久久av青久久久av三区三区_血液灌流的原理及臨床應用_江蘇威肯碳環(huán)?？萍加邢薰?/title> <link href="/jscss/style.css" rel="stylesheet"> <meta http-equiv="Cache-Control" content="no-transform" /> <meta http-equiv="Cache-Control" content="no-siteapp" /> <script>var V_PATH="/";window.onerror=function(){ return true; };</script> </head> <body> <h1><a href="http://www.cdhdxy.com/">久久夜色精品国产噜噜亚洲SV,亚洲国产精品v在线播放,成年网站在线在免费播放,夜色www国产精品资源站</a></h1> <div class="pl_css_ganrao" style="display: none;"><meter id="3tjz9"></meter><pre id="3tjz9"></pre><pre id="3tjz9"><th id="3tjz9"><meter id="3tjz9"><label id="3tjz9"></label></meter></th></pre><sup id="3tjz9"><th id="3tjz9"></th></sup><legend id="3tjz9"></legend><dfn id="3tjz9"><ruby id="3tjz9"><legend id="3tjz9"><u id="3tjz9"></u></legend></ruby></dfn><b id="3tjz9"><sub id="3tjz9"></sub></b><pre id="3tjz9"></pre><pre id="3tjz9"><tt id="3tjz9"><ol id="3tjz9"><track id="3tjz9"></track></ol></tt></pre><tt id="3tjz9"></tt><sub id="3tjz9"></sub><var id="3tjz9"></var><ol id="3tjz9"><track 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class="pro"> <h2>技術(shù)資料</h2> <span><a href="/">首頁(yè)</a> > <a href='/support/1/'>技術(shù)支持</a> > <a href='/support/2/'>技術(shù)資料</a> > </span></div> <div id="vz5rlnd" class="con"> <div align="center"> <h1>血液灌流的原理及臨床應用</h1> </div> <div id="9nnn5fl" class="n"><span>發(fā)布日期：2015-07-07</span><span>文章來(lái)源:本站</span><span> </span></div> <div id="55rdpnz" class="wenzhang"> <p style="text-align:center;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;background-color:#FFFFFF;color:#000000;">血液灌流的原理及臨床應用</span></p><p style="line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;"> </span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">血液灌流是血液凈化學(xué)的一個(gè)重要組成部分，自從</span><span style="font-family:宋體,simsun;font-size:16px;">60</span><span style="font-family:宋體,simsun;font-size:16px;">年代中</span><span style="font-family:宋體,simsun;font-size:16px;">Yatzidis</span><span style="font-family:宋體,simsun;font-size:16px;">應用未經(jīng)包膜處理的活性炭對藥物中毒進(jìn)行血液灌流后，由于包膜材料的采用和改進(jìn)，以及各種特異樹(shù)脂的研制成功，血液灌流技術(shù)在臨床得到了廣泛的應用。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">一、基本原理</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　血液灌流就是使病人的動(dòng)</span><span style="font-family:宋體,simsun;font-size:16px;">脈</span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">血液流經(jīng)體外一內含特制活性炭</span><span style="font-family:宋體,simsun;font-size:16px;">(activated charcoal)</span><span style="font-family:宋體,simsun;font-size:16px;">或樹(shù)脂</span><span style="font-family:宋體,simsun;font-size:16px;">(resin)</span><span style="font-family:宋體,simsun;font-size:16px;">顆粒的筒型灌流器，通過(guò)吸附作用清除血液中的有害物質(zhì)，灌流后的血液再經(jīng)導管返回體內。影響這種治療的核心部分就是吸附材料。最常用的吸附材料是活性炭和樹(shù)脂。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">一</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">活性炭是一種疏松多孔的物質(zhì)，具有孔徑分布寬，孔隙率高，屬于廣譜型的吸附劑。常用椰子殼、木材、聚乙烯醇、石油等材料在有控制的氧化條件下高溫炭化而成。目前以石油珠狀炭效果較佳?；钚蕴恐苯优c血液接觸，對血液的有形成分如紅細胞、白細胞、特別是血小板破壞嚴重</span></span><span style="font-family:宋體,simsun;font-size:16px;">，</span><span style="font-family:宋體,simsun;font-size:16px;">且不可避免會(huì )有顆粒脫落進(jìn)入血流形成微栓塞，故必須在炭粒表面包上一層具有一定孔徑的半透膜，使之克服了炭粒脫落，又提高了生物相容性。而被包裹后的活性炭又能保持原有的吸附性能。理想的膜材料應具有足夠的強度，不易破損，通透性能好，血液相容性好，容易消毒，本身無(wú)致熱源，無(wú)毒性等條件。目前已使用的膜材料有白蛋白火棉膠、醋酸纖維素、丙烯酸水凝膠、聚甲基丙烯酸羥乙基酯、甲殼素等。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">二</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">合成樹(shù)脂是另外一類(lèi)應用較廣的醫用吸附劑。它分為吸附樹(shù)脂與離子交換樹(shù)脂兩大類(lèi)。離子交換樹(shù)脂對血液有一定影響，因此在血液灌流中很少應用。臨床上用得較多的是吸附樹(shù)脂。它們的比表面積有</span><span style="font-family:宋體,simsun;font-size:16px;">500</span></span><span style="font-family:宋體,simsun;font-size:16px;">m</span><span style="vertical-align:super;font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">/g</span><span style="font-family:宋體,simsun;font-size:16px;">左右，吸附能力略遜于活性炭。但對各種親脂性及帶有疏水基團的物質(zhì)，如膽紅素、芳香族氨基酸、有機磷農藥等吸附力較大。既往認為，吸附樹(shù)脂的化學(xué)穩定性好，故不必包膜。但近年來(lái)通過(guò)動(dòng)物試驗和臨床觀(guān)察，發(fā)現吸附樹(shù)脂亦有微粒脫落和破壞血液有形成分的副作用，故亦主張包裹后行血液灌流治療。包裹材料亦與活性炭相似。目前應有較多的樹(shù)脂有</span><span style="font-family:宋體,simsun;font-size:16px;">XDA-4</span><span style="font-family:宋體,simsun;font-size:16px;">、</span><span style="font-family:宋體,simsun;font-size:16px;">XDA-2</span><span style="font-family:宋體,simsun;font-size:16px;">、</span><span style="font-family:宋體,simsun;font-size:16px;">NK-107</span><span style="font-family:宋體,simsun;font-size:16px;">、</span><span style="font-family:宋體,simsun;font-size:16px;">DAC</span><span style="font-family:宋體,simsun;font-size:16px;">等。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">三</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">含有活性炭的透析膜。