【摘要】：背景與目的血管通路是血液透析患者的生命線,一個(gè)功能良好的血管通路是血液透析患者賴以維持生命的前提條件。自體動(dòng)靜脈內(nèi)瘺是血液透析患者的首選通路,但當(dāng)自體動(dòng)靜脈內(nèi)瘺尚未成熟或功能不良,患者或者不能承受人工血管內(nèi)瘺的高昂費(fèi)用時(shí),隧道式血液透析導(dǎo)管就成為主要的代替方式。右頸內(nèi)靜脈是導(dǎo)管置入的首選部位,而對(duì)于那些由于各種原因所致右頸內(nèi)靜脈嚴(yán)重血栓或者閉塞者,右頸外靜脈和左頸內(nèi)靜脈均是可供選擇的備選置管部位。本回顧性研究選擇右頸內(nèi)靜脈無(wú)法作為正常穿刺入路的患者,觀察隧道式血液透析導(dǎo)管在右頸外靜脈和左頸內(nèi)靜脈這兩個(gè)備選部位的臨床差異。方法自2013年01月01日至2014年12月31日在我院接受隧道式血液透析導(dǎo)管置入術(shù)的患者中,篩選出其中經(jīng)右頸外靜脈置入導(dǎo)管患者(n=21)及左頸內(nèi)靜脈置入導(dǎo)管患者(n=28)共計(jì)49例,隨訪至2015年03月31日。觀察主要終點(diǎn)為導(dǎo)管累積通暢時(shí)間,次要終點(diǎn)包括導(dǎo)管初始通暢時(shí)間、從未使用尿激酶的患者比例以及導(dǎo)管相關(guān)血流感染的發(fā)生率�；颊呋�資料分析定量變量采用獨(dú)立樣本t檢驗(yàn)或Wilcoxon秩和檢驗(yàn),分類變量采用卡方檢驗(yàn)。兩組導(dǎo)管累積通暢時(shí)間和導(dǎo)管初始通暢時(shí)間采用采用Kaplan-Meier法。應(yīng)用Cox比例風(fēng)險(xiǎn)回歸模型探究導(dǎo)管長(zhǎng)期通暢的獨(dú)立影響因素。數(shù)據(jù)分析應(yīng)用軟件SPSS 22.0完成。選取α=0.05為檢驗(yàn)水準(zhǔn)。結(jié)果1.兩組共觀察到20,870帶導(dǎo)管天數(shù),帶導(dǎo)管天數(shù)的中位數(shù)為384(四分位數(shù)間距,262-605)天;2.右頸外靜脈組比左頸內(nèi)靜脈組更少出現(xiàn)導(dǎo)管拔除事件(P=0.007);3.右頸外靜脈組的平均導(dǎo)管累積通暢時(shí)間相比左頸內(nèi)靜脈組更長(zhǎng)(P=0.031);4.兩組間在導(dǎo)管相關(guān)血流感染、導(dǎo)管初始通暢時(shí)間以及從未使用尿激酶患者的比例方面均無(wú)明顯統(tǒng)計(jì)學(xué)差異;5.應(yīng)用Cox比例風(fēng)險(xiǎn)回歸模型發(fā)現(xiàn)既往導(dǎo)管累積留置時(shí)間為影響導(dǎo)管累積通暢時(shí)間的獨(dú)立危險(xiǎn)因素(HR=2.212;95%CI,1.363 3.588;P=0.001)結(jié)論對(duì)于右頸內(nèi)靜脈無(wú)法使用的血液透析患者,如需再次進(jìn)行隧道式透析導(dǎo)管置入,選用右頸外靜脈比左頸內(nèi)靜脈有更好的臨床預(yù)后,更適合作為隧道式血透導(dǎo)管置入的第二選擇通路。
[Abstract]:Background and objective the vascular pathway is the lifeline of hemodialysis patients, and a well-functioning vascular pathway is the prerequisite for the maintenance of life for hemodialysis patients. Autogenous arteriovenous fistula is the first choice for hemodialysis patients, but when autologous arteriovenous fistula is immature or dysfunctional, the patient may not be able to afford the high cost of artificial vascular fistula. Tunneling hemodialysis catheters are the main alternative. The right internal jugular vein is the first place of choice for catheterization, but for those with severe thrombosis or occlusion of right internal jugular vein due to various reasons, right external jugular vein and left internal jugular vein are the alternative catheterization sites. This retrospective study selected patients with right internal jugular vein who could not be used as the normal puncture approach to observe the clinical differences between the right external jugular vein and the left internal jugular vein in the tunnel hemodialysis catheter. Methods from January 01, 2013 to December 31, 2014, the patients underwent tunneling hemodialysis catheter placement in our hospital. A total of 49 patients with catheterization via right external jugular vein (N21) and left internal jugular vein (NM28) were selected and followed up to March 31, 2015. The main endpoints were cumulative patency time, secondary endpoints included the initial patency time, the proportion of patients who had never used urokinase, and the incidence of catheter-related blood flow infection. Patient baseline data were analyzed by independent sample t test or Wilcoxon rank sum test, and classified variables by chi-square test. The cumulative patency time and the initial patency time were measured by Kaplan-Meier method. The Cox proportional risk regression model was used to explore the independent influencing factors of long-term patency of ducts. Data analysis application software SPSS 22. 0 is completed. 偽 = 0.05 was selected as the test level. Result 1. A total of 20870 catheterized days were observed in the two groups, and the median number of days with catheterization was 384 (quartile spacing, 262-605) days; 2. The right external jugular vein group had fewer extubation events than the left internal jugular vein group (P0. 007). The mean cumulative patency time of the right external jugular vein group was longer than that of the left internal jugular vein group (P < 0.031). There was no significant difference between the two groups in catheter-related blood flow infection, the initial patency time of catheter and the proportion of patients who had never used urokinase. The Cox proportional risk regression model was used to find that the cumulative indwelling time was an independent risk factor for the cumulative patency time of the catheter (HR=2.212;95%CI,1.363 3.588). Conclusion for hemodialysis patients whose right internal jugular vein cannot be used, the right external jugular vein is better than the left internal jugular vein if the tunnel dialysis catheter is needed again. It is more suitable as the second choice of tunnel hemodialysis catheter.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R692.5

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