以质量求发展，以服务铸品牌

护理学报 ›› 2022, Vol. 29 ›› Issue (10): 54-59.doi: 10.16460/j.issn1008-9969.2022.10.054

• 循证护理 • 上一篇    下一篇

无肝素连续性肾脏替代治疗体外循环凝血预防及管理的最佳证据总结

杨建国1a, 何细飞1b, 鄢建军1a, 张仲华1a, 童辉1a, 杨纯子1c, 王艳芳2   

  1. 1.华中科技大学同济医学院附属同济医院 a.血液净化中心,b.内科教研室,c.护理部,湖北 武汉 430030;
    2.南方医院JBI循证护理合作中心,广东 广州 510515
  • 收稿日期:2021-08-13 出版日期:2022-05-25 发布日期:2022-06-09
  • 通讯作者: 何细飞（1979-）,女,湖北武汉人,硕士,副主任护师,总护士长。E-mail: 26817600@qq.com
  • 作者简介:杨建国（1987-）,男,湖北武汉人,硕士,主管护师,循证护理师。

Best Evidence Summary of Prevention and Management of Coagulation during Continuous Renal Replacement Therapy without Heparin

YANG Jian-guo1a, HE Xi-fei1b, YAN Jian-jun1a, ZHANG Zhong-hua1a, TONG hui1a, YANG Chun-zi1c, WANG Yan-fang2   

  1. 1a. Blood Purification Center; 1b. Teaching and Research Office of Internal Medicine; 1c. Dept. of Nursing Administration,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
    2. JBI Evidence-based Nursing Cooperation Center of Nanfang Hospital, Guangzhou 510515, China
  • Received:2021-08-13 Online:2022-05-25 Published:2022-06-09

PDF (PC)

213

赞

摘要： 目的 总结无肝素连续性肾脏替代治疗（continuous renal replacement therapy, CRRT）体外循环凝血预防及管理的最佳证据,为临床护理工作提供参考。方法 根据循证护理的方法确定问题,检索澳大利亚JBI循证卫生保健中心、国际指南协作网等指南网站,中国知网、PubMed等中英文数据库以及国际肾脏病学会和中华医学会肾脏病学分会等专业领域学术网站中关于CRRT体外循环的相关证据,包括临床实践指南、临床决策、专家共识、最佳临床实践、证据汇总及系统评价。通过文献质量评价,对符合质量标准的文献进行证据提取及整合。结果 共纳入10篇文献,包括临床指南1篇、专家共识2篇、证据综合1篇和系统评价6篇,最后从风险评估、血管通路、耗材选择、抗凝方式、参数设置、过程监测6个方面形成了30条最佳证据。结论 临床上行无肝素CRRT时,可结合具体的临床情境,参考最佳证据,降低体外循环凝血的发生,为患者提供专业的护理。

关键词: 连续性肾脏替代治疗, 体外循环, 凝血, 最佳证据, 循证护理

Abstract: Objective To summarize the best evidence for the prevention and management of coagulation during continuous renal replacement therapy (CRRT) without heparin, and to provide reference for clinical practice. Methods The questions were identified based on evidence-based nursing, and we searched the guide websites including the JBI international cooperation center database, Guidelines International Network, and Chinese and English databases including CNKI, PubMed, and professional academic websites including the International Society of Nephrology, and the Chinese Medical Association Nephrology Branch to collect clinical practice guidelines, expert consensus, best clinical practice, evidence summaries and systematic reviews related to CRRT. Then evidence was extracted from the eligible literature through quality evaluation. Results Ten articles were collected, including 1 clinical practice guidelines, 2 expert consensuses, 1 evidence synthesis and 6 systematic reviews. Thirty pieces of best evidence from 6 aspects covering risk assessment, vascular access, consumable materials, heparin-free anti-coagulation, parameters setting, and monitoring during treatment were summed up. Conclusion The best evidence provides guidance for clinical practice, helps to reduce the occurrence of coagulation during heparin-free CRRT and provide patients with professional care.

