本文選題：肝素 + 尿激酶　； 參考：《湖南師范大學(xué)》2016年碩士論文

【摘要】：研究背景:導(dǎo)管血栓形成是血液透析患者中心靜脈導(dǎo)管功能不良乃至拔管的主要原因之一。為防治導(dǎo)管血栓形成,美國(guó)腎臟病與透析病人生存質(zhì)量指導(dǎo)(K/DOQI)指南推薦使用肝素,在透析結(jié)束回血后對(duì)導(dǎo)管動(dòng)靜脈端進(jìn)行封管。臨床研究發(fā)現(xiàn),由于封管液可以從導(dǎo)管尖端滲漏進(jìn)入體內(nèi),使用肝素封管后患者發(fā)生出血事件機(jī)率增加。因此,找到一種出血風(fēng)險(xiǎn)較小的封管藥物對(duì)于有高出血風(fēng)險(xiǎn)、圍手術(shù)期及需要行有創(chuàng)操作的血液透析患者有重大的意義。尿激酶對(duì)機(jī)體的凝血功能影響小,最開(kāi)始主要用于導(dǎo)管血栓形成時(shí)的溶栓治療。Gabutti L等[1]對(duì)比5000U/ml尿激酶與K/DOQI指南推薦的5000U/ml肝素封管發(fā)現(xiàn),規(guī)律使用5000U/ml尿激酶封管可以增加導(dǎo)管的血流和減少導(dǎo)管功能不良的發(fā)生,是一種較好的封管藥物。有研究表明,血液中D-二聚體與靜脈血栓形成密切相關(guān),那么,中心靜脈導(dǎo)管周圍血液中D-二聚體是否也與導(dǎo)管血栓形成相關(guān)?這些臨床上少有研究。目的:通過(guò)比較肝素與尿激酶封管10min后患者外周血中APTT、PT的變化及封管時(shí)、封管1天后、封管2天后導(dǎo)管周圍血液中D-二聚體變化,分析肝素與尿激酶封管致血液透析患者出血及導(dǎo)管血栓形成的風(fēng)險(xiǎn)。方法:選取湖南省人民醫(yī)院血液凈化中心使用帶隧道帶滌綸套導(dǎo)管規(guī)律血液透析患者30例,將所有入選患者隨機(jī)分為兩組,分別在透析結(jié)束后使用5000U/ml肝素和5000U/ml的尿激酶封管。收集兩組入選患者的年齡、性別、透析時(shí)間、導(dǎo)管使用時(shí)間、透析頻率、基礎(chǔ)疾病、干體重、導(dǎo)管流量、APTT、PT、Fib、D-二聚體、PLT、Hb、ALB、LDL、HDL、TG、TC等資料;每例患者分別于透析結(jié)束后封管前經(jīng)導(dǎo)管采血2m L檢測(cè)APTT、PT、D-二聚體(此時(shí)也相當(dāng)于外周血中APTT、PT);于封管10min后取外周血2m L檢測(cè)APTT、PT;在封管1天后,抽出導(dǎo)管中的透明封管液后經(jīng)導(dǎo)管采血2m L檢測(cè)D-二聚體,然后按原方案封管;于封管2天后再次抽出導(dǎo)管中的透明封管液后經(jīng)導(dǎo)管采血2m L檢測(cè)D-二聚體(相當(dāng)于下次透析前)。連續(xù)兩個(gè)月觀察患者透析時(shí)的導(dǎo)管流量,記錄患者發(fā)生出血的情況及次數(shù),記錄導(dǎo)管中出現(xiàn)肉眼纖維凝塊及溶栓治療的次數(shù),當(dāng)導(dǎo)管流量小于180m L/min或出現(xiàn)肉眼纖維凝塊時(shí),抽出導(dǎo)管中的封管液后經(jīng)導(dǎo)管采血2m L檢測(cè)D-二聚體并與同一病人原來(lái)封管時(shí)、封管2天后的D-二聚體水平比較;并使用高溶度尿激酶(50000U/ml)保留封管30min進(jìn)行溶栓。結(jié)果:1.兩組患者在年齡、性別、透析時(shí)間、導(dǎo)管使用時(shí)間、透析頻率、基礎(chǔ)疾病、干體質(zhì)量、導(dǎo)管流量及一般生化資料方面比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。2.兩組患者之間封管前APTT、PT比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P1=0.945,P2=0.714),兩組患者之間封管10min后APTT、PT比較差異有統(tǒng)計(jì)學(xué)意義(P1=0.034,P2=0.019),肝素組較尿激酶組高。3.同組患者封管前后比較,其中肝素組封管10min后APTT較封管前延長(zhǎng)(11.37±10.39)S,較封管前比較差異有統(tǒng)計(jì)學(xué)意義(P=0.001),尿激酶組封管10min后APTT較封管前比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.33);肝素組封管10min后PT較封管前延長(zhǎng)(5.58±6.46)S,較封管前比較差異有統(tǒng)計(jì)學(xué)意義(P=0.005),尿激酶組封管10min后PT較封管前比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P=0.99)。4.肝素組封管時(shí)D-二聚體為(1.61±0.85)ug/ml,封管1天后D-二聚體為(1.79±0.85)ug/ml,封管2天后D-二聚體為(4.95±5.46)ug/ml,封管2天后與封管時(shí)、封管1天后比較差異有統(tǒng)計(jì)學(xué)意義(P0=0.007,P1=0.01),封管2天后明顯升高;尿激酶組封管前D-二聚體為(1.50±0.89)ug/ml,封管1天后D-二聚體為(1.81±0.98)ug/ml,封管2天后D-二聚體為(3.58±2.74)ug/ml,封管2天后與封管時(shí)、封管1天后比較差異有統(tǒng)計(jì)學(xué)意義(P0=0.002,P1=0.009),封管2天后明顯升高。