Objective:To explore the puncture management in hemodialysis patients with difficult new arteriovenous fistula based on the finest evidence-based best practice evidence and evaluate the clinical effects.Methods:A team was formed, according to theoretical framework basing on the evidence of continuous quality improvement model, the best evidence-based interventions were obtained by adopting evidence-based practice. Formulated review indicators, evaluated obstacles and promoting factors in the process of practice, and took corresponding action strategies. From February 2020 to June 2020, 30 patients admitted to the dialysis center of Sir Run Run Shaw Hospital of Zhejiang University were recruited in the baseline review group by convenience sampling method. From September 2020 to January 2021, 30 patients from September 2020 to January 2021 were recruited in the after-effect evaluation group. The baseline review group adopted the original difficult new arteriovenous fistula puncture management scheme, and the after-effect evaluation group adopted the difficult autologous new internal fistula puncture management scheme based on the best evidence. The success rate of one puncture of fistula, the incidence rate of hematoma during puncture and dialysis, the incidence rate of discontinuation of treatment and the compliance with examination indexes were compared in the patients before and after applying for the evidences.Results:Compared with the baseline review group, the success rate of one-time puncture of internal fistula in the aftereffect evaluation group increased from 36.7% (11/30) to 73.3% (22/30), the incidence rate of hematoma during puncture and dialysis were decreased from 33.3%(10/30) to 6.67%(2/30) and 40%(12/30) to 0, the incidence rate of discontinuation of treatment were decreased from 40%(12/30) to3.33% (1/30), the difference was statistically significant ( χ2 values were 6.67-11.88, P<0.05). The implementation rate of review indexes in the aftereffect evaluation group was higher than that in the baseline review group, and the difference was statistically significant ( P<0.05). Conclusions:Evidence-based practice can improve the success rate of difficult new arteriovenous fistula, and reduce the incidence of arteriovenous fistula hematoma, reduce treatment interruption, and better maintain the lifeline of patients.

目的 探讨罗沙司他治疗维持性血液透析(MHD)患者微炎症状态下贫血的作用.方法 选取30例超敏C反应蛋白(hs-CRP)＞5 mg·L-1的MHD患者作为微炎症组,另选30例hs-CRP≤5 mg·L-1的MHD患者作为非微炎症组.根据患者体重选择罗沙司他起始剂量,根据血红蛋白(Hb)变化调整罗沙司他剂量,治疗12周.记录比较2组治疗前后的Hb、血细胞比容(Hct)和血清铁蛋白(SF)、总铁结合力(TIBC)、转铁蛋白饱和度(TSAT)等指标.结果 2组用药剂量和Hb达标时间组间比较均无显著差异(P＞0.05).治疗前,微炎症组Hb、Hct和TSAT水平显著低于非微炎症组,hs-CRP和SF水平高于非微炎症组(均P＜0.05).与治疗前相比,治疗12周后2组的Hb和Hct水平均升高(P＜0.05),SF降低(P＜0.05),TIBC升高(P＜0.05),TSAT和hs-CRP无显著改变(P＞0.05).治疗前后的差值组间比较均无显著差异(P＞0.05).结论 罗沙司他可有效改善微炎症状态下MHD患者的贫血,调节机体铁代谢.

对1例尿毒症患者行腹腔镜下腹膜透析(PD)导管置入术.患者术前体格检查未发现腹股沟疝,术中腹腔镜探查发现双侧腹股沟隐匿性疝,遂行腹腔镜下PD导管置入术联合双侧腹股沟隐匿性疝无张力修补术;手术过程顺利,术后无出血、血肿、感染等并发症发生.随访2年,无疝复发、PD液渗漏和腹膜炎等并发症发生.该修补术表明,腹腔镜下PD导管置入术联合腹股沟隐匿性疝无张力修补术是安全、可行的.

目的 探讨双重血浆置换(DFPP)治疗抗N-甲基-D-天冬氨酸受体(NMDAR)脑炎的临床疗效及安全性.方法 回顾性分析2019年4月至12月收治的10例抗NMDAR脑炎患者DFPP治疗的临床疗效及不良反应.结果 10例患者接受DFPP治疗48次,治疗后临床好转,血清抗NMDAR抗体滴度均有减低或转为阴性.DFPP的不良反应有:管路凝血1例次,低血压1例次,无致死的严重不良反应.结论 DFPP可有效治疗抗NMDAR脑炎,临床安全可行.

目的 探讨超声引导在经皮穿刺腹膜透析导管植入术中应用的可行性、安全性、具体方法和近中期效果. 方法 回顾性纳入23例接受超声引导下经皮穿刺腹膜透析导管置入术患者.术中使用超声引导穿刺针穿入腹腔并引导导管到达目标位置.术后至少随访6个月.观察超声影像对手术过程的显示效果,统计该手术的技术成功率、术中及术后并发症(出血、肠道损伤、导管移位、堵管、渗漏、网膜包裹、腹膜炎等)发生率以及腹膜透析导管的技术生存率.结果 超声可清晰显示穿刺及置管过程,技术成功率达100.0％.导管移位1例,保守治疗后复位,透析不充分改血液透析1例,余无明显并发症.估算6个月、12个月、18个月和24个月的腹膜透析导管的技术生存率分别为100.0％、100.0％、100.0％、75.0％.结论 研究初步显示该种超声引导下经皮穿刺腹膜透析导管置入术是一种安全、可行、微创的腹膜透析置管方法,具有良好的近中期效果.