Key words: continuous renal replacement therapy, extracorporeal circulation, coagulation, best evidence, evidence-based nursing

中图分类号: 

  • R459.5
[1] Neyra JA, Tolwani A.CRRT Prescription and Delivery of Dose[J].Semin Dial,2021,34(6):432-439.DOI:10.1111/sdi.12974.
[2] Claure-Del GR, Clark WR.Continuous Renal Replacement Therapy Principles[J]. Semin Dial, 2021,34(6):398-405.DOI:10.1111/sdi.12967.
[3] Romagnoli S, Clark WR, Ricci Z, et al.Renal Replacement Therapy for AKI: When? How Much? When to Stop?[J]. Best Pract Res Clin Anaesthesiol, 2017,31(3):371-385.DOI:10.1016/j.bpa.2017.10.001.
[4] Uchino S, Bellomo R, Morimatsu H, et al.Continuous Renal Replacement Therapy: A Worldwide Practice Survey. The Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators[J].Intensive Care Med, 2007,33(9):1563-1570.DOI:10.1007/s00134-007-0754-4.
[5] Fu X, Liang X, Song L, et al.Building and Validation of a Prognostic Model for Predicting Extracorporeal Circuit Clotting in Patients with Continuous Renal Replacement Therapy[J]. Int Urol Nephrol, 2014, 46(4):801-807.DOI:10.1007/s11255-014-0682-5.
[6] 朱政,胡雁,邢唯杰,等.不同类型循证问题的构成[J].护士进修杂志,2017,32(21):1991-1994.DOI:10.16821/j.cnki.hsjx.2017.21.025.
[7] Dicenso A, Bayley L, Haynes RB.Accessing Pre-appraised Evidence: Fine-tuning the 5S Model into a 6S Model[J]. Evid Based Nurs, 2009,12(4):99-101.DOI:10.1136/ebn.12.4.99-b.
[8] 谢利民, 王文岳.《临床指南研究与评价系统Ⅱ》简介[J].中西医结合学报, 2012, 10(2):160-165.DOI:10.3736/jcim20120206.
[9] 周芬,郝玉芳,丛雪,等.指南研究与评价工具AGREE Ⅱ及各领域分值的补充解释及思考[J].护理学报, 2018,25(18):56-58.DOI:10.16460/j.issn1008-9969.2018.18.056.
[10] Foster MJ, Shurtz S.Making the Critical Appraisal for Summaries of Evidence(CASE) for Evidence-based Medicine (EBM): Critical Appraisal of Summaries of Evidence[J]. J Med Libr Assoc, 2013,101(3):192-198.DOI:10.3163/1536-5050.101.3.008.
[11] 胡雁,郝玉芳.循证护理学[M].2版.北京:人民卫生出版社,2018.
[12] 顾莺,张慧文,周英凤, 等.JBI循证卫生保健中心关于不同类型研究的质量评价工具——系统评价的方法学质量评价[J].护士进修杂志, 2018, 33(8):701-703.DOI:10.16821/j.cnki.hsjx.2018.08.008.
[13] 王春青, 胡雁.JBI证据预分级及证据推荐级别系统(2014版)[J].护士进修杂志, 2015, 30(11):964-967.DOI:10.16821/j.cnki.hsjx.2015.11.002.
[14] 周英凤, 胡雁, 朱政, 等.JBI循证卫生保健模式的更新及发展[J].护理学杂志, 2017,32(3):81-83.DOI:10.3870/j.issn.1001-4152.2017.03.081.
[15] 国家肾脏病医疗质量控制中心.血液净化标准操作规程(2021版)[EB/OL].(2021-11-08)[2022-01-12]. http://www.cnrds.net/Static/QualityControlFile.html.
[16] 中国重症血液净化协作组,中国重症血液净化协作组护理学组.中国重症血液净化护理专家共识(2021年)[J].中华现代护理杂志, 2021,27(34):4621-4632.DOI:10.3760/cma.j.cn115682-20210428-01873.
[17] Alvarez G, Chrusch C, Hulme T, et al.Renal Replacement Therapy: A Practical Update[J]. Can J Anaesth, 2019,66(5):593-604.DOI:10.1007/s12630-019-01306-x.
[18] Connor MJ, Karakala N.Continuous Renal Replacement Therapy: Reviewing Current Best Practice to Provide High-Quality Extracorporeal Therapy to Critically Ill Patients[J]. Adv Chronic Kidney Dis,2017,24(4):213-218.DOI:10.1053/j.ackd.2017.05.003.
