不同动静脉瘘穿刺方式对血液透析患者透析充分性的影响

干雁群; 郑志波

doi:10.16766/j.cnki.issn.1674-4152.003030

不同动静脉瘘穿刺方式对血液透析患者透析充分性的影响

doi: 10.16766/j.cnki.issn.1674-4152.003030

干雁群^,,
郑志波

浙江医院血液净化中心, 浙江杭州 310013

基金项目:

浙江省医药卫生科技计划项目 2022RC093

详细信息

通讯作者:
干雁群, E-mail: yanqun198212@126.com

中图分类号: R459.5
计量
- 文章访问数: 140
- HTML全文浏览量: 22
- PDF下载量: 6
- 被引次数: 0
出版历程
- 收稿日期: 2022-09-01
- 网络出版日期: 2023-08-26

Effect of different arteriovenous fistula puncture methods on the dialysis adequacy of hemodialysis patients

GAN Yanqun^,,
ZHENG Zhibo

Blood Purification Center, Zhejiang Hospital, Hangzhou, Zhejiang 310013, China

摘要

摘要: 目的动静脉穿刺针插入技术可显著影响透析效果，本文旨在探究不同穿刺方式对透析充分性的影响差异以供临床实践参考。方法以2020年1月—2021年10月至浙江医院血液净化中心进行透析的217例患者为研究对象，进行区域、绳梯和扣眼3种不同穿刺方式，采集患者临床信息，通过透析开始后6个月内的平均尿素清除指数(Kt/V)和尿素下降率(urea reduction ratio, URR)比较透析的充分性差异，通过logistic回归分析探究相关的影响因素。结果患者透析龄为(55.6±2.8)个月，动静脉内瘘使用时间为(45.3±1.6)个月。穿刺技术中区域穿刺法116例(53.5%)，绳梯穿刺70例(32.2%)，扣眼穿刺31例(14.3%)。Kt/V、URR值与动静脉瘘位置间存在显著关联，肱动脉-头静脉内瘘组患者的Kt/V及URR值更优于桡动脉-头静脉内瘘组患者(P值分别为0.002、0.028)。穿刺针沿顺行方向使得Kt/V增加了0.892倍(95% CI：0.851~0.963，P=0.033)，而穿刺方法、动脉针旋转、动静脉瘘位置和动静脉针是否位于同一血管节段对Kt/V、URR值即透析充分性无显著影响(均P>0.05)。结论血液透析患者动静脉瘘穿刺方式中穿刺针方向与血流方向一致时可增加血液透析的充分性，不同穿刺方式、插入后动脉针旋转及动静脉穿刺针位于同一血管节段均不会对透析充分性产生显著影响。
- 血液透析 /
- 穿刺 /
- 动静脉瘘 /
- 尿素清除指数 /
- 尿素下降率
Abstract: Objective Arteriovenous puncture technique can significantly affect the adequacy of dialysis. This study aims to explore the differences in the impact of different puncture methods on dialysis adequacy for clinical practice reference. Methods A total of 217 patients who underwent hemodialysis at the Blood Purification Center, Zhejiang Hospital from January 2020 to October 2021 were selected as the research objects. Regional, rope ladder, and buttonhole puncture methods were used, and patient clinical information was collected. The adequacy of dialysis was compared by the average urea clearance index (Kt/V) and urea reduction rate (URR) within 6 months after dialysis. Logistic regression analysis was used to explore the related influencing factors. Results The average age of the patients was (55.6±2.8) months, and the average use time of the arteriovenous fistula was (45.3±1.6) months. Among the puncture techniques, 116 cases (53.5%) used regional puncture, 70 cases (32.2%) used rope ladder puncture, and 31 cases (14.3%) used buttonhole puncture. There was a significant correlation between Kt/V, URR values and the location of the arteriovenous fistula. Patients with brachial artery-cephalic vein fistula had better Kt/V and URR values than those with radial artery- cephalic vein fistula (P=0.002, 0.028). Puncture needle direction along the blood flow direction increased Kt/V by 0.892 times (95% CI: 0.851-0.963, P=0.033), while puncture method, arterial needle rotation, whether the arterial and venous needles were in the same vascular segment had no significant effect on Kt/V, URR values, and dialysis adequacy (all P>0.05). Conclusion When the direction of the puncture needle is consistent with the blood flow direction in arteriovenous fistula puncture, it can increase the adequacy of hemodialysis. Different puncture methods, arterial needle rotation after insertion, and whether the arterial and venous needles are in the same vascular segment do not have a significant effect on dialysis adequacy.
- Hemodialysis /
- Puncture /
- Arteriovenous fistula /
- Urea clearance index /
- Urea reduction rate

