重症血液净化技术在陕西省ICU开展现状的调查

doi:10.3877/cma.j.issn.2096-1537.2022.02.012

中华重症医学电子杂志 ›› 2022, Vol. 08 ›› Issue (02) : 153 -166. doi: 10.3877/cma.j.issn.2096-1537.2022.02.012

重症医学研究

重症血液净化技术在陕西省ICU开展现状的调查

沙莎¹, 黄登超², 孙元慧³, 孙琪³, 李昊³, 石秦东³^,^†(

)

^1. 710061　西安，西安交通大学第一附属医院重症医学科；710032　西安，西安电力中心医院重症医学科
^2. 710061　西安，西安交通大学第一附属医院重症医学科；726000　陕西商洛，陕西省商洛市中心医院重症医学科
^3. 710061　西安，西安交通大学第一附属医院重症医学科

收稿日期:2022-03-17 出版日期:2022-07-04
通信作者: 石秦东
基金资助:
陕西省科技攻关资助项目(S2015FESF0146)

A survey of the application of critical care blood purification in Shaanxi province

Sha Sha¹, Dengchao Huang², Yuanhui Sun³, Qi Sun³, Hao Li³, Qindong Shi³^,^†()

^1. Department of Intensive Care Unit, the First Affiliated Hospital of Xi′an JiaoTong University, Xi′an 710061, China; Department of Intensive Care Unit, the Xi′an Power Center Hospital of State Grid, Xi′an 710032, China
^2. Department of Intensive Care Unit, the First Affiliated Hospital of Xi′an JiaoTong University, Xi′an 710061, China; Department of Intensive Care Unit, Shangluo Center Hospital, Shangluo 726000, China
^3. Department of Intensive Care Unit, the First Affiliated Hospital of Xi′an JiaoTong University, Xi′an 710061, China

Received:2022-03-17 Published:2022-07-04
Corresponding author: Qindong Shi

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引用本文：

沙莎, 黄登超, 孙元慧, 孙琪, 李昊, 石秦东. 重症血液净化技术在陕西省ICU开展现状的调查[J]. 中华重症医学电子杂志, 2022, 08(02): 153-166.

Sha Sha, Dengchao Huang, Yuanhui Sun, Qi Sun, Hao Li, Qindong Shi. A survey of the application of critical care blood purification in Shaanxi province[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2022, 08(02): 153-166.

目的

了解陕西省（以下简称我省）ICU开展重症血液净化技术的现状。

方法

2021年8月31至9月10日，采用方便抽样法通过网络调查形式向我省境内各级医院ICU医护人员发放调查问卷，收集我省ICU重症血液净化开展现状信息数据，分析其潜在影响因素。

结果

本研究共收集到146份调查问卷，剔除10份存在逻辑性错误的问卷，最终136份问卷纳入研究分析；本研究涵盖我省陕南、关中及陕北三个地域，涉及11个不同城市或区域。调查结果表明，我省重症血液净化主要在三级医院ICU开展，三级甲等医院占比50.70%，三级乙等医院占比11.27%，二级甲等医院占比38.03%。重症血液净化技术在医院级别、开展年限、科室床位数、机器保有量、月均治疗例数之间存在一定的相关性（Spearman检验，P＜0.05）。调查结果还显示科室自配置换液为主要构成（50.00%）；治疗病种主要为多器官功能障碍综合征（MODS）、急性肾损伤（AKI）及脓毒症休克（18.20%，17.38%，16.56%）；常见重症血液净化模式为连续性静脉-静脉血液滤过（CVVH）、连续性静脉-静脉血液透析滤过（CVVHDF）、血浆置换（PE）（28.18%，21.95%，15.96%）；置管方法主要依靠解剖定位，常见部位为右股静脉（41.91%）。全身肝素抗凝与局部枸橼酸抗凝均为常见抗凝方式。出血与管路凝血仍为重症血液净化过程中最主要的并发症。

结论

我省ICU重症血液净化技术开展存在不均衡现状，基层医院开展重症血液净化的能力有待进一步提升。本研究结果将为我省重症血液净化技术的推动发展和卫生行政部门制定相关的政策及培训制度提供一定的依据。

关键词: 陕西省, 重症血液净化, 横断面调查, 抽样研究

Objective

To investigate the application of critical care blood purification (CCBP) in Intensive care units (ICUs) in Shaanxi province.

Methods

From August 31^st to September 10^th, 2021, a comprehensive Network Survey with simple sampling was released to ICU staffs in the hospitals of various levels aimed to collect data about the current application and underlying influence factors of CCBP in the ICUs in Shaanxi province.

Results

A total of 146 questionnaires were collected in this cross-sectional study. Ten questionnaires with obvious logical errors were excluded and finally 136 questionnaires were included in this analysis. This study covers 11 different cities or regions in Southern, Central and Northern Shaanxi. The survey showed that CCBP was mainly carried out in the department of critical medicine of tertiary hospitals, 50.70% in class A tertiary hospitals, 11.27% in class B tertiary hospitals and 38.03% in class A secondary hospitals. A Spearman Correlation coefficient analysis of grades of hospital, years of applying purification, numbers of beds and machines and case numbers by month in these ICUs showed correlations between these factors and the application of blood purification (P＜0.05). 50% of ICUs use self-made dialysis fluid. Multiple organ dysfunction syndrome (MODS), acute kidney injury (AKI) and septic shock were the top three diseases treated by CCBP (18.20%, 17.38%, 16.56%). The most commonly used modes were continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodiafiltration (CVVHD) and plasma exchange (PE) (28.18%, 21.95%, 15.96%). The catheterization mostly was performed with anatomical positioning, and the right femoral vein was the first choice of catheterization (41.91%). Systemic heparin anticoagulation and regional citrate anticoagulation were commonly used. Bleeding and pipeline coagulation were the main complications in the process of CCBP.