在常規的血液透析膜如銅仿膜、醋酸纖維膜中加入活性炭，制成含活性炭的透析膜，然后制成中空纖維透析器，在透析的同時(shí)行吸附治療，即可加強對內、外毒素的清除，又可糾正水潴留和電解質(zhì)、酸堿平衡紊亂。目前這種膜有銅仿膜和</span><span style="font-family:宋體,simsun;font-size:16px;">812-</span><span style="font-family:宋體,simsun;font-size:16px;">樹(shù)脂</span><span style="font-family:宋體,simsun;font-size:16px;">-</span><span style="font-family:宋體,simsun;font-size:16px;">活性炭膜等。</span></span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">四</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">免疫吸附。將特定的高度專(zhuān)一的抗原或抗體物質(zhì)與吸附材料制成吸附劑，通過(guò)抗原抗體的反應或物理化學(xué)反應作用，從血液中特異地吸附并清除與免疫有關(guān)的致病因子的一種治療方法。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;"> </span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">吸附材料必須能固定一種稱(chēng)為配體的物質(zhì)，配體與吸附對象</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">既致病因子</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">之間具有特異的親合力。這種親合力可以是生物性的，如抗原抗體結合。也可以是物理化學(xué)性的，如靜電結合。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;"> </span><span style="font-family:宋體,simsun;font-size:16px;">固定配體的吸附材料為載體，常用的有瓊脂糖凝膠，丙烯酰凝膠，聚羥乙基異丁烯酸酯凝膠，活性炭等。</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">血液灌流的抗凝療法</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;">血液灌流要在體外循環(huán)中進(jìn)行，為了使血液不凝結在體外循環(huán)的管路及灌流器中，必須使用抗凝劑，以防止血栓的形成，同時(shí)要預防抗凝劑過(guò)量導致出血的危險。因此，合理地使用抗凝劑是非常重要的。目前使用最廣泛的抗凝劑是肝素。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　肝素是一種水溶性物質(zhì)，其結構為一種粘多糖，存在于哺乳動(dòng)物的組織中，如肝、肺、脾、肌肉等均含有肝素，由于它從肝臟內提取出來(lái)，故名為肝素。分子量為</span><span style="font-family:宋體,simsun;font-size:16px;">6000-25000</span><span style="font-family:宋體,simsun;font-size:16px;">道爾頓，肝素在消化道滅活，故口服無(wú)效。靜注肝素可迅速產(chǎn)生抗凝作用，半衰期</span><span style="font-family:宋體,simsun;font-size:16px;">1-2</span><span style="font-family:宋體,simsun;font-size:16px;">小時(shí)，在肝臟滅活，由腎臟排出，由于肝素在使用過(guò)量時(shí)可致出血，因此合理使用肝素并嚴密監測血的指標是非常重要的，也是非常安全的。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　肝素在灌流中的作用</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、全身肝素化適用于無(wú)出血傾向的患者。首次肝素劑量為</span><span style="font-family:宋體,simsun;font-size:16px;">1.5-3mg/kg</span><span style="font-family:宋體,simsun;font-size:16px;">。然后根據凝血指標給予一定量的追加肝素。一般追加</span><span style="font-family:宋體,simsun;font-size:16px;">8-15mg/h</span><span style="font-family:宋體,simsun;font-size:16px;">。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、邊緣肝素化適用于輕度出血或有心包炎的病人，首次肝素劑量為</span><span style="font-family:宋體,simsun;font-size:16px;">1-1.5mg/kg</span><span style="font-family:宋體,simsun;font-size:16px;">，當</span><span style="font-family:宋體,simsun;font-size:16px;">WBPTT</span><span style="font-family:宋體,simsun;font-size:16px;">、</span><span style="font-family:宋體,simsun;font-size:16px;">ACT</span><span style="font-family:宋體,simsun;font-size:16px;">比基礎值延長(cháng)</span><span style="font-family:宋體,simsun;font-size:16px;">40%</span><span style="font-family:宋體,simsun;font-size:16px;">或</span><span style="font-family:宋體,simsun;font-size:16px;">LWCT</span><span style="font-family:宋體,simsun;font-size:16px;">達</span><span style="font-family:宋體,simsun;font-size:16px;">16</span><span style="font-family:宋體,simsun;font-size:16px;">分左右時(shí)追加肝素</span><span style="font-family:宋體,simsun;font-size:16px;">5-7mg/h</span><span style="font-family:宋體,simsun;font-size:16px;">。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、體外肝素化用于有出血傾向患者，不給首次劑量肝素，灌流開(kāi)始從肝素泵持續地注入肝素，并自靜脈端不斷地注入魚(yú)精蛋白以中和肝素，每小時(shí)注入肝素量可參考以下公式：</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">肝素量</span><span style="font-family:宋體,simsun;font-size:16px;">(u/h)=0.375</span></span><span style="font-family:宋體,simsun;font-size:16px;">×</span><span style="font-family:宋體,simsun;font-size:16px;">QB</span><span style="font-family:宋體,simsun;font-size:16px;">×</span><span style="font-family:宋體,simsun;font-size:16px;">60</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">QB=</span><span style="font-family:宋體,simsun;font-size:16px;">血流量</span><span style="font-family:宋體,simsun;font-size:16px;">(ml/min)</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">60=60min</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">① </span><span style="font-family:宋體,simsun;font-size:16px;">先做體外中和試驗即預測出用多少毫克魚(yú)精蛋白可以中和</span><span style="font-family:宋體,simsun;font-size:16px;">1mg</span><span style="font-family:宋體,simsun;font-size:16px;">肝素。一般肝素：魚(yú)精蛋白</span><span style="font-family:宋體,simsun;font-size:16px;">=1.0</span><span style="font-family:宋體,simsun;font-size:16px;">：</span><span style="font-family:宋體,simsun;font-size:16px;">0.87-1.2</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">② </span><span style="font-family:宋體,simsun;font-size:16px;">靜注魚(yú)精蛋白要慢，否則可引起呼吸抑制或過(guò)敏反應，甚至休克。