[19] Zhang W, Bai M, Yu Y, et al.Continuous Renal Replacement Therapy without Anticoagulation in Critically Ill Patients at High Risk of Bleeding: A Systematic Review and Meta-analysis[J]. Semin Dial, 2021,34(3):196-208.DOI:10.1111/sdi.12946.
[20] Tsujimoto H, Tsujimoto Y, Nakata Y, et al.Pharmacological Interventions for Preventing Clotting of Extracorporeal Circuits During Continuous Renal Replacement Therapy[J]. Cochrane Database Syst Rev, 2020, 12(12):12467-12622.DOI:10.1002/14651858.CD012467.pub3.
[21] 李依桥, 胡芳.局部枸橼酸钠与普通肝素在连续性肾脏替代疗法中抗凝疗效的Meta分析[J].中外医疗, 2020,39(20):34-37.DOI:10.16662/j.cnki.1674-0742.2020.20.034.
[22] Zhang W, Bai M, Yu Y, et al.Safety and Efficacy of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy in Liver Failure Patients: A Systematic Review and Meta-analysis[J]. Crit Care, 2019,23(1):22-34.DOI:10.1186/s13054-019-2317-9.
[23] Brain M, Winson E, Roodenburg O, et al.Non Anti-coagulant Factors Associated with Filter Life in Continuous Renal Replacement Therapy (CRRT): A Systematic Review and Meta-analysis[J]. BMC Nephrol, 2017,18(1):69-97.DOI:10.1186/s12882-017-0445-5.
[24] Rewa OG, Villeneuve PM, Lachance P, et al.Quality Indicators of Continuous Renal Replacement Therapy (CRRT) Care in Critically Ill Patients: A Systematic Review[J]. Intensive Care Med,2017,43(6):750-763.DOI:10.1007/s00134-016-4579-x.
[25] Hatamizadeh P, Tolwani A, Palevsky P.Revisiting Filtration Fraction as an Index of the Risk of Hemofilter Clotting in Continuous Venovenous Hemofiltration[J].Clin J Am Soc Nephrol, 2020,15(11):1660-1662.DOI:10.2215/CJN.02410220.
[26] 鄢建军, 童辉, 张仲华, 等.血液透析患者血管通路“一体化全程管理”模式的构建与实践[J].中国护理管理, 2019,19(z1):8-10.DOI:10.3969/j.issn.1672-1756.2019.z1.004.
[27] 张仲华, 曾铁英, 徐蓉, 等.无抗凝连续性血液净化治疗体外循环装置堵塞危险因素分析[J]. 中华现代护理杂志, 2019, 25(34):4405-4411. DOI:10.3760/cma.j.issn.1674-2907.2019.34.001.
[28] 张仲华, 曾铁英, 徐蓉, 等.无抗凝连续性肾脏替代治疗非计划性下机相关因素分析[J].护士进修杂志, 2019, 34(18):1633-1639.DOI:10.16821/j.cnki.hsjx.2019.18.001.
[29] 张仲华, 鄢建军.无肝素连续性肾脏替代治疗体外循环凝血危险因素及护理研究进展[J].护理学杂志, 2015, 30(11):102-106.DOI:10.3870/hlxzz.2015.11.102.
[30] 王李胜, 张仲华, 杨建国, 等.血液净化中心血管通路护士岗位设立与实践[J].护理学报, 2021,28(19):30-32.DOI:10.16460/j.issn1008-9969.2021.19.030.
[31] Wong ET, Ong V, Remani D, et al.Filter Life and Safety of Heparin-grafted Membrane for Continuous Renal Replacement Therapy - a Randomized Controlled Trial[J]. Semin Dial, 2021,34(4):300-308.DOI:10.1111/sdi.12951.
[32] Claudel SE, Miles LA, Murea M.Anticoagulation in Hemodialysis: A Narrative Review[J]. Semin Dial, 2021,34(2):103-115.DOI:10.1111/sdi.12932.
