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連續性血液凈化治療蜂蜇傷致急性腎功能衰竭的臨床觀察與護理體會

目的:觀察連續性血液凈化(CBP)治療蜂蜇傷致急性腎功能衰竭(ARF)的療效分析及護理體會。方法:回顧2005～2007 年蜂蜇傷致急性腎功能衰竭17例,采用連續性靜靜脈血液濾過(CVVH)方式進行治療,從存活率、治愈率及腎功能恢復時間等多個方面比較CVVH治療蜂蜇傷致腎功能衰竭是否具有優越性,從護理角度總結CVVH過程中護理的經驗和作用。結果:患者治療前APACHE評分差異無統計學意義。（1）CVVH:17 例患者早期行持續性靜靜脈血液濾過,CVVH治療1～4次,總治療時間(38.6±14.8)h,情況穩定后給予間歇性血液透析(間歇性血液透析)治療。16例患者好轉出院,1例患者死亡。⑵在CVVH治療過程中嚴密監測生命體征、液體管理、預防出血、預防感染、血管通路的護理是CVVH治療護理重點。結論:早期CVVH可能有利于患者受損器官功能的恢復,縮短患者的住院時間。在CVVH治療過程良好的護理和密切的觀察是保證CVVH順利進行的重要保障。

腹膜透析液加藥小技巧

保赫曼妙貼預防腹透導管出口處感染效果觀察

【摘要】　目的　觀察腹膜透析患者使用保赫曼妙貼覆蓋腹透導管出口處其感染預防的臨床效果。　方法　選擇2008年10月-2009年3月首次行腹膜透析置管手術患者60例，按行腹膜透析置管手術單雙日分為兩組，觀察組:腹透導管出口處使用保赫曼妙貼（8 cm×10 cm）；對照組:使用傳統敷料（6 cm×7 cm 的12層無菌紗布），并用紙膠布固定。觀察兩組患者術后腹透導管出口處敷料固定情況及感染發生率。　結果　術后7 d，觀察組腹透導管出口處敷料固定良好，優于對照組（Plt;0.05）；術后6周內，觀察組腹透導管出口處感染率低于對照組（Plt;0.05），差異有統計學意義。　結論　保赫曼妙貼能有效預防腹透導管出口處感染，使用簡便，值得推廣。

A Clinical Analysis of the Disorders of Calcium and Phosphorus Metabolism Peritoneal Dialysis Patients

【摘要】　目的　探討生理鈣透析液對持續性不臥床腹膜透析（CAPD）患者鈣磷代謝的影響。　方法　回顧性分析2008年1月-2009年12月腹膜透析患者的鈣磷指標，資料齊全的患者中使用鈣濃度為1.25 mmol/L的腹膜透析液（生理鈣組）的患者有30例，使用鈣濃度為1.75 mmol/L的透析液（標準鈣組）患者30例。對兩組患者鈣磷代謝指標進行比較。　結果　治療前后兩組的血磷、鈣磷乘積和全段甲狀旁腺素差異均無統計學意義（Pgt;0.05）；治療后標準鈣組血鈣較前升高，差異有統計學意義（Plt;0.05），而生理鈣組治療前后血鈣差異無統計學意義（Pgt;0.05）。　結論　不同含鈣濃度腹膜透析液對機體鈣磷代謝的影響是不同的，在高鈣、高磷、低轉運骨病的腹膜透析患者中使用鈣濃度為1.25 mmol/L的生理鈣透析液減輕了鈣負荷，為臨床醫生使用含鈣磷結合劑提供了治療空間。【Abstract】　Objective　To investigate the effects of physiological calcium dialysate on the calcium and phosphorus metabolism in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).　Methods　We retrospectively analyzed the clinical data of 60 patients having undergone CAPD in West China Hospital of Sichuan University between January 2008 and December 2009. The patients were divided into two groups with 30 in each by calcium concentration of the dialysate: the physiological calcium dialysate group (1.25 mmol/L) and the standard calcium dialysate group (1.75 mmol/L). The metabolism indexes of calcium and phosphorus for the two group of patients were compared.　Results　Levels of Serum phosphate, calcium-phosphate product and immoreactive parathyroid hormone (iPTH) of all the patients in both groups before and after treatment showed no significant differences (Pgt;0.05). Serum calcium increased significantly in patients treated with standard calcium dialysate (Plt;0.05), while it did not change significantly in patients treated with physiological calcium dialysate (Pgt;0.05).　Conclusions　Dialysate with different concentrations of calcium provides different influence on the metabolism of calcium and phosphorus. Changing calcium concentration to 1.25 mmol/L in the dialysate can lower the calcium load for patients with hypercalcium and/or hyperphosphate with low bone turnover, providing treatment space for clinical doctors to use binders containing both calcium and phosphorus.

