Twardowski Z J
Department of Medicine, University of Missouri Dialysis Clinic, Inc, Harry S. Truman Veterans Administration Hospital, Columbia, USA.
Am J Kidney Dis. 1998 May;31(5):841-7. doi: 10.1016/s0272-6386(98)70054-x.
From November 1, 1995, to April 30, 1997, in our outpatient dialysis facility, 7,179 or 24.3% of hemodialyses were performed with soft, cuffed, intravenous catheters as blood accesses. Inadequate blood flow (pump speed < 400 mL/min) was noted in 286 instances (4.0%). Locking of catheter lumina with 5,000 to 9,000 IU urokinase was only partly successful in three of 21 cases. Infusions of 20,000 to 40,000 IU urokinase in 25 instances during dialysis restored catheter function in 10 cases. In nine instances in which blood could not be aspirated from the catheter and dialysis could not be performed, the infusion was done through the catheter while the patient remained in the chair. In eight instances, the catheter was opened, and dialysis was performed on the next shift. In 162 instances, a new method was used to open failing catheters most conveniently, efficiently, and with minimal cost. Whenever a nonpositional deterioration of blood flow was noted, 250,000 IU urokinase was infused during dialysis over 3 hours, if there were no contraindications. Full restoration of pump speed was achieved during 132 infusions; in another 21 cases, blood flow improved. In 59 cases, in which an adequate pump speed was not achieved during the next dialysis, the infusion was repeated with restoration of blood flow in 50 instances and flow improvement in six; infusion was re-repeated in the nine instances without complete restoration of flow and in one of the 50 in which restoration of flow was temporary. Adequate flow was restored in nine of these 10 cases in which re-repeated infusion was done. Routine doses of heparin were used concomitantly with urokinase in all cases. No adverse reaction to urokinase has been encountered in any case. To maintain long-term catheter patency, warfarin therapy was started in patients who required repeated urokinase infusions. Vials of 250,000 IU, 9,000 IU, and 5,000 IU urokinase cost $358.47, $77.07, and $43.76, respectively. The higher cost of high-dose intradialytic urokinase as compared with the catheter "lock" is offset by the high probability of positive results, saving of nursing and patient time, and saving on transportation expenses. The convenience and cost are even more remarkably in favor of intradialytic urokinase compared with catheter stripping ($2,433) or surgical replacement ($3,060).
1995年11月1日至1997年4月30日期间，在我们的门诊透析机构中，7179次（占24.3%）血液透析采用柔软、带 cuff的静脉导管作为血液通路。发现286例（4.0%）血流量不足（泵速<400 mL/分钟）。用5000至9000 IU尿激酶封管在21例中的3例仅部分成功。透析期间25例输注20000至40000 IU尿激酶，10例恢复了导管功能。9例无法从导管抽吸血液且无法进行透析的情况，在患者仍坐在椅子上时通过导管进行输注。8例中，导管被打开，下一班次进行透析。162例中，采用了一种新方法以最方便、高效且成本最低的方式打开功能不良的导管。每当发现血流量出现非位置性恶化时，若无禁忌证，在透析期间3小时内输注250000 IU尿激酶。132次输注后泵速完全恢复；另外21例血流量有所改善。59例在下一次透析时未达到足够泵速，其中50例重复输注后血流量恢复，6例血流量改善；9例未完全恢复血流的情况以及50例中血流恢复为暂时的1例再次重复输注。这10例中9例在再次重复输注后恢复了足够的血流。所有病例中尿激酶均与常规剂量肝素同时使用。任何病例均未出现对尿激酶的不良反应。为维持导管长期通畅，对需要重复输注尿激酶的患者开始使用华法林治疗。250000 IU、9000 IU和5000 IU尿激酶小瓶的成本分别为358.47美元、77.07美元和43.76美元。与导管“封管”相比，高剂量透析中尿激酶成本较高，但阳性结果的高概率、节省护理和患者时间以及节省运输费用抵消了这一差异。与导管剥离（2433美元）或手术置换（3060美元）相比，透析中尿激酶在便利性和成本方面更具优势。
