学位論文の内容要旨（和文）
題名：輸液中における適切な採血部位に関する実証研究 専攻領域・分野：実証看護技術学領域 ・ 実証看護技術学 学籍番号 氏名：2162013002 小池祥太郎
要 約
【研究目的】 リンパ節郭清を伴う乳房切除を行った患者や，透析用シャントを造設した患者 が輸液を行う場合，健側に輸液用のラインを確保することが多い．このような患者から採血 を行う際，患側の穿刺は禁忌であり，さらに輸液をしている腕も正確な検査データが得られ ないと考えられており，多くの医療施設では下肢の静脈が採血部位として選択されている．
下肢からの採血は痛みを伴い患者にとって苦痛で ，看護師も苦慮しているのが現状である ．
また，
採血ガイドラインや看護技術書には下肢からの採血は血栓形成のリスクがあることから採血 部位として避けるよう記載されている．そこで，患者に苦痛を与えることなく安全性にも考 慮した採血部位を検討し，輸液中においても正確な血液データが得られる新たな採血部位を 検証することを本研究の目的とした．
【研究方法】 輸液は静脈から実施されるため，薬液は輸液実施部位より中枢側に流れるので 末梢側から採血することで，検査データは輸液の影響が少ない可能性があるとの作業仮説に 基づき以下のプロセスで基礎研究および実証研究を実施した．
＜研究Ⅰ・Ⅱ（基礎研究） ：因果仮説検証研究，実験研究＞20 週齢（体重約 3.5kg）の日本白 色種雄性ウサギ７匹を使用した．ウサギを小動物用麻酔器で鎮静させ，左耳介静脈に輸液ラ インを確保した．絶食中で 24 時間点滴を受けている患者を想定し，このような患者に臨床で もっとも活用されている３号輸液（商品名：ソリタ T3G）を用いた．輸液開始５分後に実施 部位より２cm 中枢側・末梢側，反対側（右耳介静脈）から各部位２ml の採血を行った．反対 側はウサギの基準となる採血データとした．分析は血球検査・生化学検査 39 項目とし，中枢 側・末梢側・反対側で得たデータを Tukey の検定で比較し有意水準は５％未満とした（研究
Ⅰ）．以上の研究後，輸液実施部位から一定の距離をあけた検討が必要と考え ，輸液開始 5 分後に実施部位より２cm 末梢側（近位末梢側） ・５cm 末梢側（遠位末梢側） ・反対側から採血 を行い，同様に Tukey の検定で比較した（研究Ⅱ）．
＜研究Ⅲ（実証研究） ：因果仮説検証研究，準実験研究＞医療系の国家試験免許有資格者男性 5 名を対象とし，左上肢前腕からソリタ T3G を 84ml/h で開始し，５分後に２人の看護師が輸 液実施部位の 15cm 末梢側である手背（末梢側）および反対側の上肢の肘窩部（反対側）より 同時にホルダーを用いた真空採血法で採血を行った ．反対側は輸液の影響を受けずに対象者 の正確な生体機能を表す採血部位であり，輸液の影響の有無を検証するために採血した ．血 液分析は血球検査・生化学検査 41 項目を専門業者に委託した．分析方法として 2 箇所の血液 データを paired t-test で比較し，有意水準は５％未満とした．
【研究結果】 研究Ⅰにおいて，各部位の平均採血データは総蛋白が中枢側 4.7±1.1 g/dL，
末梢側 5.9±0.5g/dL，反対側 5.8±0.3g/dL であった．アルブミンは中枢側 1.8±0.4g/dL，
末梢側 2.3±0.1g/dL，反対側 2.3±0.2g/dL であった．ナトリウムは中枢側 126±18.7mEq/L，
末梢側 144±3.5mEq/L，反対側 144±2.1mEq/L であった．クロールは中枢側 88.4±12.7mEq/L，
末梢側 100±3.7mEq/L，反対側 101±3.9mEq/L であった．カルシウムは中枢側 11.4±2.6mg/dL，
末梢側 14.1±0.8 mg/dL，反対側 14.0±0.9mg/dL であった．マグネシウムは中枢側 2.1±
0.4mg/dL，末梢側 2.6±0.1mg/dL，反対側 2.5±0.2mg/dL で，これらの中枢側データは末梢 側・反対側データと比較し有意に低かった．また，血糖値は中枢側 487±170mg/dL，末梢側 179±91mg/dL，反対側 127±29mg/dL であった．カリウムは中枢側 6.7±2.6mEq/L，末梢側 4.3
