本文選題：肝衰竭 + 終末期肝病�。� 參考：《山東大學(xué)》2014年碩士論文

【摘要】：研究背景與目的 肝衰竭是多種因素引起的嚴(yán)重肝臟損害,導(dǎo)致其合成、解毒、排泄和生物轉(zhuǎn)化等功能發(fā)生嚴(yán)重障礙或失代償,出現(xiàn)以凝血功能障礙、黃疸、肝性腦病、腹水等為主要表現(xiàn)的一組臨床癥候群。其治療主要包括內(nèi)科綜合治療、人工肝支持治療及肝移植。人工肝支持系統(tǒng)能替代肝臟解毒功能,清除體內(nèi)毒性物質(zhì),改善內(nèi)環(huán)境,為肝移植或肝細(xì)胞再生贏(yíng)得時(shí)間。血漿置換和MARS是目前應(yīng)用最廣泛的人工肝技術(shù),但兩者的有效性和安全性缺乏深入的對(duì)照研究,特別是對(duì)不同的人工肝技術(shù)如何采取有針對(duì)性的護(hù)理缺少系統(tǒng)研究。人工肝治療操作主要由護(hù)士完成,護(hù)理人員在人工肝治療過(guò)程中扮演著重要角色。護(hù)理人員掌握熟練的操作規(guī)程,做好治療前對(duì)患者的評(píng)估、術(shù)中的配合與病情觀(guān)察、術(shù)后的護(hù)理是人工肝治療得以順利進(jìn)行和成功的保證。所以,認(rèn)真總結(jié)經(jīng)驗(yàn),探索合理的護(hù)理方案,所以如何根據(jù)不同人工肝技術(shù)的特點(diǎn)有針對(duì)性地構(gòu)建護(hù)理對(duì)策,以最大程度地減少副作用或并發(fā)癥、提高人工肝的治療水平是非常必要的。 方法 本研究為回顧性對(duì)照研究。對(duì)2009年1月～2013年6月在我院接受人工肝治療且資料相對(duì)完整的病例進(jìn)行療效、費(fèi)用、病死率、死亡原因、副作用、并發(fā)癥等方面進(jìn)行多層次分析。研究對(duì)象為150例慢性乙型肝炎并肝衰竭的患者。肝衰竭的診斷符合《肝衰竭診治指南(2012年版)》的診斷標(biāo)準(zhǔn)。根據(jù)不同的人工肝治療,分A組和B組。A組為單用血漿置換組,共62例,其中男45例,女17例,平均年齡43.5±11.2歲；B組為血漿置換和MARS聯(lián)合組,共88例,其中男60例,女28例,平均年齡42.6±12.4歲。B組中又將接受血漿置換的稱(chēng)為B1組,接受MARS治療的稱(chēng)為B2組。人工肝治療標(biāo)準(zhǔn)：血清總膽紅素水平大于350μmol/L,且每日總膽紅素上升幅度大于17.1μ mol/L, PTA小于40%；停止人工肝治療標(biāo)準(zhǔn)：患者血清總膽紅素小于200μ mol/L,每天上升幅度10μ mol/L, PTA大于60%；最低出院標(biāo)準(zhǔn)：患者消化道癥狀明顯改善,無(wú)肝性腦病、肝腎綜合癥、感染、消化道出血等重要并發(fā)癥,總膽紅素小于100μ mol/L, PTA大于70%。護(hù)理措施包括術(shù)前護(hù)理,如患者的心理護(hù)理、環(huán)境及物品的準(zhǔn)備、病員的準(zhǔn)備(如備皮)和機(jī)器及管道準(zhǔn)備；術(shù)中護(hù)理包括嚴(yán)格執(zhí)行無(wú)菌操作、密切觀(guān)察生命體征變化、注意觀(guān)察儀器運(yùn)行情況和抗凝血的護(hù)理；術(shù)后護(hù)理包括術(shù)后觀(guān)察不良反應(yīng)、股靜脈置管的護(hù)理和飲食指導(dǎo)等。觀(guān)察項(xiàng)目為,分析比較A組和B組的總體療效、并發(fā)癥和死亡原因；對(duì)存活患者的住院天數(shù)、人工肝治療費(fèi)用以及總醫(yī)療費(fèi)用進(jìn)行比較分析；分析比較A組患者每次血漿置換后、B1組患者每次血漿置換后以及B2組患者每次MARS后的血常規(guī)、肝功生化指標(biāo)的變化以及并發(fā)癥的發(fā)生情況。統(tǒng)計(jì)學(xué)處理,均數(shù)間比較采用方差分析或t檢驗(yàn),率的比較采用x2檢驗(yàn)。當(dāng)P＜0.05視為有統(tǒng)計(jì)學(xué)差異。 結(jié)果 在接受人工肝治療前A組和B組患者,肝功能各項(xiàng)指標(biāo)均顯著異常并達(dá)到重型肝炎的診斷標(biāo)準(zhǔn),兩組各項(xiàng)肝能功指標(biāo)均無(wú)顯著性差異(P＞0.05)。生化學(xué)指標(biāo)中,兩組患者血鈉水平均有不同程度下降,其余指標(biāo)無(wú)明顯異常,兩組生化學(xué)指標(biāo)無(wú)顯著差異(P＞0.05)。經(jīng)人工肝治療后,兩組死亡例數(shù)無(wú)顯著差異(P＞0.05),A組和B組病死率分別為35.5%和36.4%,提示總體療效兩組相同(P＞0.05),但直接死因兩組略有差異,A組因腎衰死亡的比率明顯高于B組(12.9.0%vs2.3%,P＜O.05),其他死因兩組無(wú)顯著差異。主要并發(fā)癥中,A組新發(fā)肝性腦病發(fā)生率明顯高于B組(35.5%vs19.3%,P＜0.05),其他并發(fā)癥兩組無(wú)顯著差異。對(duì)兩組經(jīng)治療而存活的患者進(jìn)行住院天數(shù)和醫(yī)療費(fèi)用分析顯示,B組患者住院天數(shù)略長(zhǎng)于A(yíng)組,但無(wú)統(tǒng)計(jì)學(xué)差異。人工肝費(fèi)用和總醫(yī)療費(fèi)用B組均顯著高于A(yíng)組(P＜0.01),主要差別在MARS治療費(fèi)用高昂。分析比較A組患者每次血漿置換前后、B組患者每次血漿置換前后、以及B組患者每次MARS治療前后的肝功、生化指標(biāo)以及血常規(guī)變化。無(wú)論是A組的血漿置換還是B2組的血漿置換,總膽紅素的下降幅度均顯著大于MARS治療(P0.01),PTA的上升幅度也顯著高于MARS治療(P0.01), ALT、血氨和總膽固醇水平的變化各組無(wú)顯著差異(P0.05)。