HTML全文

表 1 糖尿病和高血压患者中穿刺方式相关变量比较

Table 1. Comparison of puncture mode related variables between diabetic patients and hypertensive patients

变量	存在糖尿病		统计量	P值	存在高血压		统计量	P值
变量	是(n=59)	否(n=158)	统计量	P值	是(n=111)	否(n=106)	统计量	P值
穿刺方式[例(%)]			0.492^a	0.782			1.484^a	0.476
区域穿刺	31(52.5)	85(53.8)			56(50.5)	60(56.6)
绳梯穿刺	18(30.5)	52(32.9)			40(36.0)	30(28.3)
扣眼穿刺	10(17.0)	21(13.3)			15(13.5)	16(15.1)
穿刺针方向[例(%)]			0.166^a	0.684			0.001^a	0.977
顺行	30(50.8)	66(41.8)			49(44.1)	47(44.3)
逆行	29(49.2)	92(58.2)			62(55.9)	59(55.6)
穿刺针旋转[例(%)]			0.166^a	0.684			0.087^a	0.768
是	38(64.4)	97(61.4)			68(61.3)	67(63.2)
否	21(35.6)	61(38.6)			43(38.7)	39(36.8)
动静脉瘘位置[例(%)]			1.693^a	0.429			6.782^a	0.034
桡动脉-头静脉内瘘	37(62.7)	113(71.5)			68(61.3)	82(77.4)
肱动脉-头静脉内瘘	21(35.6)	42(26.6)			40(36.0)	23(21.7)
鼻烟窝内瘘	1(1.7)	3(1.9)			3(2.7)	1(0.9)
动静脉管位于同一血管内[例(%)]			2.849^a	0.091			3.749^a	0.053
是	5(8.5)	28(17.7)			22(19.8)	11(10.4)
否	54(91.5)	130(82.3)			89(80.2)	95(89.6)
Kt/V(x±s)	1.64±0.29	1.62±0.34	0.041^b	0.968	1.60±0.28	1.64±0.32	-0.944^b	0.372
URR(x±s，%)	73.36±8.02	74.02±7.79	-0.385^b	0.709	73.46±7.88	72.98±8.02	0.860^b	0.412
注：^a为χ²值, ^b为t值。

下载: 导出CSV

表 2 不同穿刺技术Kt/V及URR值比较情况

Table 2. Comparison of Kt/V and URR values of different puncture techniques

变量	例数(%)	Kt/V(x±s)	统计量	P值	URR值(x±s，%)	统计量	P值
穿刺方式			1.120^a	0.886		1.800^a	0.167
区域穿刺	116(53.5)	1.60±0.30			73.33±7.88
绳梯穿刺	70(32.2)	1.61±0.31			74.25±7.15
扣眼穿刺	31(14.3)	1.63±0.32			71.16±7.06
穿刺针方向			0.451^b	0.652		0.665^b	0.507
顺行	96(44.2)	1.64±0.33			74.36±7.96
逆行	121(55.8)	1.62±0.32			73.69±6.88
穿刺针旋转			0.237^b	0.813		0.450^b	0.653
是	135(62.2)	1.62±0.29			72.88±7.36
否	82(37.8)	1.63±0.32			73.36±8.02
动静脉瘘位置			0.430^a	0.002		3.650^a	0.028
桡动脉-头静脉内瘘	150(69.1)	1.53±0.32			71.96±6.96
肱动脉-头静脉内瘘	63(29.0)	1.68±0.21			74.38±7.90
鼻烟窝内瘘	4(1.9)	1.74±0.37			78.36±8.99
动静脉管位于同一血管内			0.827^b	0.409		1.363^b	0.174
是	33(15.2)	1.60±0.32			74.25±8.06
否	184(84.8)	1.65±0.32			72.36±7.20
注：^a为F值，^b为t值。

