1腹膜透析

2020/2/261血液透析與腹膜透析之使用方法小兒部腎臟科林廣彥醫師2020/2/26PICUTrainingCourseSlide2血液透析(H/D)腹膜透析(PD)慢性連續性腎臟替代療法(Slowcontinuerenalreplacementtherapy):CVVH,CAVH,CVVHD,CAVHD,CVVHDF,CAVHDFRenalreplacementtherapy1.何時該介入腎臟替代療法?2.該如何選擇何種腎臟替代療法?H/D;P/DorCVVH;CVVHD2020/2/26PICUTrainingCourseSlide4IndicationsforAcuteDialysis(1)1.Symptomaticfluidoverload2.Hyperkalemia(K+≧7.0mEq/L)3.Symptomaticuremiaand/orBUN150-175mg/dL4.Severeintractableacidosis(pH≦7.1)5.Nonobstructiveanuria6.Oliguriawithrapidprogressionofrenalinsufficiency7.Severehyponatremiaorhypernatremia2020/2/26PICUTrainingCourseSlide5IndicationsforAcuteDialysis(2)8.Severehyperphosphatemiaandhypocalcemia9.InadequateurineoutputwithobligatoryIVfluidrequirements10.Potentiallyharmfullevelsoftoxins.poisons.ordrugs(hemodialysisorhemoperfusion)11.Tumorlysissyndrome(uricacid20mg/dL)12.Hyperammonemiaininbornerrorsormetabolism(hemodialysis)2020/2/26PICUTrainingCourseSlide6血液透析與腹膜透析之比較溶質由腹膜清除率或體內生化環境較穩定中分子及大分子清除率較每週三次的HD好對於hemodynamicunstablepatient(Shock;ICH;CADect.)較適合P/D水分與鉀離子之移除率:H/D較P/D好2020/2/26PICUTrainingCourseSlide7AcutePeritonealDialysisinChildrenPDismoreefficientininfantsandchildrenPeritonealsurfaceareainchildren:twicethanthatofadultperkgbodyweightTheultrafiltrationrateperKgBW:higherinsmallerpediatricpatientsshortdialysatedewelltimesareusedPediatrichemodialysis:technicalchallengesandrequiresspeciallytrainedpersonnel2020/2/26PICUTrainingCourseSlide8TechnicalConsiderationofPDSingle(orTwo)cuffTenckhoffcatheterInsertion:SurgicalinsertionorPercutaneousinsertionInsertionSite:TenckhoffPDcatheterTenckhoffPDcatheter-2cuff2020/2/26PICUTrainingCourseSlide13該如何開立腹膜透析處方?2020/2/26PICUTrainingCourseSlide17Acuteperitonealdialysisorder1.Dialysatesolution%(1.5%,2.5%4.25%)2.Exchangevolume:initial20ml/kgandgraduallyupto40~50ml/kgduringoneweek3.Warmdialysatefluidto37℃(用bloodexchange之溫血環)4.Cycletime:inflow5~10minutesdwell30~40minutesoutflow15~20minutes5.Addheparin500~1000units/Lofdialysatetilldialysatecelar6.AddK+4meq/Lofdialysate,ifserumK+4meq/L7.Turnandpositionpatientp.r.n.foroptimumoutflow.8.BUN/Cre,ABG,Na,K,Cl,andglucoseqdatleastTheStandardperitonealdialysissolutionformulation(mEq/L)Na:132;K:0;Mg:0.5;Ca:3.5;Cl:96;Lactate:40Dextrose(glucosemonohydrate):1.5%;2.5%;4.25%Package:1L(1.5%);2L;2.5L;5L/bagDextroseGlucoseOsmolarityUltrafiltrateVolumeg/dLg/dLmOsm/LmL/exchangeL/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.62020/2/26PICUTrainingCourseSlide19NotifyDoctorimmediatelyif:1.Poordialysateflowordrainage2.Severeabdominalpainordistension3.Brightredbloodorcloudydialysatedrainage4.Dialysateleakorpurulentdrainagearoundcatheterexitsite5.TachypneiaorSOB6.Fever2020/2/26PICUTrainingCourseSlide20ComplicationsofPD(1)BleedingfromskinincisionIntestinalperforationBladderperforationLeakageofDialysateAirunderthediaphragmHypokalemiaHyperglycemiaHerniaandHydrocelePDtubemigrationandobstruction2020/2/26PICUTrainingCourseSlide21ComplicationsofPD(2)Decreasedultrafiltration/IncreasingfluidretentionIncreasedultrafiltration/ExcessivefluidremovalHypotensionExitsiteinfectionTunnelinfectionPeritonitisPulmonarycomplicationsProteinlossandNutritionaldeficiencies2020/2/26PICUTrainingCourseSlide22AcuteHemodialysis(1)Dual-lumencatheterinsertion:femoralvein,subclavianvein,internaljugularveinSinglecatheterinumbilicalveinwiththeothercentralvenouscatheterAblood-flowrateofatleast2to3mL/Kg/minTheextracorporealbloodvolumeshouldnotexceed10%ofthepatient’sbloodvolume(orapproximately8ml/kgBW)Fluidremovalshouldgenerallynotexceed5%ofBWover4-6hrs2020/2/26PICUTrainingCourseSlide23Bloodflowrate(BFR):BFR=2.5xBW(kg)+100ml/min(p’tBW:10-40kg)BFR100ml/min(p’tBW10kg)BFR=100~250ml/min(p’tBW40kg)Ureaclearance:3-5ml/min/kgAcuteHemodialysis(2)2020/2/26PICUTrainingCourseSlide24HemodialysisprescriptionDialyzer:dialyzermembrane;KUf;dialyzerefficiencyBloodflowrate:100~250ml/minsDialysissolutionflowrate:300~500ml/minsDialysissoultionTemp.:35-36℃Anticoagulation:HeparinSessionlength:aspatient’scondition2020/2/26PICUTrainingCourseSlide25DialysissolutioncompositionBicarbonate:25mEq/LNa:145(135-145)mEq/L;K:3.5(2-4)mEq/LCa:3.5(2.5-3.5)mEq/L;Mg:0.75(0.75-1.5)mEq/L;P:noneDextrose:200mg/dL2020/2/26PICUTrainingCourseSlide26ComplicationsduringHDHypotension:N/Sbolusor5%albumin;mannitol(0.5-1.0g/kg);25%albumin(0.3-0.5gm/kg)↑dialysateNa(140mEq/Landhigher)UltrafiltrationinthefirsthourandthendialysisDialysisDisequilibriumSyndromeArrthymia2020/2/26PICUTrainingCourseSlide28小兒科血液透析交班單床號姓名1.血壓:透析前,透析後2.心跳:透析前,透析後____;呼吸:透析前,透析後____3.體重:透析前,透析後____4.輸血:PRBCU,WBU,PLTU,FFPU領血單位:病房();PICU()5.ComplicationsduringH/D:THEEND