Objective To study the relationship between tip position and flow rate of the tunneled cuffed catheter (TCC) in femoral vein.Methodology We selected 215 cases of maintenance hemodialysis patients with TCC in femoral vein.According to X-ray examination,distal tip of the catheter was categorized into group A,group B and group C.Blood flow (ml/min) was recorded within one hour of the first hemodialysis.Blood flow was compared between the groups.Results of Kruskal-Wallis test showed that x2=11.5,Df=2 and P=0.003.Average blood flow was different between the 3 groups,with 235.3±25.5ml/min in group A,249.5± 18.1ml/min in group B and 234.7±26.8ml/min in group C.Comparison between the groups using Mann-Whitney U test showed that the difference was statistically significant in group B (P＜0.05).Conclusion Blood flow of the tunneled cuffed catheter in femoral vein was related to the position of the catheter tip.At L3 level,the blood flow was the highest.The most suitable tip position was at L3 level in inferior vena cava.The different flow rate within a group may relate to the anatomical variation of inferior vena cava.

Objective To investigate the efficacy and safety of cutting balloon angioplasty for the treatment of hemodialysis arteriovenous fistula stenosis resistant to conventional percutaneous transluminal angioplasty (PTA). Methods The patients with arteriovenous fistula stenosis who had suboptimal results (residual stenosis >30%) by conventional PTA from December 2011 to February 2015 were enrolled. All the patients received cutting balloon angioplasty were rechecked every three months. Results A total of 25 patients with age of (60.7 ± 12.9) years had suboptimal PTA results. Eleven patients with native arteriovenous fistula (AVF) and 14 patients with graft fistula (AVG) underwent cutting PTA for 30 times. The technical success rate was 86.7% and clinical success rate was 100%. The diameter stenosis pre-procedural and post-procedural of cutting PTA was (1.7±0.6) mm and (4.5 ± 0.8) mm respectively (P<0.05). Six patients had multiple lesions and the stenosis consisted of 21 outflow venous, 6 graft-to-vein anastomosis, 6 cephalic arch, 2 artery and 1 puncture hole stenosis. The primary access patency at 3 and 6 months for AVF group were 70.0% and 10.0%, while for AVG group the figures were 64.3% and 7.1% (P>0.05). The secondary access patency at 3 and 6 months for AVF group were 70.0% and 30.0%, while for AVG group the figures were 85.7% and 64.3% (P>0.05). The follow-up time was (8.1 ± 7.3) months. The restenosis rate was 64.0%. Cutting PTA failed to achieve technical success for four times, of whom 2 patients required graft stent implantation and 2 patients required ultra-high-pressure balloons angioplasty to finally achieve technical success. The median survival time of fistula was 173 days. Conclusions Cutting balloon angioplasty have well short-term patency and safety in arteriovenous fistula stenosis resistant to conventional PTA, especially for calcified lesion or "balloon waist". Although it could provide a satisfied long patency by recurrent PTA, the use of cutting balloon would be not advocated as the first-line treatment for fistula stenosis. The efficacy superiority of cutting balloon between AVF and AVG, as well as the cost-effect comparison between cutting balloon and high-pressure balloon, remains unclear, the verification of which requires large-sampled, prospective and randomized studies.

动静脉内瘘是尿毒症患者维持血液透析治疗最常用的一种血管通路,头臂静脉闭塞直接影响同侧内瘘血液回流甚至血栓形成,导致患者丧失透析通路.头臂静脉闭塞临床报道少见,药物治疗效果不佳,我们通过经皮血管腔内支架植入成功再通头臂静脉.现报道如下.

Arteriovenous fistula is a long-term vascular access for treatment of uremia patients in maintenance hemodialysis. The complication of lymphatic fistula after arteriovenous fistula operation is rare. Lymphatic fistula is lymphatic outflow caused by lymph-vessel impairment. The clinical manifestation is the mass or discharge of unknown cause appeared in early postoperative wound. Treatment commonly used for lym- phatic fistula is filling and compression,then it could use lymphatic ligation for those patients who had large volume of lymphatic fistula output and invalid compression therapy. Here we reported a case of treatment of lymphatic fistula in the upper arm of a uremia patient after arteriovenous fistula operation. The diagnosis of lym- phatic fistula was made according to the clinical manifestation,physical sign and leakage chyle test. The pa- tient started with drainage of the lymphatic fistula debridement surgery and local compression therapy which had poor effect,finally the incision healed by use of immersion with 50% glucose,compression bandage by com- pression air sac after local lymphatic fistula cavity exploration drainage surgery and combined with atropine in- jection treatment,follow-up evaluation was good.