下载: 导出CSV

表 3 影响Kt/V及URR值相关因素回归分析

Table 3. Regression analysis of related factors affecting Kt/V and URR values

变量	Kt/V						URR值(%)
变量	β	SE	Waldχ²	P值	OR值	95% CI	β	SE	Waldχ²	P值	OR值	95% CI
穿刺方式	0.120	1.103	0.012	0.913	1.127	0.130~3.564	-2.285	1.348	2.874	0.090	0.102	0.007~2.708
穿刺针方向	0.114	0.126	0.017	0.033	0.892	0.851~0.963	-0.988	1.398	0.499	0.480	0.372	0.024~1.061
穿刺针旋转	1.718	1.065	2.604	0.107	5.573	0.692~9.654	0.921	1.642	0.315	0.575	2.512	0.101~4.263
动静脉瘘位置	-0.215	1.154	0.035	0.852	0.807	0.084~1.656	1.437	1.511	0.585	0.958	4.208	0.019~7.058
动静脉管位置	1.125	0.143	0.024	0.055	3.080	0.014~5.592	-0.381	1.578	2.461	0.085	0.814	0.036~1.689

下载: 导出CSV

参考文献(16)

[1]	袁静, 李恒, 应金萍, 等. 102例血液透析患者动静脉内瘘血栓形成的原因及护理[J]. 中华护理杂志, 2020, 55(4): 607-610. doi: 10.3761/j.issn.0254-1769.2020.04.024 YUAN J, LI H, YING J P, et al. Causes and care of arteriovenous fistula thrombosis in 102 hemodialysis patients[J]. Chinese Journal of Nursing, 2020, 55(4): 607-610. doi: 10.3761/j.issn.0254-1769.2020.04.024
[2]	GORA R, BOJAKOWSKI K, FORONCEWICZ B, et al. Hybrid procedures in the dialysis fistula aneurysm treatment[J]. Vascular, 2020, 28(6): 775-783. doi: 10.1177/1708538120931626
[3]	李隽, 李海燕. 动静脉内瘘和透析导管对老年透析患者透析充分性、微炎症状态和肾性贫血的影响[J]. 中国中西医结合肾病杂志, 2020, 21(2): 148-150. https://www.cnki.com.cn/Article/CJFDTOTAL-JXSB202002021.htm LI J, LI H Y. Effects of arteriovenous internal fistula and dialysis catheter on dialysis adequacy, microinflammatory status, and renal anemia in elderly dialysis patients[J]. Chinese Journal of Integrated Traditional and Western Nephrology, 2020, 21(2): 148-150. https://www.cnki.com.cn/Article/CJFDTOTAL-JXSB202002021.htm
[4]	李海磊, 陈燿志, 崔东哲, 等. 影响自体桡动脉头静脉瘘成熟的因素[J]. 中华血管外科杂志, 2020, 5(3): 191-196. doi: 10.3760/cma.j.cn101411-20200107-00003 LI H L, CHEN Y Z, CUI D Z, et al. Factors affecting maturation of native radiocephalic arteriovenous fistula[J]. Chinese Journal of Vascular Surgery, 2020, 5(3): 191-196. doi: 10.3760/cma.j.cn101411-20200107-00003
[5]	HILL K, SHARP R, CHILDS J, et al. Cannulation practices at haemodialysis initiation via an arteriovenous fistula or arteriovenous graft[J]. J Vasc Access, 2020, 21(5): 573-581. doi: 10.1177/1129729819869093
[6]	陆光兴, 黄媚, 李桂兰. 自体动静脉内瘘通路对血液透析患者透析充分性及并发症的影响[J]. 微创医学, 2021, 16(2): 210-212. https://www.cnki.com.cn/Article/CJFDTOTAL-WCYX202102017.htm LU G X, HUANG M, LI G L. Effect of autologous arteriovenous fistula pathway on dialysis adequacy and complications in hemodialysis patients[J]. Journal of Minimally Invasive Medicine, 2021, 16(2): 210-212. https://www.cnki.com.cn/Article/CJFDTOTAL-WCYX202102017.htm
[7]	梁桂兰, 宛梅清, 殷贵兰, 等. 基于老年综合评估的延续护理方案在维持性血液透析患者中的应用[J]. 中华全科医学, 2020, 18(6): 1051-1054. doi: 10.16766/j.cnki.issn.1674-4152.001425 LIANG G L, WAN M Q, YIN G L, et al. Application of a continuous nursing program for elderly maintenance hemodialysis patients based on comprehensive geriatric assessmen[J]. Chinese Journal of General Practice, 2020, 18(6): 1051-1054. doi: 10.16766/j.cnki.issn.1674-4152.001425