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">③ </span><span style="font-family:宋體,simsun;font-size:16px;">肝素</span><span style="font-family:宋體,simsun;font-size:16px;">-</span><span style="font-family:宋體,simsun;font-size:16px;">魚(yú)精蛋白復合物是一種不穩定的結合，由于血漿中蛋白酶的作用，魚(yú)精蛋白的分解速度比肝素快，因此在肝素</span><span style="font-family:宋體,simsun;font-size:16px;">-</span><span style="font-family:宋體,simsun;font-size:16px;">魚(yú)精蛋白復合物分解后會(huì )出現肝素再抗凝及出血現象，要引起重視。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　肝素抗凝的監測方法</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　為防止肝素加重患者的出血傾向，常應用下列指標監測肝素的抗凝作用。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">一</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">全血部分凝血活</span></span><span style="font-family:宋體,simsun;font-size:16px;">酶</span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">時(shí)間</span><span style="font-family:宋體,simsun;font-size:16px;">(Whole blood partial thromboplastin time,WBPTT)</span><span style="font-family:宋體,simsun;font-size:16px;">，正常值為</span><span style="font-family:宋體,simsun;font-size:16px;">60-85</span><span style="font-family:宋體,simsun;font-size:16px;">秒。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">二</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">活化凝血時(shí)間</span><span style="font-family:宋體,simsun;font-size:16px;">(activated clotting time,ACT) </span><span style="font-family:宋體,simsun;font-size:16px;">，正常值為</span><span style="font-family:宋體,simsun;font-size:16px;">120-150</span><span style="font-family:宋體,simsun;font-size:16px;">秒。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">三</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">試管凝血時(shí)間</span><span style="font-family:宋體,simsun;font-size:16px;">(Lee-white clotting time,LWCT)</span><span style="font-family:宋體,simsun;font-size:16px;">正常值為</span><span style="font-family:宋體,simsun;font-size:16px;">4-8</span><span style="font-family:宋體,simsun;font-size:16px;">分，透析中肝素的目標抗凝時(shí)間見(jiàn)表：</span></span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;"> </span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">肝素簡(jiǎn)介</span></p><p style="line-height:1.75em;"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　肝素系天然酸性黏多糖，為線(xiàn)性陰離子聚電解質(zhì)，是由結構不一，帶有很強負電荷鏈所組成的一族化合物，具有延長(cháng)血凝時(shí)間的作用。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素是一種水溶性物質(zhì)，由多種不同分子量的肝素組成，其分子量約為3000-50000道爾頓。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素最早得自肝臟，但以肺臟含量最豐富。動(dòng)物體內的肝素與蛋白結合成復合體形式存在，故不顯抗凝血作用。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　藥用肝素系自豬或牛的腸黏膜中提取，故可能發(fā)生過(guò)過(guò)敏反應。2000年藥典規定肝素鈉每1mg的效價(jià)不得少于150單位。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素的生物學(xué)標準，以每毫克肝素制劑(60℃2mmHg柱真空干燥3小時(shí))所相當的單位數來(lái)表示。1μ 為24h內在冷處阻止1ml貓血凝結所需的最低肝素量。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-weight:bold;font-family:宋體,simsun;font-size:16px;">〖性質(zhì)〗</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">：</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素對熱穩定，對一般微生物及酶不敏感，為白色或類(lèi)白色無(wú)定形粉末。具有吸濕性，易溶于水(1：20)，不溶于乙醇、乙醚及丙酮等，具有兩性化合物特點(diǎn)，可與Na</span><span style="color:#333333;vertical-align:super;font-family:宋體,simsun;font-size:16px;">＋</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">、Ba</span><span style="color:#333333;vertical-align:super;font-family:宋體,simsun;font-size:16px;">2＋</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">、Ca</span><span style="color:#333333;vertical-align:super;font-family:宋體,simsun;font-size:16px;">2＋</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">成鹽，亦可與HCI、苦味酸等成鹽。本品在酸性水溶液中容易水解，而在堿性溶液中則很穩定，PH越高，穩定性越大。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-weight:bold;font-family:宋體,simsun;font-size:16px;">〖藥理作用〗</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">：</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素在體內和體外均有抗凝作用，靜脈注射肝素時(shí)還可使脂蛋白質(zhì)酶釋放和穩定，因而降低血漿甘油三脂。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素的抗凝作用非常迅速、強大。不同制劑的肝素分子量不一，肝素鈉的分子量在10000左右，低分子肝素為4800。據認為低分子量者比高分子量者抗凝作用為強。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素的抗凝機制在于可與血漿中的抗凝血酶Ⅲ(AT-Ⅲ)結合成復合物。AT-Ⅲ是一種a2-球蛋白，是凝血酶的抑制物，它對某些激活的凝血因子如XⅡa、激肽釋放酶、Ⅺa、Ⅸa、Ⅹa、和ⅩⅢa均有抑制作用，但不能溶解已形成的栓子。因此，在正常情況下AT-Ⅲ起到抗凝的作用，肝素與AT-Ⅲ結合后則大大加強了后者的抑制凝血因子的作用。故肝素是通過(guò)凝血過(guò)程的多個(gè)環(huán)節而發(fā)揮作用，但其中以抑制Xa為主，且在低濃度時(shí)即可產(chǎn)生作用，此即小劑量肝素療法的作用基礎。因此，在持續應用肝素治療后，血漿中AT-Ⅲ消耗增多而含量減少，停藥后到AT-Ⅲ尚未恢復正常期間，病人可能有血栓形成的危險性，故停用肝素后宜繼續應用口服抗凝劑。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-weight:bold;font-family:宋體,simsun;font-size:16px;">〖臨床藥理〗</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">： </span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素的極性和大分子使其難以通過(guò)生物膜，不被胃腸道吸收，故口服無(wú)效。