兩組患者之間封管時(shí)、封管1天后及封管2天后D-二聚體比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0=0.714,P1=0.961,P2=0.394)。5.當(dāng)出現(xiàn)導(dǎo)管功能不良時(shí),溶栓前導(dǎo)管周圍血液中D-二聚體為(6.25±5.40)ug/ml,與該患者封管時(shí)、封管2天后D-二聚體水平比較差異均有統(tǒng)計(jì)學(xué)意義(P0=0.003,P2=0.025),較封管時(shí)、封管2天后顯著升高。6.兩組患者發(fā)生皮下瘀斑、牙齦出血、導(dǎo)管中出現(xiàn)肉眼纖維凝塊方面比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05);兩組患者在溶栓次數(shù)上比較差異有統(tǒng)計(jì)學(xué)意義(P=0.017),其中肝素組較尿激酶組溶栓次數(shù)多。結(jié)論:1.透析后使用5000U/ml肝素封管,患者潛在出血風(fēng)險(xiǎn)較透析后使用5000U/ml尿激酶封管高。2.與5000U/ml的肝素封管比較,使用5000U/ml的尿激酶封管可以減少導(dǎo)管溶栓次數(shù)。3.導(dǎo)管周圍血液中D-二聚體水平與封管時(shí)間及導(dǎo)管功能不良事件密切相關(guān),有可能成為導(dǎo)管內(nèi)及管周血栓形成的早期預(yù)測(cè)因子。
[Abstract]:Background: catheter thrombosis is the function of central venous catheter in hemodialysis patients and the main causes of poor extubation. One of the forms for the prevention of catheter thrombosis, kidney disease and dialysis patient survival quality guidelines (K/DOQI) guidelines recommend the use of heparin tube sealing of arteriovenous catheter end after hemodialysis. Blood after clinical findings because, sealing fluid from the catheter tip leakage into the body, the use of heparin tube sealing after bleeding events increased. Therefore, to find a small risk of bleeding tube drug for high risk of bleeding, and the need for perioperative hemodialysis patients with invasive operation has great significance. The coagulation effect of urokinase on the function of the body, the primary conduit for thrombosis during thrombolytic therapy of.Gabutti L [1] 5000U/ml comparison urokinase and K/DOQI guidelines recommend 5000U/ml heparin sealing The tube found that regular use of 5000U/ml urokinase can increase blood flow and reduce catheter catheter dysfunction, is a kind of good sealing drugs. Studies have shown that D- in the blood of two dimers and venous thrombosis are closely related, so the central venous catheter in blood around two D- dimer also and catheter thrombosis? These rare clinical research. Objective: APTT patients were compared by heparin and urokinase 10min in peripheral blood, the changes of PT and sealing, sealing for 1 days, 2 days after sealing around the catheter in the blood two D- dimer changes, analysis of heparin induced bleeding in patients with hemodialysis and the risk of catheter thrombosis and urokinase. Methods: Hunan People's Hospital blood purification center using tunnel cuffed catheter hemodialysis patients 30 cases, all patients were randomly divided into two groups, respectively in dialysis 緇撴潫鍚庝嬌鐢，

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