±0.5mEq/L，反対側 4.1±0.6mEq/L で，これらの中枢側データは末梢側・反対側データと比 較し有意に高かった．その他の項目に有意な差は認められなかった ．研究Ⅱにおいて，近位 末梢側・遠位末梢側・反対側を比較したところ，研究Ⅰで有意差が確認された検査項目も含 めて統計学的な差は認められなかった．ただし，近位末梢側の血糖値は 159.4±78.3mg/dL，
遠位末梢側は 123.7±19.9 mg/dL，反対側は 125.3±14.2 mg/dL で，近位末梢側の平均値は 遠位末梢側・反対側と比較して高く，標準偏差が大きかった．一方で，遠位末梢側は反対側 と平均値および標準偏差ともに類似した結果となった．研究Ⅲでは，輸液実施部位の末梢側 と反対側から得られた全ての検査項目において，各データの平均値と標準偏差は同程度であ り有意差は認められなかった．
【考察】 研究Ⅰで総蛋白・アルブミン・ナトリウム・クロール・カルシウム・マグネシウム の中枢側データが末梢側と反対側に比べて有意に低くなった 理由として，ソリタ T3G のこれ らの組成が血液濃度より低いため，採血した血液が薄くなったと考えられる．一方で，血糖・
カリウムの中枢側データが高い理由は輸液の組成が血液濃度より高いためであると考えられ る．また，末梢側と反対側で有意な差は認められなかったが，血糖の末梢側データが反対側 にくらべて平均値の差および標準偏差 が大きかった．これはソリタ T3G に含まれる糖質が 7,500mg/dL とウサギの標準的な血糖 135mg/dL と比較し大幅に濃度が高いため末梢側でも影 響を受けたと考えられ，限局的ではあるが輸液は末梢側に影響する可能性が示唆された．そ こで，輸液実施部位より一定の距離をとることで影響を排除できるかを研究Ⅱで検証したと ころ，近位末梢側では輸液の影響がみられたが，遠位末梢側では影響が認められなかった．
この理由として，血液は血管内を層流にながれているが，血流速度の増加と血液粘性が低下 することでレイノルズ数が上昇し乱流が起きる．輸液が血管内に入ることで，血流速度の増 加と血液粘性の低下という条件下となり局所的に乱流が起こり，近位末梢側には輸液の影響 が一部で認められたと考えられる．そして，遠位末梢側で影響がなかったことから，乱流に 影響されない距離をとることで末梢側からも採血が可能であると考察される．そこで，臨床 への応用を目的に行った研究Ⅲでは輸液実施部位より 15cm 離した末梢側と反対側で採血し た血液データを比較し，その結果，有意な差が認められた項目はなく平均値および標準偏差 も同程度となった．以上のことから，輸液実施部位より 15cm 離れた末梢側から得た血液デー タは輸液の影響を受けておらず，対象者の生体機能を正確に反映しており，15cm 末梢側は採 血部位として適切であることが明らかとなった．
キーワード：採血 採血部位 輸液 看護技術
学位論文の内容要旨（英文）
Title: Experimental Research into Suitable Blood Collection Sites During Fluid Infusion Field: Advanced physiological research in practical nursing skills/Evidence-based approaches to nursing
No.2162013002．Name: Shotaro Koike
Abstract
Background and Objectives: In patients who have undergone surgical procedures such as mastectomy with lymph node dissection or the creation of a shunt for dialysis, future fluid infusions have to be performed on the unaffected side. When a blood sample is collected from these patients, the affected side cannot be used for any paracentesis tests.
