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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

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.

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.

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。

Cause Analysis and Nursing of Peritoneal Dialysis-related Peritonitis

目的　分析持續腹膜透析患者發生腹膜炎的情況及相關因素，降低腹膜透析患者腹膜炎發生率、退出率，提高患者的生存率、生活質量。 方法　回顧分析2011年1月－6月收治的41例在家中行持續非臥床性腹膜透析且發生腹膜炎患者的臨床資料，觀察腹膜炎的發生率及轉歸，腹膜炎癥狀出現后初始的處理，對腹膜炎的誘因進行分析。 結果　41例腹膜透析患者共發生腹膜炎43例次，痊愈35例（85.4%），轉血液透析3例（7.3%），死亡3例（7.3%）。在癥狀出現初期，3例（7.3%）患者繼續在家觀察，10例（24.4%）患者立即到當地就醫，15例（36.6%）患者采用電話咨詢，13例（31.7%）患者到腹膜透析中心就診；18例（43.9%）患者直接將腹膜透析引流液帶到醫院進行藥敏試驗。就感染誘因而言，16例（39.0%）患者未嚴格進行空氣消毒，13例（31.7%）患者未嚴格進行環境清潔，10例（24.4%）患者操作過程存在污染行為。 結論　加強對居家行腹膜透析患者的初次培訓、操作指導及監測，可避免腹膜炎的發生，提高患者生活質量。

Evaluation of the Relationship between Age and Nutrition Status in Continuous Ambulatory Peritoneal Dialysis Patients

【摘要】　目的　探索持續非臥床腹膜透析（CAPD）患者年齡與營養狀況的關系，為營養教育提供指導。　方法　對2007年8月-2010年1月腹膜透析177例患者的臨床資料進行回顧性分析，包括血紅蛋白（HGB）、血清白蛋白（ALB）、年齡、體重指數（BMI）、腹膜平衡試驗（PET）、尿素清除指數（Kt/V）、24 h尿蛋白、腹透液漏出蛋白、標準化每日蛋白質分解率（nPCR）等，分析年齡與營養狀況的關系。　結果　老年組（≥60歲）和中青年組（lt;60歲）ALB分別為（31.54±5.91）、（33.24±4.75）g/L，老年組ALB較低（Plt;0.05）；老年組Kt/V值1.95±0.63和HGB水平（95.25±22.89） g/L均高于青年組（Plt;0.05）。兩組患者營養不良與BMI、PET、每日蛋白漏出總量、nPCR無關。　結論　CAPD老年患者（≥60歲）更容易發生營養不良，且老年組低蛋白血癥與透析充分性無明顯關系。故應加強老年CAPD患者的飲食營養管理指導，設計合理的飲食。【Abstract】　Objective　To investigate the relationship between age and nutrition status of the patients undergoing continuous ambulatory peritoneal dialysis (CAPD), and provide instructions for nutrition education.　Methods　We retrospectively analyzed the clinical data of 177 patients having undergone CAPD in the Department of Nephrology of West China Hospital between April 2007 and January 2010. Clinical parameters collected included hemoglobin (HGB), serum albumin (ALB), age, body mass index (BMI), results of the peritoneal equilibrium test (PET), urea clearance index (Kt/V), 24-hour urinary protein, protein loss in the peritoneal dialysate, normalized protein catabolic rate (nPCR). Relationship between age and nutrition status in these patients were analyzed.　Results　Plasma albumin was (31.54±5.91) g/L and (33.24±4.75) g/L respectively in patients of or older than 60 years old (the elderly group) and in patients younger than 60 years old (the younger group). Compared with the younger group, patients in the elderly group had lower ALB (Plt;0.05), but higher Kt/V 1.95±0.63 and hemoglobin level (95.25±22.89) g/L (Plt;0.05). In addition, malnutrition in both groups was not associated with BMI, PET results, daily protein loss in the peritoneal dialysate or nPCR.　Conclusions　Patients of or older than 60 years old undergoing CAPD are more likely to develop malnutrition, indicating that hypoalbuminemia is not associated with dialysis inadequacy. We advocate enhancing diet nutrition education in elderly CAPD patients and providing them with balanced diet regime.

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.

Organization and Management of Hemodialytic Treatment for 77 Patients with Crush Syndrome after Wenchuan Earthquake

During the medical rescue after Wenchuan earthquake, based on the design and implementation of the management process of blood purification equipment, we gave the top priority to those patients with post-disaster crush syndrome to ensure their hemodialytic treatment. Through strict management of blood purification technology, the outcomes of these patients have been fundamentally improved and the incidence of complications was substantially reduced. Safe and effective hemodialytic treatment have been administered to 77 patients with crush syndrome (813 case-times).

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。