[8]	KUMBAR L, RAMANI K, BROUWER-MAIER D. Considerations in access cannulation: traditional and evolving approaches[J]. Adv Chronic Kidney Dis, 2020, 27(3): 199-207. doi: 10.1053/j.ackd.2020.03.007
[9]	窦素冰, 李建平, 黄琦, 等. PDCA循环护理对血液透析动静脉内瘘保护效果的影响[J]. 护理实践与研究, 2020, 17(11): 49-52. https://www.cnki.com.cn/Article/CJFDTOTAL-HLSJ202011021.htm DOU S B, LI J P, HUANG Q, et al. Effect of applying PDCA cycle nursing for the protective efficacy of hemodialysis arteriovenous fistula[J]. Nursing Practice and Research, 2020, 17(11): 49-52. https://www.cnki.com.cn/Article/CJFDTOTAL-HLSJ202011021.htm
[10]	EVES J, CAI P, LATHAM R, et al. A randomised clinical trial of ultrasound guided cannulation of difficult fistulae for dialysis access[J]. J Vasc Access, 2021, 22(4): 635-641. doi: 10.1177/1129729820954725
[11]	王莉, 颜杰浩, 曾华韫, 等. 不同血管通路对血液透析患者透析充分性及并发症的影响[J]. 国际护理学杂志, 2017, 36(13): 1859-1861. https://www.cnki.com.cn/Article/CJFDTOTAL-NMYX202206009.htm WANG L, YAN J H, CENG H Y, et al. Influence of different vascular passages on the dialysis adequacy and complication of hemodialysis patients[J]. International Journal of Nursing, 2017, 36(13): 1859-1861. https://www.cnki.com.cn/Article/CJFDTOTAL-NMYX202206009.htm
[12]	梁绮祯, 全梓林, 宋利, 等. 血液透析患者动静脉内瘘穿刺失败的多因素分析[J]. 国际医药卫生导报, 2020, 26(24): 3866-3869. LIANG Q Z, QUAN Z L, SONG L, et al. Multivariate analysis of failure of arteriovenous fistula puncture in hemodialysis patients[J]. International Medicine and Health Guidance News, 2020, 26(24): 3866-3869.
[13]	MALLIOS A, BEATHARD G A, JENNINGS W C. Early cannulation of percutaneously created arteriovenous hemodialysis fistulae[J]. J Vasc Access, 2020, 21(6): 997-1002.
[14]	黎秀娜, 罗运红, 范晓坤. 彩色多普勒超声应用于血液透析患者动静脉瘘并发症防治中的效果分析[J]. 中国医药科学, 2020, 10(21): 198-201. https://www.cnki.com.cn/Article/CJFDTOTAL-GYKX202021064.htm LI X N, LUO Y H, FAN X K. Efficacy analysis of color Doppler ultrasound in prevention and treatment of complications of arteriovenous fistula in hemodialysis patients[J]. China Medicine And Pharmacy, 2020, 10(21): 198-201. https://www.cnki.com.cn/Article/CJFDTOTAL-GYKX202021064.htm
[15]	漆争艳, 张娟. 血液透析患者自体动静脉内瘘穿刺方法的改良[J]. 国际护理学杂志, 2020, 39(2): 307-309. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXJH202022005.htm QI Z Y, ZHANG J. Improvement of autologous arteriovenous internal fistula puncture method in hemodialysis patients[J]. International Journal of Nursing, 2020, 39(2): 307-309. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXJH202022005.htm
[16]	SHI K, JIANG H, WAKABAYASHI M. Effect of early cannulation with plastic cannula on arteriovenous fistula patency in hemodialysis patients[J]. Blood Purif, 2020, 49(1-2): 79-84.