肌內注射后可形成大血腫，故僅能深部皮下注射(小劑量)或靜脈給藥。靜注肝素迅速產(chǎn)生抗凝作用，其抗凝活性的消除相的半衰期與劑量有關(guān)，如100μ/kg、200μ/kg、400μ/kg的t1/2分別為1，1.6，2.5小時(shí)。持續靜點(diǎn)24小時(shí)并不能達到穩態(tài)血濃度，原因是其消除相的劑量依賴(lài)動(dòng)力學(xué)而且可被網(wǎng)狀內皮系統攝取所致。肝素在肝臟中被肝素酶所代謝，少量由腎排泄。肝腎功能不全者其t1/2延長(cháng)。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-weight:bold;font-family:宋體,simsun;font-size:16px;">〖不良反應〗</span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">：</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素雖不是最理想的抗凝劑，但仍然是目前應用最廣泛的抗凝劑。其最大的缺點(diǎn)就是過(guò)量可致出血。如血尿、創(chuàng )傷血腫、關(guān)節出血、胃腸道出血等。但是只要合理地把握有效劑量，嚴密地監測凝血指標，一般說(shuō)來(lái)還是比較安全的，如出血嚴重，應停止用藥，并應立即用魚(yú)精蛋白中和，因魚(yú)精蛋白的精氨酸含量很高，顯強堿性，可以離子鍵與肝素相結合使肝素失去抗凝活性。通常按魚(yú)精蛋白1-1.5mg中和肝素1mg計，一次用量不超過(guò)50mg，靜脈注射。此外，偶爾出現過(guò)敏反應，脫發(fā)和骨質(zhì)疏松。有過(guò)敏體質(zhì)患者應慎用，可先試用1000μ。</span><span style="font-family:宋體;color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　肝素禁用于對其過(guò)敏的患者，活動(dòng)性出血者、或有血友病、紫癜癥、血小板減少癥、顱內出血、細菌性心內膜炎、活動(dòng)性結核病、毛細血管通透性增加、胃腸道潰瘍、嚴重高血壓等，在腦、眼和脊髓手術(shù)期間及手術(shù)后不應用肝素。</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">血液灌流與低血壓</span><span style="font-family:'times new roman';color:#333333;font-size:12px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">低血壓是血液灌流中最常見(jiàn)的合并癥之一，發(fā)病率約為</span><span style="font-family:宋體,simsun;font-size:16px;">25%-70%</span><span style="font-family:宋體,simsun;font-size:16px;">。發(fā)生的原因很多，臨床癥狀表現各異。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">一、常見(jiàn)原因：</span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、有效血容量減少，這是血液灌流最常見(jiàn)的原因，尤其是在剛開(kāi)始灌流時(shí)更易出現。多由于病人在數分鐘內引出大量血液</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">約</span><span style="font-family:宋體,simsun;font-size:16px;">200</span></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">ml</span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">，致使有效循環(huán)血量減少，心搏擊量和輸出量降低最終導致低血壓。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、自主神經(jīng)功能失調：毒物或藥物中毒的病人多發(fā)生自主神經(jīng)功能失調，表現為頸動(dòng)脈和主動(dòng)脈壓力感受器反射弧存在缺陷，故對血管加壓物質(zhì)的反應性降低，這也是低血壓的原因之一。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、血液灌流器的生物相容性：在血液灌流的過(guò)程中，吸附材料的包膜與血液相互接觸時(shí)，有些生物相容性較差的包膜可以激活補體，使白細胞粘附在肺毛細血管床上，造成低氧血癥，同時(shí)產(chǎn)生</span><span style="font-family:宋體,simsun;font-size:16px;">IL-1</span><span style="font-family:宋體,simsun;font-size:16px;">和其它血管活性物質(zhì)。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、病人因素：中毒較重的病人可使外周血管擴張，原有心血管系統疾病、心包炎、心功能不齊、心律不齊、影響心輸出量減少，重度貧血、低蛋白血癥、出血、嚴重創(chuàng )傷等均可引起低血壓。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">5</span><span style="font-family:宋體,simsun;font-size:16px;">、內毒素：血液灌流器及血管通路均為無(wú)菌的，操作時(shí)不慎易造成細菌侵入血液，產(chǎn)生內毒素。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">二、低血壓的預防</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">應根據病人的不同原因采取不同的防治措施</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">：</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、在病人進(jìn)行血液灌流前一定要維持病人的血壓在一個(gè)正常范圍內。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、血壓偏低的病人，在灌流開(kāi)始時(shí)，動(dòng)脈端引出血液后靜脈端同時(shí)接到血管通路上，將預沖液全部輸回體內或用新鮮血液作預沖液，這樣可避免灌流一開(kāi)始就出現低血壓。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、選擇生物相容性較好的灌流器</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、嚴格無(wú)菌操作</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">5</span><span style="font-family:宋體,simsun;font-size:16px;">、給升壓藥時(shí)在通路的靜脈端輸入，以免被吸附劑吸附，達不到有效的藥量。</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">6</span><span style="font-family:宋體,simsun;font-size:16px;">、對心源性低血壓和毒物、藥物中毒所致的休克病人，可用強心劑或升壓藥物治療：</span></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">三、處理：</span><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-family:'times new roman';color:#333333;font-size:14px"><span style="color:#333333;font-family:宋體,simsun;font-size:16px;">　　對于急性低血壓發(fā)作，若病情許可，病人可采用平臥、頭低位，快速經(jīng)靜脈血路給予</span><span style="font-family:宋體,simsun;font-size:16px;">0.9%</span><span style="font-family:宋體,simsun;font-size:16px;">的鹽水或</span><span style="font-family:宋體,simsun;font-size:16px;">5%</span><span style="font-family:宋體,simsun;font-size:16px;">葡萄糖液</span><span style="font-family:宋體,simsun;font-size:16px;">250-500ml</span><span style="font-family:宋體,simsun;font-size:16px;">以維持病人一定的血容量，也可給予白蛋白、血漿或右旋糖酐等提高病人體內膠體滲透壓水平，同時(shí)適當的減慢血流量，若血壓回升不理想，可加用升壓藥物治療，邊進(jìn)行灌流邊升壓，不要輕易停止灌流，以免喪失搶救時(shí)機，如果病情危重，血壓仍不好轉可中止灌流，改用其他方法治療。</span></span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:'times new roman';color:#333333;font-size:14px"><br /></span><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">血液灌流與發(fā)熱</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;">在血液灌流治療疾病的早期，由于活性炭不加包裹，致熱反應比較常見(jiàn)，目前經(jīng)過(guò)最先進(jìn)的膜材料包裹的吸附材料已很少引起致熱反應，但使用生物相容性較差的膜材料、管道消毒劑清洗不當、活性炭微粒脫落或污染體外循環(huán)均可導致機體產(chǎn)生發(fā)熱反應，常表現為寒戰、發(fā)熱、惡心、嘔吐、肌痛、痙攣和低血壓等。