In addition, it is believed that accurate data cannot be obtained from the arm where a fluid infusion is being given. Therefore, in many medical institutions, a vein in a lower limb is selected as the blood collection site. However, collecting blood from a lower limb causes pain and is distressing to the patients. It is also a cause of concern for nurses.
Furthermore, the blood collection guidelines and textbooks on nursing technique state that blood collection from the lower limbs should be avoided because of the risk of thrombosis. Therefore, the objectives of this research were to determine a safe blood collection site that would not cause distress to the patient and to verify that accurate blood data could be obtained from the new site, even during fluid infusion.
Methods: It has been hypothesized that as a fluid infusion is given intravenously, the drug flows to the central side of the fluid infusion site; therefore, collecting blood on the peripheral side of the infusion site may result in test data that are minimally affected by the infusion. Based on this working hypothesis, we conducted both basic and applied research using the following processes.
[Research Assessments I and II (Basic Research): Research to verify the causal hypothesis and experimental research]. Seven 20-week-old Japanese white male rabbits (body weight of approximately 3.5 kg) were used. The rabbits were sedated using an anesthetic device for small animals, and fluid infusion routes were secured via the left auricular veins. To simulate the scenario of a fasting patient who was receiving a 24-h fluid infusion, we used a type 3 fluid for infusion (brand name: Solita T3G), as this is the most common type in clinical use for those patients. The infusion was started after 5 min, blood samples of 2 mL each were collected from 2 cm on the central side of the infusion
site, from the peripheral side of the infusion site, and from the opposite side (the right auricular vein). The test results for the blood sampled from the opposite side were considered as the standard data for the rabbits. For analysis, we measured 39 blood cell test and biochemical test items, and the data obtained from the central, peripheral, and opposite sides were compared using the Tukey test, with a significance level of <5%
(Research Assessment I). After the above investigation, it was necessary to investigate different distances from the fluid infusion site for blood collection . Therefore, 5 min after the start of the fluid infusion, blood samples were collected from the following loca tions:
2 cm away from the infusion site on the peripheral side (the proximal peripheral site), 5 cm away from the infusion site on the peripheral side (the distal peripheral side), and on the opposite side. The results were compared using the Tukey test in the same way (Research Assessment II).
[Research Assessment III (Applied Research): Research to verify the causal hypothesis and semi-experimental research]. In five male subjects with nationally accredited healthcare qualifications, we started the administration of Solita T3G at 84 mL/h via the forearm of the left upper limb. After 5 min, two nurses simultaneously took blood samples using the vacuum blood collection method from the dorsum of the hand, which was 15 cm away on the peripheral side of the fluid infusion site (the peripheral side), and the cubital fossa of the upper limb on the opposite side (the opposite side). The opposite side was the collection site that accurately demonstrated the biological functioning of the subject without any influence from the fluid infusion, and this sample was used to verify any influence of fluid infusion. Blood analysis of the 41 blood cell test and biochemical test items was ordered from a specialist company. For analysis, the blood data for the two locations were compared using the paired t-test, with a significance level of <5%.
Results: From Research Assessment I, for the mean blood sample data, the total protein levels were 4.7 ± 1.1, 5.9 ± 0.5, and 5.8 ± 0.3 g/dL at the central, peripheral, and opposite sides, respectively. The albumin levels were 1.8 ± 0.4, 2.3 ± 0.1, and 2.3 ± 0.2 g/dL at the central, peripheral, and opposite sides, respectively. The sodium levels were 126 ± 18.7, 144 ± 3.5, and 144 ± 2.1 mEq/L at the central, peripheral, and opposite sides, respectively.
