說老實話,我以為找這個題目的文獻很容易,但是出乎意料地,我找了好久,還是沒有很滿意的文獻可以閱讀,只好再回頭拜讀腎臟病經典治療指引:KDOQI,於2006年更新的血管通路照護指引,裡頭是這麼寫的……
促進血管成熟的建議
建議使用“等長運動(isometric exercise)”,如:握球動作來增強握力(視情況可輕輕地綁壓脈帶),來使前臂變的更強壯,這樣的動作能夠促進靜脈的成熟,而在做握球動作的時候,能夠看到血管管徑變粗,文獻中提到能使血管變粗9.3%,因此能夠增加手臂血流量,而促進血管成熟;而手臂變強壯的同時,肌肉量也增加,血流量也會跟著增加;手臂運動也會減少皮下脂肪,或許血管能夠浮上來一點。
全部漏漏長的血管照護指引裡頭,只有這樣一段,在寫握球運動,而且還是寫在“促進血管成熟”的這個章節,但是其他的章節,全部沒有提到運動。其實,我本來有興趣的是:當血管已經使用一陣子了,持續做運動,能不能幫忙減少血管不通的機會,可是很遺憾的是,我沒有找到這樣的文獻。
遠紅外線治療的證據
至於,有沒有其他能夠幫忙維持血管的方法呢?於2007年,北榮林志慶醫師的研究告訴我們,每次洗腎時,使用遠紅外線治療40分鐘,能夠延長血管通暢的時間。結果如下:
對於這個結果,文中作者於討論中提到,人工血管者並不適用這個結果,而且剛新作好的血管,也不適用,而且由於實驗設計的關係,仍然需要進一步大型的研究,才能夠確認這樣的研究結果。進一步說明,即使這樣的結果看起來很棒,但是仍有很多未能解答的問題,如:是否某一群患者特別有效?是否時間一定要40分鐘?血管開完多久之後才能開始用?是否使用這樣的治療,能夠真的減少通血管的次數?更簡單直接的問,是否這個治療已經得到各國認可,而列入治療指引?
在找尋文獻的過程中,不管是2006年剛更新的KDOQI治療指引,心臟血管外科2008年的治療指引,2012年的KDIGO治療指引,裡頭都沒有提到遠紅外線的治療是否有幫助。直到2012年的這篇文章“影響透析血管通暢的因子”中,才確實有整理林志慶醫師的這篇研究。所以,在看到一個新的觀念時,還是要考量證據是否豐富,才能確認是否能夠應用在臨床上。
已經寫在治療指引中的,比較能夠當作我們的治療的準則,至於沒有的,就只能各自解讀了。
簡單結論
1. 握球或手臂的運動,能夠增加透析血管的流量,促進血管的成熟。
2. 對於維持透析血管的健康,在各大治療指引中,沒有特別的治療顯示有幫助。世界各國的醫師護理師,仍然會建議患者要做握球或手臂的運動。
3. 遠紅外線的治療,雖然看起來是有希望,但是應用上仍需進一步證據支持,目前只能說證據的質量,還沒有強到可以放到治療指引中。
Reference:
KDOQI Guidelines for Dialysis Care: Vascular Access (2006)
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