[33] Dingman JS, Smith ZR, Coba VE, et al.Argatroban Dosing Requirements in Extracorporeal Life Support and Other Critically Ill Populations[J]. Thromb Res, 2020,189:69-76.DOI:10.1016/j.thromres.2020.02.021.
[34] 朱亚莉, 杨超, 范湘鸿.枸橼酸钠对比肝素封管液对血液透析导管维护有效性的Meta分析[J].护理学报, 2019,26(2):39-44.DOI:10.16460/j.issn1008-9969.2019.02.039.
[35] Kindgen-Milles D, Brandenburger T, Dimski T.Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy[J]. Curr Opin Crit Care, 2018,24(6):450-454.DOI:10.1097/MCC.0000000000000547.
[36] Bi X, Zhang Q, Zhuang F, et al.Optimized Calcium Supplementation Approach in Post-dilution CVVHDF Using Regional Citrate Anticoagulation[J].Int J Artif Organs, 2021,44(3):165-173.DOI:10.1177/0391398820951813.
[37] 万娜, 张春艳, 贾燕瑞.12例重症肺炎患者体外膜氧合联合连续肾脏替代治疗的护理[J].护理学报, 2015,22(14):44-47.DOI:10.16460/j.issn1008-9969.2015.14.044.
[38] 黄博伦, 张仲华, 童辉, 等.无抗凝日间肾脏替代治疗凝血堵管相关因素分析[J].内科急危重症杂志, 2017,23(4):278-280, 314.DOI:10.11768/nkjwzzzz20170405.
[39] 黄卓凡, 陈巧玲, 陈钗英, 等.不同冲洗方式在无抗凝连续性肾脏替代治疗中的效果分析[J].全科护理, 2021, 19(3):354-358.DOI:10.12104/j.issn.1674-4748.2021.03.020.
[40] 黄美春, 庄耀宁, 陈敏敏, 等.无肝素连续性肾脏替代治疗血液透析导管堵塞临床征象及相关因素分析[J].全科护理,2021, 19(22):3089-3094.DOI:10.12104/j.issn.1674-4748.2021.22.016.
[41] Li P, Zhang L, Lin L, et al.Effect of Dynamic Circuit Pressures Monitoring on the Lifespan of Extracorporeal Circuit and the Efficiency of Solute Removal During Continuous Renal Replacement Therapy[J]. Front Med (Lausanne), 2021,8(1):621921-621932.DOI:10.3389/fmed.2021.621921.
[1] 李翔, 冯英璞, 孟晓静, 周立民, 霍晓冉, 许梦敏, 王昊. 脑卒中患者口腔健康管理的最佳证据总结[J]. 护理学报, 2022, 29(9): 36-41.
[2] 陈芳芳, 叶灵晓, 胡雁, 郑亚华, 李娟, 楼钶楠, 刘梅, 胡康丽. 心脏起搏器术后患者早期运动康复的最佳证据总结[J]. 护理学报, 2022, 29(8): 53-58.
[3] 邱昌翠, 于晓丽, 冯亚婷, 杨正雄, 徐婷, 朱晓萍. ICU营养支持患者再喂养综合征风险评估及预防干预研究[J]. 护理学报, 2022, 29(7): 57-62.
[4] 蔡莹莹, 张俊峰, 蔡艾芳, 曾雅燕, 李玲, 黄琼珊, 刘兴玲. 以培养护士核心能力为导向的循证护理查房模式探索[J]. 护理学报, 2022, 29(6): 50-54.
[5] 任鹏娜, 胡小懿, 汤爱玲, 张月, 许方蕾. 基于循证构建老年尿失禁患者出院准备护理方案[J]. 护理学报, 2022, 29(6): 7-10.
[6] 曹咪, 张军, 岳少婷. 早产儿出院后神经发育支持性照护的最佳证据总结[J]. 护理学报, 2022, 29(6): 44-49.
[7] 杨阳, 刘宁. 支气管哮喘患者冬病夏治穴位敷贴护理评估及管理的最佳证据总结[J]. 护理学报, 2022, 29(5): 15-21.
[8] 吴玉洁, 吴利平, 冷虹瑶, 王燕, 林光燕. 狗咬伤患者伤口感染预防及管理的最佳证据总结[J]. 护理学报, 2022, 29(5): 52-56.
[9] 周毅峰, 杨继平, 彭瑶丽, 袁浩, 石泽亚. 体外循环心脏手术中体温管理循证实践[J]. 护理学报, 2022, 29(3): 40-45.
[10] 杨莉, 叶红芳, 孙倩倩, 方金林. 1 386名临床护士创新行为现状及其影响因素分析[J]. 护理学报, 2022, 29(2): 57-61.
[11] 殷青霞, 王莉慧, 区洁霞, 文红, 罗笑婷, 刘赛君, 黄心梅, 刘灿灿. 克罗恩病患者饮食管理的证据总结[J]. 护理学报, 2022, 29(1): 47-52.
[12] 许志娟, 李秀轻, 孔晔宏, 史蕾, 乔秋阁, 凌冬兰. 成年患者中线导管留置与维护的最佳证据总结[J]. 护理学报, 2022, 29(1): 41-46.
[13] 李萍, 靳小雯, 李燕玲, 徐玉兰, 喻姣花, 李卓颖, 李应, 邓睿. 成年患者结直肠镜检查肠道准备不充分的预防及管理证据总结[J]. 护理学报, 2021, 28(9): 22-28.
[14] 邓瑛瑛, 裴华清, 文梅, 殷春梅, 张小玲. 神经外科重症患者PICC相关性血栓物理预防的最佳证据总结[J]. 护理学报, 2021, 28(8): 28-32.
[15] 高兴莲, 余文静, 肖瑶, 胡娟娟, 赵诗雨, 杨英. 手术患者围术期压力性损伤预防及管理最佳证据总结[J]. 护理学报, 2021, 28(6): 22-26.
Viewed
Full text


Abstract

Cited
  Shared   
No Suggested Reading articles found!