血液透析和腹膜透析之使用方法

血液透析與腹膜透析之用法小兒部腎臟科林廣彥醫(yī)師10/4/20231第1頁血液透析(H/D)腹膜透析(PD)慢性連續(xù)性腎臟替代療法(Slowcontinuerenalreplacementtherapy):CVVH,CAVH,CVVHD,CAVHD,CVVHDF,CAVHDF

Renalreplacementtherapy10/4/20232PICUTrainingCourseSlide第2頁何時該介入腎臟替代療法?該如何選擇何種腎臟替代療法?H/D;P/DorCVVH;CVVHD10/4/20233PICUTrainingCourseSlide第3頁IndicationsforAcuteDialysis(1)SymptomaticfluidoverloadHyperkalemia(K+

≧7.0mEq/L)Symptomaticuremiaand/orBUN>150-175mg/dLSevereintractableacidosis(pH≦7.1)NonobstructiveanuriaOliguriawithrapidprogressionofrenalinsufficiencySeverehyponatremiaorhypernatremia10/4/20234PICUTrainingCourseSlide第4頁IndicationsforAcuteDialysis(2)SeverehyperphosphatemiaandhypocalcemiaInadequateurineoutputwithobligatoryIVfluidrequirementsPotentiallyharmfullevelsoftoxins.poisons.ordrugs(hemodialysisorhemoperfusion)Tumorlysissyndrome(uricacid>20mg/dL)

Hyperammonemia

ininbornerrorsormetabolism(hemodialysis)10/4/20235PICUTrainingCourseSlide第5頁血液透析與腹膜透析之比較

溶質(zhì)由腹膜清除率或體內(nèi)生化環(huán)境較穩(wěn)定中分子及大分子清除率較每週三次旳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10/4/20236PICUTrainingCourseSlide第6頁AcutePeritonealDialysisinChildrenPDismoreefficientininfantsandchildrenPeritonealsurfaceareainchildren:twicethanthatofadultperkgbodyweightTheultrafiltrationrateperKgBW:higherinsmallerpediatricpatientsshortdialysatedewelltimesareusedPediatrichemodialysis:technicalchallengesandrequiresspeciallytrainedpersonnel10/4/20237PICUTrainingCourseSlide第7頁TechnicalConsiderationofPDSingle(orTwo)cuffTenckhoffcatheterInsertion:SurgicalinsertionorPercutaneousinsertionInsertionSite:10/4/20238PICUTrainingCourseSlide第8頁TenckhoffPDcatheter10/4/20239PICUTrainingCourseSlide第9頁TenckhoffPDcatheter-2cuff10/4/202310PICUTrainingCourseSlide第10頁10/4/202311PICUTrainingCourseSlide第11頁10/4/202312PICUTrainingCourseSlide第12頁10/4/202313PICUTrainingCourseSlide第13頁10/4/202314PICUTrainingCourseSlide第14頁10/4/202315PICUTrainingCourseSlide第15頁該如何開立腹膜透析處方?10/4/202316PICUTrainingCourseSlide第16頁AcuteperitonealdialysisorderDialysatesolution%(1.5%,2.5%4.25%)Exchangevolume:initial20ml/kgandgraduallyupto40~50ml/kgduringoneweekWarmdialysatefluidto37℃(用bloodexchange之溫血環(huán))Cycletime:inflow5~10minutesdwell30~40minutesoutflow15~20minutesAddheparin500~1000units/LofdialysatetilldialysatecelarAddK+4meq/Lofdialysate,ifserumK+<4meq/LTurnandpositionpatientp.r.n.foroptimumoutflow.BUN/Cre,ABG,Na,K,Cl,andglucoseqdatleast10/4/202317PICUTrainingCourseSlide第17頁TheStandardperitonealdialysissolutionformulation(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/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.610/4/202318PICUTrainingCourseSlide第18頁NotifyDoctorimmediatelyif:PoordialysateflowordrainageSevereabdominalpainordistensionBrightredbloodorcloudydialysatedrainageDialysateleakorpurulentdrainagearoundcatheterexitsiteTachypneiaorSOBFever

10/4/202319PICUTrainingCourseSlide第19頁ComplicationsofPD(1)BleedingfromskinincisionIntestinalperforationBladderperforationLeakageofDialysateAirunderthediaphragmHypokalemiaHyperglycemiaHerniaandHydrocelePDtubemigrationandobstruction10/4/202320PICUTrainingCourseSlide第20頁ComplicationsofPD(2)

Decreasedultrafiltration/IncreasingfluidretentionIncreasedultrafiltration/ExcessivefluidremovalHypotensionExitsiteinfectionTunnelinfectionPeritonitisPulmonarycomplicationsProteinlossandNutritionaldeficiencies10/4/202321PICUTrainingCourseSlide第21頁AcuteHemodialysis(1)Dual-lumencatheterinsertion:femoralvein,subclavianvein,internaljugularveinSinglecatheterinumbilicalveinwiththeothercentralvenouscatheterAblood-flowrateofatleast2to3mL/Kg/minTheextracorporealbloodvolumeshouldnotexceed10%ofthepatient’sbloodvolume(orapproximately8ml/kgBW)Fluidremovalshouldgenerallynotexceed5%ofBWover4-6hrs10/4/202322PICUTrainingCourseSlide第22頁Bloodflowrate(BFR):BFR=2.5xBW(kg)+100ml/min(p’tBW:10-40kg)BFR<100ml/min(p’tBW<10kg)BFR=100~250ml/min(p’tBW>40kg)Ureaclearance:<3-5ml/min/kgAcuteHemodialysis(2)10/4/202323PICUTrainingCourseSlide第23頁HemodialysisprescriptionDialyzer:dialyzermembrane;KUf;dialyzerefficiencyBloodflowrate:100~250ml/minsDialysissolutionflowrate:300~500ml/minsDialysissoultionTemp.:35-36℃

Anticoagulation:HeparinSessionlength:aspatient’scondition10/4/202324PICUTrainingCourseSlide第24頁

DialysissolutioncompositionBicarbonate:25mEq/LNa:145(135-145)mEq/L;K:3.5(2-4)mEq/LCa:3.5(2.5-3.5)mEq/L;Mg:0.75(0.75-1.5)mEq/L;P:noneDextrose:200mg/dL10/4/202325PICUTrainingCourseSlide第25頁ComplicationsduringHDHypotension:

N/Sbolusor5%albumin;mannitol(0.5-1.0g/kg);25%albumin(0.3-0.5gm/kg)↑dialysateNa(140mEq/Landhigher)UltrafiltrationinthefirsthourandthendialysisDialysisDise