臨床需及時(shí)處理，以防影響灌流治療。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　一、生物相容性反應：血液灌流后</span><span style="font-family:宋體,simsun;font-size:16px;">0.5-1</span><span style="font-family:宋體,simsun;font-size:16px;">小時(shí)后出現寒顫、發(fā)熱、粒細胞及血小板減少，均提示吸附劑生物相容性差。由于病人血液直接與灌流材料接觸，可激活血液中補體，活化的補體碎片使循環(huán)血液里的中性粒細胞沉積</span></span><span style="font-family:宋體,simsun;font-size:16px;">在</span><span style="font-family:宋體,simsun;font-size:16px;">肺毛細血管壁上，導致中性粒細胞、血小板減少。治療前后應檢測白細胞及血小板，最好選用相容性較好的灌流器。一旦發(fā)生發(fā)熱，給予地塞米松應用，可不中斷治療，除非出現嚴重的低血壓狀態(tài)和休克。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　二、熱原反應：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、感染：常用于細菌、病毒、自身疾病的感染以及操作本身，污染體外循環(huán)而引起的革蘭氏陰性細菌感覺(jué)導致機體產(chǎn)生發(fā)熱反應，在病人機體抵抗力較低時(shí)，循環(huán)的內毒素易激活單核</span><span style="font-family:宋體,simsun;font-size:16px;">—</span><span style="font-family:宋體,simsun;font-size:16px;">巨噬細胞系統產(chǎn)生多種淋巴因子</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">如</span><span style="font-family:宋體,simsun;font-size:16px;">INF</span><span style="font-family:宋體,simsun;font-size:16px;">、</span><span style="font-family:宋體,simsun;font-size:16px;">IL-1)</span><span style="font-family:宋體,simsun;font-size:16px;">，其中</span><span style="font-family:宋體,simsun;font-size:16px;">IL-1</span><span style="font-family:宋體,simsun;font-size:16px;">可引起發(fā)熱，處理可給予抗生素治療，如果高熱嚴重應做血培養。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、消毒液：嚴格消毒是預防熱原反應的有效辦法，應用消毒劑沖洗管路時(shí)如過(guò)氧乙酸、福爾馬林等。如沖洗不凈，其化學(xué)反應可影響體溫調節中樞，應及時(shí)更換管路或應用抗組織胺類(lèi)藥物。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、微粒脫落：如灌流開(kāi)始即出現發(fā)熱，伴有胸悶、呼吸困難，不</span></span><span style="font-family:宋體,simsun;font-size:16px;">排</span><span style="font-family:宋體,simsun;font-size:16px;">除是否有炭顆粒脫落伴肺栓塞的可能。灌流前宜使用大量生理鹽水沖洗灌流器，可將微小顆粒預先沖出，故可減少該合并癥。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、輸血、輸液反應：臨床上輸血輸液也可導致熱源反應。</span></span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">血液灌流的血管通路</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;">血管通路是指血液從體內引出來(lái)進(jìn)入人體外循環(huán)，再返回體內的過(guò)程。它是進(jìn)行血液灌流的必要條件，血管通路一般分為兩類(lèi)：臨時(shí)性血管通路及永久性血管通路。目前，血液灌流多選用臨時(shí)性血管通路，臨時(shí)性血管通路分為動(dòng)、靜脈直接穿刺，外瘺，經(jīng)皮穿刺插管，頸內靜脈，鎖骨下靜脈，股靜脈，但臨床上應用最多的為留置式經(jīng)皮頸內靜脈，股靜脈的穿刺插管。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">一、經(jīng)皮穿刺插管術(shù)的適應癥：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、經(jīng)皮股靜脈插管：適用于不需留置導管或留置導管易感染，臥床及全身情況較差或鎖骨下靜脈、上腔靜脈有血栓的患者。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、頸內靜脈、鎖骨下靜脈插管：適用于長(cháng)期不能進(jìn)食或丟失大量液體者，如食道術(shù)后病人、危重病人等，用以補充大量高熱量高營(yíng)養液體及電解質(zhì)，緊急透析血管通路及血液灌流。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">二、禁忌癥：出血傾向，下肢靜脈，鎖骨下靜脈，上腔靜脈有血栓的患者。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">三、物品準備：治療盤(pán)內放消毒劑、棉簽、</span><span style="font-family:宋體,simsun;font-size:16px;">1%</span><span style="font-family:宋體,simsun;font-size:16px;">普魯卡因</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">支、膠布、無(wú)菌手套、</span><span style="font-family:宋體,simsun;font-size:16px;">5ml</span><span style="font-family:宋體,simsun;font-size:16px;">射器、</span><span style="font-family:宋體,simsun;font-size:16px;">1%</span><span style="font-family:宋體,simsun;font-size:16px;">甲紫、</span><span style="font-family:宋體,simsun;font-size:16px;">0.4%</span><span style="font-family:宋體,simsun;font-size:16px;">肝素鹽水、單針雙腔導管一套</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">內含穿刺針</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">支、導絲</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">根、擴張導管</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">根、導管帽</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">個(gè)、手術(shù)刀</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">把、縫合線(xiàn)、持針鉗</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">把等</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">、無(wú)菌穿刺包</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">個(gè)。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">四、操作方法：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、股靜脈插管：取仰臥位，膝關(guān)節彎曲，大腿外旋外展位，于腹股溝韌帶下</span><span style="font-family:宋體,simsun;font-size:16px;">2-100px</span><span style="font-family:宋體,simsun;font-size:16px;">，股動(dòng)脈內側</span><span style="font-family:宋體,simsun;font-size:16px;">0.5-25px</span><span style="font-family:宋體,simsun;font-size:16px;">處，局麻下做</span><span style="font-family:宋體,simsun;font-size:16px;">—50px</span><span style="font-family:宋體,simsun;font-size:16px;">皮膚切口，以</span><span style="font-family:宋體,simsun;font-size:16px;">16</span><span style="font-family:宋體,simsun;font-size:16px;">號針頭穿刺進(jìn)入股靜脈，然后沿針頭送入導絲，退回針頭，將導管沿導絲插入股靜脈，至導管硅膠段撥出導絲，連接透析管道，皮膚縫合一針固定導管，即可進(jìn)行透析。