The chlorine levels were 88 ± 12.7, 100 ± 3.7, and 101 ± 3.9 mEq/L at the central, peripheral, and opposite sides, respectively. The calcium levels were 11.4 ± 2.6, 14.1 ± 0.8, and 14.0 ± 0.9 mg/dL at the central, peripheral, and opposite sides, respectively. The magnesium levels were 2.1 ± 0.4, 2.6 ± 0.1, and 2.5 ± 0.2 mg/dL at the central, peripheral, and opposite sides, respectively; for this item, the data for the central side were significantly lower than those for the peripheral and opposite sides. The blood sugar levels were 487 ± 170, 179 ± 91, and 127 ± 29 mg/dL at the central, peripheral, and opposite sides, respectively. The potassium levels were 6.7 ± 2.6, 4.3 ± 0.5, and 4.1 ± 0.6 mEq/L at the central, peripheral, and opposite sides, respectively; for this item, the data for the central side were significantly higher than those for the peripheral and opposite
sides. No statistically significant differences were found for any other items. In Research Assessment II, no statistically significant differences were found for any items when the proximal peripheral, distal peripheral, and opposite sides were compared; this included those items for which a significant difference had been found in Research Assessment I.
However, the blood sugar levels were 159.4 ± 78.3, 123.7 ± 19.9, and 125.3 ± 14.2 mg/dL at the proximal peripheral, distal peripheral, and opposite sides, respectively; therefore, the mean for the proximal peripheral side was higher than those for the distal peripheral and opposite sides with a large standard deviation. However, results showed that the distal peripheral side had similar means and standard deviations compared with the opposite side. In Research Assessment III, the means and standard deviations for each item of data were similar for all test items obtained from the peripheral and opposite sides, and no significant differences were found.
Discussion: In the first evaluation (Research Assessment I), the results for the total protein, albumin, sodium, chlorine, calcium, and magnesium tests were significantly lower for the central side than for the opposite side; this may be because of the lower concentrations of these constituents in Solita T3G relative to blood. Conversely, the blood sugar and potassium levels were higher at the central side because these components were present at a higher concentration in the infused fluid. No significant difference between the peripheral and opposite sides was found, but the blood sugar data for the peripheral side had greater differences in the means and standard deviations than those values for the opposite side. This may be due to the most widespread effects of the infusion solution because the sugar concentration in Solita T3G was 7,500 mg/dL, which was far higher than the normal blood sugar concentration in rabbits (135 mg/dL); these findings suggested that infusions affect the peripheral side as well, although only in a localized manner. When the Research Assessment II was then conducted to verify whether the influence could be removed by collecting blood at a certain distance from the fluid infusion site, we found that fluid infusion influenced the results on the proximal peripheral side, but did not influence those of the distal peripheral side. The reason for this was that blood flows in layers within blood vessels, but if the rate of blood flow increases and viscosity decreases, the Reynolds number increases and turbulence occur s.
The entry of infused fluid into a blood vessel caused an increase in the rate of blood flow and decreased blood viscosity, and localized turbulence occurred under these conditions;
thus, we observed some influence from the fluid infusion on the proximal peripheral side.
As there was no influence on the distal peripheral side, it was inferred that it might be possible to collect blood from the peripheral side by maintaining sufficient distance to avoid influence from the turbulence. Then, in Research Assessment III, with the objective of applying these findings to clinical practice, blood was collected from the peripheral side at a distance of 15 cm from the fluid infusion site, as well as from the opposite side. The comparison of the data for these samples showed no significant
differences in any items, and the means and standard deviations were similar. From these findings, we determined that data from a blood sample collected at a distance of 15 cm from a fluid infusion site on the peripheral side was not affected by the fluid infusion and accurately reflected the biological function of the subject. Therefore, a site at a distance of 15 cm on the peripheral side can be suitable for blood collection.
Keywords: blood collection, collection site, fluid infusion, nursing technique