Conclusions

This study illustrates an imbalanced development of CCBP in Shaanxi province. Application of CCBP in low-level hospitals needs to be improved. This study provides some valuable information to the local health administration for developing relevant policies and training system and improving CCBP in Shaanxi province.

Key words: Shaanxi province, Critical care blood purification, Cross-sectional survey, Sampling study

图1 受调查医疗机构的分布情况。图a为医院等级分布；图b为ICU构成；图c为CRRT开展情况；图d为CRRT独立开展情况注：CRRT为连续性肾替代治疗

图2 受调查者从业特征的分布情况。图a为每月主导或协助CRRT情况；图b为接受CRRT培训情况；图c为从事CRRT年限分布；图d为可否按周期进行床旁CRRT培训注：CRRT为连续性肾替代治疗

图3 医护群体自我评价情况。图a为是否可熟练制定CRRT方案；图b为是否可熟练进行置换液处方配制；图c为是否可熟练进行管路装配及实时参数调整；图d为是否可根据医嘱熟练配制置换液；CRRT为连续性肾替代治疗注：CRRT为连续性肾替代治疗

图4 置换液使用情况。图a为置换液来源；图b为商品置换液品牌分布；图c为科室自配置换液含钙情况；图d为自配置换液含钙离子浓度分布注：PIVAS为静脉用药集中调配中心

图5 过去1年CRRT主要治疗病种的分布情况注：MODS为多器官功能障碍综合征；AKI为急性肾损伤；Sepsis Shock为脓毒症休克；Toxic为中毒；SAP为重症急性胰腺炎；CKD为慢性肾病；ARDS为急性呼吸窘迫综合征；RM为横纹肌溶解综合征；Heat Stroke为热射病；HF为心力衰竭；Bee Sting为蜂蜇伤；Fulminant Myocarditis为暴发性心肌炎；CRRT为连续性肾替代治疗

图6 启动CRRT临床指征。图a为临床常见CRRT使用指征；图b为非肾脏疾病CRRT适应证的分布注：CRRT为连续性肾替代治疗；Sepsis Shock为脓毒症休克；SAP为重症急性胰腺炎；MODS为多器官功能障碍综合征；ARDS为急性呼吸窘迫综合征

图7 常用CRRT模式及开展例数。图a为常见CRRT模式实施医院分布；图b为常见CRRT模式开展例数注：CVVH为连续性静脉-静脉血液滤过；CVVHDF为连续性静脉-静脉血液透析滤过；PE为血浆置换；CVVHD为连续性静脉-静脉血液透析；DPMAS为双重血浆分子吸附系统；CHVHF为连续性高容量血液滤过；SCUF为缓慢连续单纯超滤；DFPP为双重滤过血浆置换；HD为血液透析；CHFD为持续性局通量透析；CRRT为连续性肾替代治疗

图8 常用CRRT模式下常用参数设定情况。图a、b分别为CVVH模式下常用置换液泵速及血流速度分布；图c、d分别为CVVHD模式下常用透析液泵速及血流速度分布；图e、f分别为CVVHDF模式下常用治疗液泵速及血流速度分布注：CVVH为连续性静脉-静脉血液滤过；CVVHD为连续性静脉-静脉血液透析；CVVHDF为连续性静脉-静脉血液透析滤过；CRRT为连续性肾替代治疗

图9 CRRT常见下机原因注：TMP为跨膜压；CRRT为连续性肾替代治疗

图10 CRRT循环管路相关问题。图a为CRRT导管常见置入路径；图b为常见置管技术；图c为常用导管材质；图d为常用导管腔内形状注：HIT为肝素诱发血小板减少症；CRRT为连续性肾替代治疗

图11 CRRT抗凝方式调查情况。图a为CRRT的抗凝方式及药物选择；图b为无抗凝启动指征；图c为局部抗凝指征注：CRRT为连续性肾替代治疗；RCA为局部枸橼酸抗凝

图12 体外循环管路凝血事件与抗凝并发症情况。图a为发生管路或滤器凝血征兆；图b为发生管路或滤器凝血原因；图c为过去1个月内发生管路凝血例数分布；图d为过去1个月内发生管路凝血例数分布；图e为查看体外循环管路凝血时间间隔；图f为CRRT抗凝时常见并发症注：CRRT为连续性肾替代治疗

图13 不同抗凝方式下滤器运行时长。图a、b为肝素抗凝下的单个滤器使用最短时长及最久时长分布；图c、d为RCA下的单个滤器使用最短时长及最久时长分布；图e、f为联合抗凝下的单个滤器使用最短时长及最久时长分布；图g为是否使用甲磺酸萘莫司他抗凝；图h为是否使用阿加曲班抗凝

图14 不同抗凝方式下滤器运行时长

图15 肝素类药物最大负荷剂量及最大维持剂量。图a、b分别为肝素最大负荷剂量及最大维持剂量；图c、d分别为低分子量肝素最大负荷剂量及最大维持剂量

表1 CRRT开展例数相关性矩阵（Spearman相关系数）

	每月开展例数	ICU床位数	机器保有量	开展年限
ICU床位数	0.644^b	-	-	-
机器保有量	0.688^b	0.485^b	-	-
开展年限	0.332^a	0.372^b	0.370^b	-
医院级别	0.675^b	0.510^b	0.442^b	0.244

表1 CRRT开展例数相关性矩阵（Spearman相关系数）

	每月开展例数	ICU床位数	机器保有量	开展年限
ICU床位数	0.644^b	-	-	-
机器保有量	0.688^b	0.485^b	-	-
开展年限	0.332^a	0.372^b	0.370^b	-
医院级别	0.675^b	0.510^b	0.442^b	0.244

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