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、鎖骨下靜脈插管：一般采用右鎖骨下靜脈穿刺，病人平臥于</span><span style="font-family:宋體,simsun;font-size:16px;">30°-40°</span><span style="font-family:宋體,simsun;font-size:16px;">傾斜臺面，雙小腿垂于手術(shù)臺外，頭部向穿刺對側旋轉</span><span style="font-family:宋體,simsun;font-size:16px;">45°</span><span style="font-family:宋體,simsun;font-size:16px;">并后仰，肩胛間墊高，于鎖骨中、內</span><span style="font-family:宋體,simsun;font-size:16px;">1/3</span><span style="font-family:宋體,simsun;font-size:16px;">處，鎖骨下緣下方</span><span style="font-family:宋體,simsun;font-size:16px;">25px</span><span style="font-family:宋體,simsun;font-size:16px;">處進(jìn)針，與胸骨縱軸呈</span><span style="font-family:宋體,simsun;font-size:16px;">45°</span><span style="font-family:宋體,simsun;font-size:16px;">，與胸壁呈</span><span style="font-family:宋體,simsun;font-size:16px;">15°</span><span style="font-family:宋體,simsun;font-size:16px;">度指向胸鎖關(guān)節，進(jìn)針</span><span style="font-family:宋體,simsun;font-size:16px;">3-125px</span><span style="font-family:宋體,simsun;font-size:16px;">邊進(jìn)針邊抽吸，至暗紅色血液進(jìn)入針管，再進(jìn)入少許，迅速插入導絲，輕輕推進(jìn)入鎖骨下靜脈后，撥出穿刺針，在入口處做一小皮膚切口，也可在其外下方做一皮下隧道，沿導絲送入導管，拔出導絲，連接透析管道。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、頸內靜脈插管：一般穿刺右側頸內靜脈，病人平臥，頭部轉向左側，以胸鎖乳突肌的胸骨頭和鎖骨頭以及鎖骨圍成的三角形頂點(diǎn)為穿刺點(diǎn)，針頭向下，與體表呈</span><span style="font-family:宋體,simsun;font-size:16px;">45°</span><span style="font-family:宋體,simsun;font-size:16px;">，向后稍向外，于頸動(dòng)脈內側進(jìn)針，穿刺成功后按鎖骨下靜脈插管方法處理，連接透析管理。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　五、保留導管：透析結束后，沖凈管腔內血液，兩側導管分別注入</span><span style="font-family:宋體,simsun;font-size:16px;">0.4%</span><span style="font-family:宋體,simsun;font-size:16px;">肝素鹽水</span><span style="font-family:宋體,simsun;font-size:16px;">5-6ml</span><span style="font-family:宋體,simsun;font-size:16px;">，置好肝素帽，透析期間每日用</span><span style="font-family:宋體,simsun;font-size:16px;">20ml</span><span style="font-family:宋體,simsun;font-size:16px;">注射器抽吸，見(jiàn)回血后，按上法推注肝素鹽水，以防堵管。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　六、拔出導管：拔管前需準備一個(gè)長(cháng)園形衛生紙球，穿刺部位消毒敷無(wú)菌紗布、膠布固定，將紙卷置于紗布上拔出導管用紙卷加壓局部止血，時(shí)間：股靜脈約</span><span style="font-family:宋體,simsun;font-size:16px;">40</span><span style="font-family:宋體,simsun;font-size:16px;">分鐘</span><span style="font-family:宋體,simsun;font-size:16px;">-2</span><span style="font-family:宋體,simsun;font-size:16px;">小時(shí)，鎖骨下、頸內靜脈</span><span style="font-family:宋體,simsun;font-size:16px;">40</span><span style="font-family:宋體,simsun;font-size:16px;">分</span><span style="font-family:宋體,simsun;font-size:16px;">-1</span><span style="font-family:宋體,simsun;font-size:16px;">小時(shí)左右，以免造成血腫及皮下瘀血。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　七、留置式插管并發(fā)癥：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、股靜脈插管并發(fā)癥：出血、靜脈血栓、局部感染、靜脈穿孔后的腹膜后出血及動(dòng)脈損傷，一般導管可留置</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">周左右。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、靜脈，鎖骨下靜脈插管并發(fā)癥：血腫、氣胸、血胸、感染，導管內凝血，鎖骨下靜脈血栓、狹窄及上腔靜脈血栓及梗阻。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　八、注意事項：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、需要做急性血液凈化治療者，都可以進(jìn)行頸內靜脈、鎖骨下靜脈、股靜脈插管，插管應在嚴格無(wú)操作下進(jìn)行，防止感染，不能在有感染的部位穿刺。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、有出血傾向和嚴重呼吸、循環(huán)系統疾病的患者不宜做鎖骨下靜脈插管。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、頸內靜脈、鎖骨下靜脈插管引入導絲時(shí)，如有抵抗應退回少許，旋轉導絲再試插，絕不可強行插入，進(jìn)行擴張或引入導管，一定要延導線(xiàn)輕柔地推進(jìn)，否則有穿透腔靜脈的危險。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、留置導管每次透析前后，必須用</span><span style="font-family:宋體,simsun;font-size:16px;">2%</span><span style="font-family:宋體,simsun;font-size:16px;">碘伏消毒，更換無(wú)菌敷料，定時(shí)注入肝素鹽水，應嚴格無(wú)菌操作，發(fā)生感染或閉塞需及時(shí)拔出導管。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">5</span><span style="font-family:宋體,simsun;font-size:16px;">、每次透析連接管路時(shí)，應排盡空氣，以防氣栓進(jìn)入。</span></span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-weight:bold;font-family:宋體,simsun;font-size:16px;color:#000000;">血液灌流的操作及注意事項</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">血液灌流</span><span style="font-family:宋體,simsun;font-size:16px;">(Hemoperfusion)</span><span style="font-family:宋體,simsun;font-size:16px;">是指將血液通過(guò)體外循環(huán)，經(jīng)過(guò)具有解毒作用的吸附裝置，以清除血中外源性或內源性毒物，從而達到血液凈化的一種治療方法。血液灌流的實(shí)質(zhì)是血液吸附，即溶解在血中的物質(zhì)被吸附到具有較大面積的固形特質(zhì)上去，從而清除血中有毒物質(zhì)，目前常用的吸附劑有兩種：一類(lèi)是活性炭，一類(lèi)是合成樹(shù)脂。