 had no improvement after treatment and after replacement of a new separator,they completed the treatment.Of the 731 case times of treatments,691(94.5%)had an in vitro calcium ion level 0.2-0.4 mmol/L,and the remaining 40(5.5%)reached the above range after adjusting the rate of sodium citrate pump;the ionized calcium concentrations of patients in 698(95.5%)case times of treatments were≥0.8 mmol/L,and the remaining 33(4.5%)were<0.8 mmol/L,13 of which had hypo-calcemia symptoms,and after adjusting the pump rates of sodium citrate and calcium agent,the ionized calcium concentration in vivo were≥0.8 mmol/L.After the first time of ALSS treatment in 140 patients for 3 months,their survival rate was 63.57%(89 cases).Conclusions During using ALSS for treatment of liver failure,the application of RCA has certain feasibility.To ensure the completion of the treatment much more successfully or smoothly,the nursing staff should timely and accurately adopt targeted operations and careful care.