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VPLIV ARTERIOVENSKE FISTULE KOT ŽILNEGA PRISTOPA ZA HEMODIALIZO NA PREKRVLJENOST DISTALNIH STRUKTUR - DLANI IN PRSTOV (OCENA TREH PARAMETROV)
Avtor: Maša Knehtl, Mitja Krajnc
Mentor: prof. dr. Rafael Ponikvar
IZHODIŠCE: Hemodializa, ki je najbolj razširjena metoda ledvicnega nadomestnega zdravljenja pri kronicni ledvicni odpovedi, zahteva zanesljiv permanentni žilni pristop. Arteriovenska fistula (AVF) je najpogosteje uporabljani žilni pristop, katerega zaplet je med drugim tudi ishemija roke (dlani in prstov) - incidenca se giba med 1-10%. Ishemija se pojavi kot posledica spremenjenih hemodinamskih sprememb na fistulnem podrocju (zmanjšanega distalnega arterijskega pritiska) in se kaže z znacilnimi simptomi in znaki, zlasti pri bolnikih s prej obstojecimi dejavniki. NAMEN: Želeli smo oceniti klinicni pomen treh izbranih merjenih parametrov (temperature kože: med palcem in kazalcem, palcem in sredincem, v pregibu dlani, pulzne oksimetrije, dinamometrije) pri obravnavi bolnika z motnjami prekrvavitve roke, ki so posledica konstrukcije AVF. Merjenje le-teh je dostopno, enostavno in ne zahteva posebne strokovne usposobljenosti. V literaturi pomen dinamometrije in temperature kože ni ovrednoten, za pulzno oksimetrijo pa ni dokoncnega odgovora. HIPOTEZA: Meritve izbranih parametrov smo opravljali na fistulni in nefistulni roki v razlicnih casovnih obdobjih, da bi preverili naslednji hipotezi: (1) prekrvavljenost fistulne roke pred in po konstrukciji AVF pri asimptomatskih bolnikih je tolikšna, da ne bomo ugotovili pomembnih razlik v merjenih parametrih glede na nefistulno - kontrolno roko ob merjenju na isti dan, (2) prekrvavljenost fistulne roke po konstrukciji AVF pri asimptomatskih bolnikih je tolikšna, da ne bomo ugotovili pomembnih razlik v merjenih parametrih glede na izhodišcne vrednosti pred konstrukcijo AVF na fistulni roki. METODE: Meritve smo izvajali (prospektivno) pri bolnikih s kronicno ledvicno odpovedjo, ki ob meritvi niso smeli kazati simptomov ali znakov ishemije roke, vsakic na fistulni in nefistulni roki. 1. meritev izbranih treh parametrov (temperature kože: med palcem in kazalcem, palcem in sredincem, v pregibu dlani; saturacije hemoglobina s kisikom; moci fleksorjev roke) smo opravili pred konstrukcijo AVF (n=18), 2. meritev v enem dnevu po konstrukciji (n=18), 3. v obdobju 1-4 mesecev (n=9), 4. v obdobju 5-8 mesecev (n=7) in 5. meritev v obdobju 9-12 mesecev (n=6) po konstrukciji AVF. Povprecja dveh odvisnih vzorcev smo primerjali z dvostranskim parnim Studentovim t-testom. REZULTATI: Povprecja merjenih parametrov na fistulni roki so bila (z nekaj izjemami) nižja od povprecij na nefistulni roki (meritve 2-5), povprecja na fistulni roki pri meritvah 2-5 pa nižja kot pri 1. meritvi na fistulni roki, vendar statisticno pomembnih razlik pri nobeni od metodološko upravicenih primerjav nismo ugotovili (p>0,05; dvostranski parni Studentov t-test). ZAKLJUCKI: Delovni hipotezi smo, kjer je bilo to z vidika uporabljene metode mogoce, potrdili. Prevelika razlika med fistulno in nefistulno roko v izmerjeni temperaturi kože pri asimptomatskih bolnikih ni normalna. Sklepamo, da je razlika 0 - 1 °C še normalna. Nizka vrednost saturacije na fistulni roki pri asimptomatskih bolnikih ni normalna, prav tako ni normalna nižja vrednost glede na obdobje pred konstrukcijo AVF. Pri asimptomatskih bolnikih prevelika razlika v moci mišic fleksorjev roke na fistulni roki glede na obdobje pred konstrukcijo ni normalna. Klinicni pomen dinamometrije in merjenja temperature bo, za razliko od pulzne oksimetrije, kjer smo ga potrdili, omejen, dokler ne bodo znana še normalna oz. dopustna odstopanja glede na izhodišcno meritev.