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　血液灌流技術(shù)始于</span><span style="font-family:宋體,simsun;font-size:16px;">1948</span><span style="font-family:宋體,simsun;font-size:16px;">年，吸附裝置是由</span><span style="font-family:宋體,simsun;font-size:16px;">90%</span><span style="font-family:宋體,simsun;font-size:16px;">的陽(yáng)離子交換樹(shù)脂和</span><span style="font-family:宋體,simsun;font-size:16px;">10%</span><span style="font-family:宋體,simsun;font-size:16px;">的陰離子交換樹(shù)脂組成，因副作用較大，未能推廣。</span><span style="font-family:宋體,simsun;font-size:16px;">1964</span><span style="font-family:宋體,simsun;font-size:16px;">年希臘學(xué)者</span><span style="font-family:宋體,simsun;font-size:16px;">Yatzidis</span><span style="font-family:宋體,simsun;font-size:16px;">醫生使用活性炭為吸附劑，此后加拿大、美國等學(xué)者又研究了活性炭包裹技術(shù)，使血液不與活性炭直接接觸，毒物可通過(guò)膜被吸附，從而血液灌流技術(shù)在臨床得以推廣。由于其不能消除尿素，電解質(zhì)和水，也不能糾正酸堿平衡失調，所以主要用于外源性毒物中毒的治療。雖然，其可吸附一些內源性中分子物質(zhì)，但對于尿毒癥的治療仍需與血透聯(lián)合進(jìn)行。</span><span style="font-family:宋體,simsun;font-size:16px;">70</span><span style="font-family:宋體,simsun;font-size:16px;">年代末又有人研制了吸附劑</span><span style="font-family:宋體,simsun;font-size:16px;">/</span><span style="font-family:宋體,simsun;font-size:16px;">透析膜，</span><span style="font-family:宋體,simsun;font-size:16px;">80</span><span style="font-family:宋體,simsun;font-size:16px;">年代初加拿大學(xué)者又研制出了一種混合式人工腎，即把一個(gè)透析器與灌流罐聯(lián)合在一起，為尿毒癥的治療開(kāi)拓了一個(gè)新的前景。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">一、血液灌流的特征：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">　　主要用于急性藥物或毒物中毒，特別是脂溶性毒物或與蛋白結合的毒物。</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、常規療法無(wú)效，臨床癥狀進(jìn)行性加重。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、重度中毒出現昏迷或伴有低體溫，低血壓，呼吸抑制等表現。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、血漿藥物濃度已達致死量者。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、服用未知種類(lèi)，數量和成份的藥物出現深度昏迷。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">二、血液灌流前的準備：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、使用血液透析機及透析液系統，灌流器置于透析器之前的動(dòng)脈血路中。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、血液灌流器：吸附劑有活性炭和樹(shù)脂二種，用前應仔細閱讀其說(shuō)明書(shū)。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、血液灌流的監護裝置。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(1)</span><span style="font-family:宋體,simsun;font-size:16px;">動(dòng)脈壓監護，灌流</span><span style="font-family:宋體,simsun;font-size:16px;">(</span><span style="font-family:宋體,simsun;font-size:16px;">前</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">開(kāi)始時(shí)，血壓常常下降，因此在治療前應保持血壓在正常水平，如治療開(kāi)始后血壓下降應輸液或輸血，維護正常血容量，必要時(shí)給予升壓藥，如動(dòng)脈壓升高應注意是否因灌流器內阻力增加所致，預示有血液凝固的可能性，應增加肝素用量。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(2)</span><span style="font-family:宋體,simsun;font-size:16px;">靜脈壓監護：其代表灌流器后的壓力，如出現灌流器內凝血，其壓力下降出現較早如壓力過(guò)高，可能是除濾器內凝塊形成，濾網(wǎng)堵塞。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">(3)</span><span style="font-family:宋體,simsun;font-size:16px;">其他監護裝置同血液透析</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、將灌流器垂直固定在夾具上，動(dòng)脈端朝下，靜脈管路與灌流器靜脈端連接，動(dòng)脈管路與肝素鹽水連接。首先用</span><span style="font-family:宋體,simsun;font-size:16px;">5%500ml</span><span style="font-family:宋體,simsun;font-size:16px;">葡萄糖注射液灌注炭腎和管道，繼而用</span><span style="font-family:宋體,simsun;font-size:16px;">2000ml</span><span style="font-family:宋體,simsun;font-size:16px;">內含</span><span style="font-family:宋體,simsun;font-size:16px;">800mg</span><span style="font-family:宋體,simsun;font-size:16px;">肝素的生理鹽水自下而上，以每分鐘</span><span style="font-family:宋體,simsun;font-size:16px;">50-100ml</span><span style="font-family:宋體,simsun;font-size:16px;">流量沖洗，沖洗時(shí)須用手輕拍及轉動(dòng)炭腎排除氣泡并除去微粒。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">5</span><span style="font-family:宋體,simsun;font-size:16px;">、沖洗液充滿(mǎn)整個(gè)管路系統后，可調快血泵速度一般為</span><span style="font-family:宋體,simsun;font-size:16px;">250-300ml/min</span><span style="font-family:宋體,simsun;font-size:16px;">，注意沖洗液從靜脈管路流出后是否澄清，如有炭粒必須及時(shí)更換。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">6</span><span style="font-family:宋體,simsun;font-size:16px;">、灌流與血液透析、血濾并用時(shí)，將炭腎串連在透析器前。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">三、血液灌流的步驟：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、建立臨時(shí)性動(dòng)靜脈通路</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、采用注射肝素化方法，首次劑量是</span><span style="font-family:宋體,simsun;font-size:16px;">1-1.5mg</span><span style="font-family:宋體,simsun;font-size:16px;">每公斤體重，最大劑量</span><span style="font-family:宋體,simsun;font-size:16px;">2mg</span><span style="font-family:宋體,simsun;font-size:16px;">每公斤體重，灌流前</span><span style="font-family:宋體,simsun;font-size:16px;">10</span><span style="font-family:宋體,simsun;font-size:16px;">分鐘用鹽水稀釋至</span><span style="font-family:宋體,simsun;font-size:16px;">10mg/ml</span><span style="font-family:宋體,simsun;font-size:16px;">后靜脈推注，以后每</span><span style="font-family:宋體,simsun;font-size:16px;">10</span><span style="font-family:宋體,simsun;font-size:16px;">分鐘追加</span><span style="font-family:宋體,simsun;font-size:16px;">0.1mg/</span><span style="font-family:宋體,simsun;font-size:16px;">每公斤體重。