各組人工肝治療后對(duì)外周血白細(xì)胞的影響無(wú)統(tǒng)計(jì)學(xué)差異,但MARS治療后紅細(xì)胞和血小板的下降幅度均大于A(yíng)組的血漿置換和B2組的血漿置換(p0.01)。ARS治療組對(duì)鈉、鉀、氯以及尿素氮和肌酐的復(fù)常率均顯著高于A(yíng)組的血漿置換和B2組的血漿置換(P＜0.01)。對(duì)各組的主要不良反應(yīng)包括鼻腔出血、牙齦出血、消化道出血、插管局部出血、皮疹、畏寒寒戰(zhàn)、四肢發(fā)麻等進(jìn)行分析比較,MARS治療組的鼻腔出血和牙齦出血明顯多于A(yíng)組的血漿置換和B2組的血漿置換(P＜0.05),而皮疹、畏寒寒戰(zhàn)和四肢發(fā)麻等不良反應(yīng)顯著少于A(yíng)組的血漿置換和B2組的血漿置換(P＜0.05)。 結(jié)論 人工肝技術(shù)能明顯地提高肝功能衰竭患者的存活率,單獨(dú)血漿置換和血漿置換聯(lián)合MARS治療療效相同。死亡因素中,單獨(dú)血漿置換組腎功能衰竭較多,心功能衰竭、肝性腦病、感染、多器官功能衰竭兩組無(wú)顯著差異；血漿置換聯(lián)合MARS治療費(fèi)用明顯高于單獨(dú)血漿置換治療,主要原因?yàn)镸ARS材料費(fèi)高昂；在并發(fā)癥中血漿置換組以新發(fā)肝性腦病較為突出,其他并發(fā)癥包括肝腎綜合癥、消化道出血、感染等,兩組無(wú)顯著差異；在不良反應(yīng)或副作用中,血漿置換發(fā)熱、皮疹、寒戰(zhàn)等過(guò)敏現(xiàn)象較多,其次是口周和四肢發(fā)麻；MARS治療更多見(jiàn)局部出血情況,包括鼻腔、牙齦出血,插管部位皮膚出血,以及消化道出血等；針對(duì)血漿置換和MARS治療的不同特點(diǎn),有針對(duì)性的構(gòu)建護(hù)理對(duì)策對(duì)提高臨床療效具有重要意義。這些護(hù)理對(duì)策應(yīng)包括人工肝支持治療中心的管理、嚴(yán)格控制感染、嚴(yán)密觀(guān)察并發(fā)癥和不良反應(yīng)并及時(shí)處理、對(duì)患者進(jìn)行良好的健康教育。
[Abstract]:Research background and purpose
Liver failure is a serious liver damage caused by a variety of factors, resulting in severe impairment or decompensation of its functions such as synthesis, detoxification, excretion and biotransformation, and a group of clinical syndromes mainly manifested as coagulation dysfunction, jaundice, hepatic encephalopathy, and ascites. The treatment and treatment mainly include comprehensive medical treatment, artificial liver support and treatment. Liver transplantation. Artificial liver support system can replace the function of liver detoxification, remove toxic substances in the body, improve the internal environment, and win the time for liver transplantation or liver cell regeneration. Plasma exchange and MARS are the most widely used artificial liver techniques, but the effectiveness and safety of the two are lack of a deep control study, especially for different artificial liver techniques. The operation of artificial liver is not systematically studied. The operation of artificial liver is mainly done by nurses. The nursing staff play an important role in the process of artificial liver treatment. The nursing staff master the skilled operation procedures, evaluate the patients before the treatment, cooperate with the patients in the operation and observe the condition, and the postoperative nursing is the artificial liver treatment. Therefore, it is necessary to make a careful summary of experience and to explore a reasonable nursing plan, so how to build a nursing strategy according to the characteristics of different artificial liver techniques, to reduce the side effects or complications to the maximum extent, and to improve the treatment level of artificial liver is very necessary.
Method