Application of Continuous Quality Improvement Measures in Prevention of Peritoneal Dialysis Related Peritonitis

ObjectiveTo investigate whether continuous quality improvement (CQI) measures can reduce the episodes of peritonitis. MethodsWe analyzed the data of 114 cases of peritoneal dialysis related peritonitis from January to December 2011 before applying CQI measures and 72 cases from January and December 2012 after applying CQI measures in West China Hospital. Then we studied the episodes, cause and pathogenic bacteria species of peritonitis in peritoneal dialysis patients. We implemented the process of reducing the episodes of peritonitis by applying PDCA four-step design: plan-do-check-act. ResultsThe episodes of peritonitis were reduced from per 60.8 patient-months (0.197/patient-years) to per 66.6 patient-months (0.180/patient-years) after applying CQI measures. The positive rate of pathogenic bacteria culture was both 50.0% before and after applying CQI measures, in which 66.7% were gram-positive cocci. The curing rate of peritonitis was increased from 57 case/times (76.3%) to 87 case/times (79.2%). Switching to hemodialysis rate was reduced from 17 cases/times (14.9%) to 10 cases/times (13.9%). Death cases was reduced from 9 cases/times (7.9%) to 5 cases/times (6.9%). ConclusionThese results show that the incidence of peritoneal dialysis related peritonitis decreases and the curing rate increases through CQI measures.

Comparison between the Effects of Two Different Care Methods for the Exit of Peritoneal Dialysis Catheter

目的　比較兩種不同方法護理腹膜透析患者導管出口處的效果。 方法　選取2008年7月－2009年12月51例患者作為試驗組，直接采用聚維酮碘溶液擦洗導管出口處，2007年1月－2008年7月45例患者作為對照組，先用生理鹽水清洗遂道口，再用聚維酮碘溶液擦洗導管出口處。比較兩組導管出口處感染的情況及操作所需時間。 結果　試驗組出口評分系統（ESS）＜2分15例，2～3分34例，≥4分7例；對照組＜2分10例，2～3分24例，≥4分16例；兩組差異有統計學意義（P＜0.05）。試驗組護士操作時間為（3.0 ± 1.0）min，患者操作時間為（5.0 ± 1.5）min；對照組護士操作時間為（8.0 ± 2.0）min，患者操作時間為（10.0 ± 2.0）min；兩組差異有統計學意義（P＜0.05）。 結論　聚維酮碘溶液直接清洗、消毒導管出口處降低了感染的發生率，減少了操作環節和所需物品，縮短了操作時間。

Association between initial high peritoneal transport property and prognosis of patients undergoing peritoneal dialysis