因個(gè)體差異大，肝素劑量視個(gè)體情況而定，凝血時(shí)間應保持在</span><span style="font-family:宋體,simsun;font-size:16px;">20-30</span><span style="font-family:宋體,simsun;font-size:16px;">分鐘之間。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、當病人血壓、脈博、心律穩定，灌流時(shí)血流量可逐步增加至</span><span style="font-family:宋體,simsun;font-size:16px;">150ml/min-200ml/min</span><span style="font-family:宋體,simsun;font-size:16px;">，持續</span><span style="font-family:宋體,simsun;font-size:16px;">2-3h</span><span style="font-family:宋體,simsun;font-size:16px;">結束，因</span><span style="font-family:宋體,simsun;font-size:16px;">2-3h</span><span style="font-family:宋體,simsun;font-size:16px;">后吸附劑吸附飽和，且有部分被吸附物開(kāi)始解吸，重新入血，發(fā)需延長(cháng)時(shí)間，可更換新的灌流器。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、結束時(shí)在動(dòng)脈端管路取血標本，做毒物定量分析，然后調低血泵速度，夾閉患者血流通路動(dòng)脈端，把灌流器倒過(guò)來(lái)，動(dòng)脈端朝上，靜脈端向下，用空氣回血，結束前從靜脈端注入等肝素量的魚(yú)精蛋白。拔除穿刺針，局部加壓止血。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;">四、注意事項：</span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">1</span><span style="font-family:宋體,simsun;font-size:16px;">、灌流前仔細了解病史，以選擇適宜的灌流器，注意灌流器的預充量。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">2</span><span style="font-family:宋體,simsun;font-size:16px;">、對有出血傾向者，除采用體外肝素化外，在灌流期間應在前</span><span style="font-family:宋體,simsun;font-size:16px;">2h</span><span style="font-family:宋體,simsun;font-size:16px;">內復查血小板、血色素、血球壓積。每小時(shí)做一次凝血時(shí)間。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">3</span><span style="font-family:宋體,simsun;font-size:16px;">、灌流期間注意監測血壓，呼吸，心律，有條件者應查血電解質(zhì)，肝，腎功能及動(dòng)脈血壓等。因血液灌流僅僅是清除毒物，并不能糾正毒物引起的病理生理改變，也不能代替解毒和對癥藥物，因此應注意綜合治療，如洗胃，導瀉，吸氧，呼吸，興奮劑，強心，升壓，糾正酸中毒，抗感染等</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">4</span><span style="font-family:宋體,simsun;font-size:16px;">、凝血將使灌流效果大減，甚至被迫終止灌流，其原因一是肝素用量不足，二是血流</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">量不足</span><span style="font-family:宋體,simsun;font-size:16px;">(100ml/min</span><span style="font-family:宋體,simsun;font-size:16px;">以下</span><span style="font-family:宋體,simsun;font-size:16px;">)</span><span style="font-family:宋體,simsun;font-size:16px;">，三是環(huán)境溫度低，在使用無(wú)監護裝置的單泵做血液灌流時(shí)最易出現凝血，因此要引起重視，在灌流過(guò)程中應注意動(dòng)、靜脈除濾器的變化，如出現除濾器凹陷提示動(dòng)脈壓過(guò)低，血流量不足，常見(jiàn)原因是穿刺針位置不當，動(dòng)脈管路扭曲及患者血壓下降，如除濾器變硬，膨脹，血液進(jìn)入除濾器倒置，提示動(dòng)脈壓過(guò)高，灌流器有凝血傾向，應加大肝素用量，如靜脈除濾器變硬，膨脹，提示靜脈壓過(guò)高，常見(jiàn)原因是附濾器內凝血或靜脈穿刺脫出血管及靜脈管路扭曲。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">5</span><span style="font-family:宋體,simsun;font-size:16px;">、灌流結束后，仍需嚴密監護，定期做毒物定量，如發(fā)現由于組織釋放引起血漿毒物濃度反跳時(shí)，應進(jìn)行第二次血液灌流。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">6</span><span style="font-family:宋體,simsun;font-size:16px;">、在灌流半小時(shí)后出現寒戰，發(fā)熱等癥狀，提示吸附劑的生物相容性差，可靜脈輸注地塞米松</span><span style="font-family:宋體,simsun;font-size:16px;">5-10mg</span><span style="font-family:宋體,simsun;font-size:16px;">或給予苯海拉明等治療，一般不需中止灌流。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:'times new roman';font-size:14px"><span style="font-family:宋體,simsun;font-size:16px;">　　</span><span style="font-family:宋體,simsun;font-size:16px;">7</span><span style="font-family:宋體,simsun;font-size:16px;">、在灌流中，應觀(guān)察灌流管路中的連接情況，以防空氣進(jìn)入管路造成空氣栓塞，尤其是在無(wú)空氣監測的情況下更應注意。</span></span><span style="font-family:'times new roman';font-size:14px"><br /></span><span style="font-family:宋體,simsun;font-size:16px;"> </span><span style="font-family:宋體,simsun;font-size:16px;">隨著(zhù)臨床觀(guān)察的進(jìn)一步深入，以及吸附劑，微囊膜材料的不斷改進(jìn)，血液灌流技術(shù)必將日益完善，并取得更好的臨床效果。</span></p><p style="text-indent:28px;line-height:1.75em;"><span style="font-family:宋體,simsun;font-size:16px;"> </span></p><p><br /></p> </div> <div id="5hr5bnr" class="pre">上一篇：<a href='/support/2/20150707111.html'>怎樣評價(jià)活性炭的吸附能力</a> </div> <div id="zvhphvn" class="next">下一篇：<a href='/support/2/20150707113.html'>淺談上?；瘜W(xué)工業(yè)區污水處理廠(chǎng)處理工藝設計及其控制</a> </div> </div> <div id="zb5xvxn" class="blank3"></div> </div> </div> <div id="j5z5rbj" class="clear"></div> <div id="xdjdrhb" class="foot"> <div id="db5dtlx" class="footer"> <p> <a>版權所有：江蘇威肯碳環(huán)?？萍加邢薰?/a>?? <a >蘇ICP備15030529號-1</a> </p><br/> <p>地址：江蘇省淮安市洪澤工業(yè)園 ??電話(huà)：0517-87212656 ??手機：15250897658 ??郵箱：yonn@vikenton.com</p> </div> </div> <table id="table1" height="15" cellSpacing="0" cellPadding="0" width="90%" border="0" style="font-size: 12px; cursor: default; color: buttontext"> 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