This study was a retrospective control study. A multilevel analysis was conducted on the efficacy, cost, fatality rate, death causes, side effects, complications and so on in the patients receiving artificial liver treatment in our hospital from January 2009 to June 2013. The subjects were 150 patients with chronic hepatitis B and liver failure. The diagnostic character of liver failure. According to the different artificial liver treatment, group A and group B.A were divided into 62 cases, including 45 males and 17 females, with an average age of 43.5 + 11.2 years. The B group was plasma exchange and MARS combined group, including 60 men and 28 women, and the average age was 42.6 + 12.4 years.B group. The total bilirubin level of serum total bilirubin was greater than 350 u mol/L, and the daily total bilirubin increased more than 17.1 mu mol/L and PTA was less than 40%, and the standard of total bilirubin was less than 200 mol/L, and the serum total cholesterol was less than 200 mu mol/L and increased by 10 u mol/L a day. The standard of serum total bilirubin was greater than 350 u mol/L, and the total bilirubin level was greater than 350 mu mol/L. PTA was greater than 60%; the minimum discharge standard: significant improvement in the symptoms of digestive tract in patients, no hepatic encephalopathy, liver and kidney syndrome, infection, gastrointestinal bleeding and other important complications, total bilirubin less than 100 mu, and PTA greater than 70%. nursing measures including preoperative care, such as patients' psychological care, preparation of environment and articles, and preparation of the sick (such as skin preparation). Machinery and pipeline preparation; intraoperative nursing included strict aseptic operation, close observation of the changes in vital signs, observation of the operation of the instrument and the nursing of anticoagulant; postoperative nursing including postoperative observation of adverse reactions, nursing of femoral vein catheterization and dietary guidance. The overall efficacy of A and B groups was analyzed and compared. The causes of disease and death, the number of days of hospitalization, the cost of artificial liver treatment and the total medical cost were compared and analyzed. The blood routine after every plasma exchange in group B1 patients after each plasma exchange, and after each MARS in group B2, the changes of biochemical index of liver function and the occurrence of complications were analyzed and compared in group A patients. Variance analysis or t test were used to compare the scores between the two groups. The x2 test was used for the comparison of the rates. When P < 0.05, the difference was statistically significant.