ObjectivesTo explore the association between initial peritoneal transport characteristics and patient survival, and to evaluate the risk factors for mortality of continuous ambulatory peritoneal dialysis (CAPD) patients.MethodsBetween January 2011 and December 2016, the patients diagnosed with end stage renal disease commencing CAPD in West China Hospital were enrolled. According to the value of dialysate to plasma ratio for creatinine at 4 hour [D/P Cr (4 h)], CAPD patients were divided into two groups: the lower transport group [D/P Cr (4 h)<0.65] and the higher transport group [D/P Cr (4 h)≥0.65]. The survival of these two groups of peritoneal dialysis patients were plotted using survival analysis. CAPD patient outcomes were analyzed using multivariable Cox proportional hazards regression models.ResultsCompared with the lower transporter (n=246), higher transporter (n=345) were older, and with more peritoneal protein loss, lower level of serum albumin, lower level of hemoglobin, and less ultrafiltration (P<0.001). Higher transport group had lower survival rate compared to those in the lower transport group (P=0.001). The 1-, 3- and 5-year patient survival rates were 97.0%, 83.2%, and 71.7% in the higher transport group, and 98.7%, 93.9%, and 86.1% in the lower transport group, respectively. There was a positive relationship between D/P Cr (4 h) and serum peritoneal protein loss (P<0.001). D/P Cr (4 h) was inversely related to serum albumin (P<0.001). Cox regression analysis demonstrated that lower albumin [hazard ratio (HR)=0.921, 95% CI (0.885, 0.958), P<0.001], presence of cardiovascular disease [HR=1.996, 95% CI (1.256, 3.173), P=0.003], elder age [HR=1.049, 95% CI (1.033, 1.065), P<0.001], lower hemoglobin [HR=0.988, 95% CI (0.976, 1.000), P=0.044] and lower urea clearance index (KT/V)[HR=0.680, 95%CI (0.465, 0.994), P=0.046] could independently predicted mortality with significance in CAPD patients. But higher peritoneal transport was not a risk factor for mortality [HR=1.388, 95%CI (0.829, 2.322), P=0.212] in either model including serum albumin.ConclusionsFor CAPD patients, initial higher transporter had a higher mortality than lower transporter. However, initial higher peritoneal transport was not a risk factor for mortality independent of serum albumin in CAPD patients. Relationship between D/P Cr (4 h) and serum peritoneal protein loss and serum albumin suggests that higher peritoneal transport characteristics might worsen prognosis by lowering serum albumin level at initiation of peritoneal dialysis.

The perioperative effect of non-peros time on elective general anesthesia patients in China: a systematic review

ObjectiveTo systematically review the efficacy and safety of different non-peros (NPO) times [( trial group: preoperative solid fast, 6 hours; fluid fast 2–3 hours) vs. (control group: preoperative solid fast, 12 hours; fluid fast 4–6 hours)] in elective general anesthesia patients in China.MethodsRandomized controlled trials (RCTs) and quasi-RCT of NPO time in elective general anesthesia patients were searched and retrieved through online databases (PubMed, Cumulative Index to Nursing and Allied Health, Embase, Cochrane Library, China Biology Medicine database, China National Knowledge Internet, VIP, WanFang, SUMsearch, and Google search engine) and related literatures were reviewed up to April 25th, 2018. Two investigators independently screened literatures, extracted data, and evaluated the risk of bias assessment tools for RCT using the Version 5.1.0 of Cochrane Handbook for Systematic Reviews of Interventions. Then, Meta-analysis was performed using RevMan 5.3 software.ResultsA total of 16 RCTs involving 2 722 elective general anesthesia patients (1 372 in the trial group and 1 350 in the control group) were included. The Meta-analysis showed that: the preoperative residual gastric volume [mean difference (MD)=–1.45 mL, 95% confidence interval (CI) (–2.88, –0.01) mL, P=0.05], the incidence of preoperative hypoglycemia [odds ratio (OR)=0.12, 95%CI (0.05, 0.28), P<0.000 01, the incidence of preoperative thirst [OR=0.15, 95%CI (0.11, 0.21), P<0.000 01], the incidence of preoperative hunger [OR=0.13, 95%CI (0.10, 0.18), P<0.000 01], the incidence of preoperative flustered tiredness [OR=0.11, 95%CI (0.07, 0.17), P<0.000 01], and the incidence of preoperative anxiety [OR=0.21, 95%CI (0.12, 0.37), P<0.000 1] in the trial group were significantly lower than those in the control group. There was no statistically significant difference in the intra-operative residual gastric volume between the two groups (P>0.05), and no intra-operative vomiting or aspiration took place in either group. The recovery time of exhaust and defecate of anus [MD=–8.71 hours, 95%CI (–11.43, –6.00) hours, P<0.000 01] in the trial group was significantly shorter than control group, and there was no statistically significant differences in the incidence of postoperative pneumonia, postoperative nausea, postoperative vomiting, or the postoperative thirsty and hungry between the two groups (P>0.05).ConclusionsCurrent evidence shows that, compared with the control group, the trial group could decrease the incidences of preoperative hypoglycemia, thirst, hunger, flustered tiredness and anxiety, and shorten the recovery time of exhaust and defecate of anus for postoperative patients, without increasing incidences of intraoperative or postoperative adverse reactions. Due to the limited quantity and quality of the included studies, the above conclusions still need to be verified by carrying out more large-scale samples and high-quality RCTs studies.