[Abstract / English version]
VPLIV ARTERIOVENSKE FISTULE KOT ŽILNEGA PRISTOPA ZA HEMODIALIZO NA PREKRVLJENOST DISTALNIH STRUKTUR - DLANI IN PRSTOV (OCENA TREH PARAMETROV)
Author: Maša Knehtl, Mitja Krajnc
Mentor: prof. dr. Rafael Ponikvar
BACKGROUND: Hemodialysis is the most widely used method of renal replacement therapy in end-stage renal disease. It requires a reliable permanent vascular access. Arteriovenous fistula (AVF) is the one most commonly used. Among other complications it may cause hand (palm and fingers) ischemia. The hand ischemia (incidence 1-10%) is a consequence of altered hemodynamic circumstances in the area (above all of decrease in distal arterial pressure). It manifests itself with typical signs and symptoms, especially in patients with preexisting factors. AIM: We were determined to estimate the clinical significance of the measured parameters (temperature of skin between a thumb and a forefinger, temperature of skin between a thumb and a middle finger, temperature of skin in a bend of palm, pulse oxymetry, dynamometry) in dealing with a patient that has the hand perfusion problems as a consequence of AVF creation. Measuring of the chosen parameters is accessible, simple and does not require any special professional training. Significance of dynamometry and skin temperature is yet to be established. There is not any definite answer about the value of pulse oxymetry. HYPOTHESIS: We performed measurements of the chosen parameters on a fistular and a nonfistular hand in different time periods to confirm the following hypotheses: (1) perfusion of a fistular hand before and after AVF creation is sufficient in asymptomatic patients. That is why we shall not be able to prove the significant differences in the measured parameters on a fistular hand in comparison with a nonfistular (control) hand on the same day; (2) perfusion of a fistular hand after AVF creation is such that we shall not be able to prove the significant differences in the measured parameters in asymptomatic patients between starting-point values (before AVF creation) and measured values on the same hand. METHODS: We prospectively performed measurements of the previously mentioned parameters on the coincidentally chosen end-stage renal disease patients that at the time of a measurement did not manifest any signs/symptoms of hand ischemia, on both hands. The first measuring was done just before AVF creation (n=18), the second in the first 24 hours after AVF creation (n=18), the third between the 2nd and the 5th month after AVF creation (n=9), the fourth between the 6th and the 9th month (n=7) and the last (fifth) was done between 10th and 13th month after AVF creation. We used the 2-tailed paired Student's t-test to compare the average values of two samples. RESULTS: The average values of the chosen parameters were lower on a fistular hand (with some exceptions) than those on a nonfistular hand (measurings 2-5). On measurings 2-5 the average values were lower on a fistular hand than the values of the first measuring on a fistular hand. Nevertheless we could not prove statistical significance of any of the metodically substantiated comparisons (p>0,05; 2-tailed paired Student's t-test). CONCLUSIONS: We confirmed the working hypotheses. The too large difference between a fistular and a nonfistular hand is not normal. We think that the difference 0 - 1 °C is acceptable. In an asymptomatic patient low pulse oxymetry values are not to be considered normal, just like lower values in regard to period before AVF creation. In asymptomatic patients, dynamometric values that are lower than those measured before AVF creation, should not be considered normal. We can confirm the clinical usefulness of pulse oxymetry. For dynamometry and temperature it remains limited just as long it becomes clear what magnitude of deviation from the normal values is to be considered tolerable.