Result
In group A and group B before the treatment of artificial liver treatment, all indexes of liver function were significantly abnormal and reached the diagnostic standard of severe hepatitis. There was no significant difference between the two groups (P > 0.05). In the biochemical indexes, the level of sodium in the two groups decreased in varying degrees, the other indexes were not obvious, and the two groups of biochemical indexes were not. Significant difference (P > 0.05). After the treatment of artificial liver, there was no significant difference in the number of deaths in the two groups (P > 0.05), the mortality rate of group A and B was 35.5% and 36.4%, respectively, indicating that the overall efficacy of the two groups was the same (P > 0.05), but the direct cause of death was slightly different, and the ratio of death to renal failure in the A group was significantly higher than that of the B group (12.9.0%vs2.3%, P < O.05), and the other two groups of the two groups did not. Among the main complications, the incidence of new hepatic encephalopathy in group A was significantly higher than that in group B (35.5%vs19.3%, P < 0.05), and there was no significant difference in other complications. The number of hospitalization days and medical costs in the two groups of patients who survived were slightly longer than those in the group A, but there was no statistical difference. The total medical cost in the B group was significantly higher than that in the A group (P < 0.01), and the major difference was high in the cost of MARS treatment. The analysis and comparison of the liver function, biochemical indexes, and blood routine changes before and after each MARS treatment in the group of A patients, before and after each plasma exchange in the A group, and in the B group before and after each MARS treatment, whether the plasma exchange in the A group or the plasma of the B2 group. The decrease of total bilirubin was significantly greater than that of MARS (P0.01), and the increase of PTA was significantly higher than that of MARS (P0.01), ALT, blood ammonia and total cholesterol levels were not significantly different in each group (P0.05). There was no statistical difference in the effect of leukocyte in peripheral blood after artificial liver treatment, but after MARS treatment, red blood cells and platelets were treated with MARS. The decrease was greater than the plasma exchange in the A group and the plasma replacement (P0.01) in group B2. The recurrent rates of sodium, potassium, chlorine, urea nitrogen and creatinine were significantly higher than those in the A group and the plasma replacement in the group B2 (P < 0.01). The major adverse reactions included nasal cavity bleeding, gingival bleeding, gastrointestinal bleeding, and intubation. The analysis and comparison of blood, rash, chill and chills, and the numbness of limbs were compared. The nasal bleeding and gingival bleeding in the MARS treatment group were significantly more than the plasma exchange in the group A and the plasma exchange in the group B2 (P < 0.05), while the adverse reactions of the rash, the cold chills and the limbs' numbness were significantly less than the plasma exchange in the A group and the plasma exchange in the group B2 (P < 0.05).
conclusion
Artificial liver technology can obviously improve the survival rate of patients with liver failure. The therapeutic effect of single plasma exchange and plasma exchange combined with MARS is the same. Among the death factors, there are more renal failure in the group of separate plasma replacement groups, no significant difference in two groups of heart failure, hepatic encephalopathy, infection, and multiple organ function failure; plasma exchange and MARS therapy The cost was significantly higher than the single plasma replacement therapy, the main reason was the high cost of MARS material; in the complications, the plasma exchange group was more prominent with new hepatic encephalopathy, other complications included liver and kidney syndrome, digestive tract bleeding, infection and so on. There were no significant differences in the two groups; in adverse reaction or side effects, plasma replacement fever, rash, shivering and so on There are more anaphylaxis, followed by the perimerent and extremities; MARS treatment is more likely to see local bleeding, including the nasal cavity, gingival bleeding, hemorrhage of the cannula, and hemorrhage of the digestive tract. In view of the different characteristics of plasma exchange and MARS treatment, the targeted construction of nursing countermeasures is of great significance to the improvement of clinical efficacy. It should include the management of artificial liver support treatment center, strict control of infection, close observation of complications and adverse reactions and timely treatment, and good health education for the patients.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R473.6

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