Application of Continuous Quality Improvement in Laparoscopic Peritoneal Dialysis Catheter Input

ObjectiveTo reduce the incidence of peritoneal dialysis (PD) catheter complications through a continuous quality improvement (CQI) process. MethodsTwenty-nine patients with catheters inserted (from January 2011 to March 2011) before CQI, and another 41 patients with catheters inserted (between April 2011 and January 2012) after CQI were observed and analyzed. The possible causes of complications of catheter were summarized, and then on the basis of that, a PDCA four-step (plan-do-check-act) method was designed with a view to reducing the incidence of postoperative complications. ResultsPD catheter dysfunction decreased from 6.90% to 2.44%. The incidence of leakage decreased from 44.83% to 9.76%. ConclusionCQI is a useful method to reduce the incidence of postoperative complications of PD catheter in peritoneal dialysis.

老年腹膜透析患者相關營養指標比較及教育對策

目的　分析比較老年腹膜透析患者營養狀況，提出針對性的營養教育對策。 方法　回顧分析2010 年12月－2011年11月328例維持性腹膜透析患者的臨床及隨訪資料，并通過兩組不同年齡段患者（≥60歲和＜60歲）的血漿白蛋白（ALB）、前白蛋白（PAB）、鐵蛋白（FER）、血清鐵（FE）、總鐵結合力（TIBC）、血紅蛋白（HGB）、標準化每日蛋白質分解率（nPCR）、尿素清除指數（Kt/V）、肌酐清除率（Ccr）、24 h尿、腹透液漏出蛋白和體質量指數（BMI）、改良定量主觀整體評估（MQSGA）等指標，比較其營養狀況。 結果　老年組腹膜透析患者營養不良的發生率（72.79%）高于中青年組（28.65%）（P＜0.05）。兩組患者ALB分別為（32.64 ± 4.78） g/L和（34.99 ± 5.42） g/L（P＜0.05），PAB分別為（303.00 ± 72.47）mg/L和（372.53 ± 88.09）mg/L（P＜0.05），HGB分別為（102.58 ± 21.05）g/L和（91.63 ± 19.37）g/L（P＜0.05）；老年組ALB和PAB水平均低于中青年組，而HGB水平高于中青年組（P＜0.05）。兩組患者BMI、FE、TIBC、FER、nPCR、Kt/V、Ccr、每日蛋白漏出總量差異無統計學意義（P＞0.05）。 結論　老年腹膜透析患者比中青年患者更容易出現低蛋白血癥，導致蛋白營養不良。故而在制定腹膜透析患者的營養教育方案時，應針對老年患者的臨床特征，加強蛋白質營養方面的指導。