【持续性肾脏替代治疗crrt英文精品课件】acute peritoneal dialysis (pd) in the picu

Acute peritoneal dialysis (PD) in the PICU,Constantinos J. Stefanidis,“P. & A. Kyriakou” Childrens Hospital, Athens, Greece,C J Stefanidis 2002,Late referral life-threatening hyperkalemia or severe volume overload,Choice of dialysis in ARF,C J Stefanidis 2002,HD,PD,Choice of dialysis in ARF,CRRT,C J Stefanidis 2002,Preferential use of PD and CRRT,Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3,PD,CRRT,C J Stefanidis 2002,When to start PD in ARF ?,Symptomatic uraemia Hyperkalaemia Volume overload Severe metabolic acidosis ( refractory to medical treatment),Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831,C J Stefanidis 2002,When to start PD in ARF ?,S. creatinine and blood urea are not primary indications for dialysis unless they relate to mental status changes,Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831,C J Stefanidis 2002,When to start PD in ARF ?,In the absence of data it is advisable to start dialysis at the earliest sign that it may be needed,There are essentially no data,Flynn JT. Pediatr Nephrol 2002;17(1):61-9,C J Stefanidis 2002,Benefits of PD,PD still remains the modality of renal replacement therapy of choice in many pediatric nephrology centers, because: 1. it requires minimal equipment and infrastructure,Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9,2. it is fairly inexpensive compared with other modalities,3. it is relatively easy to perform and does not require additional nursing personnel.,C J Stefanidis 2002,Benefits of PD,1. Less haemodynamic instability,Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9,3. Avoidance of angioaccess,2. Avoidance of systemic anticoagulation,Children with ARF who are hypotensive, requiring vasopressor support and children with multiple organ failure are successfully managed with PD,C J Stefanidis 2002,Disadvantages of PD,1. Slower correction of metabolic parameters lower urea clearances,Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9,2. Lower ultrafiltration,3. Risk of peritonitis,C J Stefanidis 2002,Thadhani R et al Acute renal failure. N Engl J Med 1996; 334: 1448-1460,Complexity,PD,Low,Intermittent,Choice of dialysis in ARF,C J Stefanidis 2002,Acute PD in the PICU,PD catheters for ARF,Choice of dialysis treatment,Prescription of PD in ARF,C J Stefanidis 2002,Trocath catheters,Their prolonged use ( 3 days) was associated with a significant risk of: leakage malfunction peritonitis,In our days very few centers use these catheters,A major complication was viscus perforation.,C J Stefanidis 2002,Acute PD catheters,Percutaneus guidewire inserted catheters,Trocath catheters,Tenckhoff catheters implanted under general anesthesia,C J Stefanidis 2002,Site of introduction: Level of umbilicus lateral to the rectus sheath (newborns) or any where along a line parallel to the rectus sheath.,Local anesthetic,Percutaneus guidewire inserted catheters,C J Stefanidis 2002,Percutaneus guidewire inserted catheters,Insertion of Angiocath 18 G Flushed with 5 ml of N/S and aspirated to ensure bowel content is not retrieved,C J Stefanidis 2002,Seldinger (Acta Radiologica, 38, 1953, 368-376),The wire is advanced through the needle in the peritoneal cavity (3-4 cm),Percutaneus guidewire inserted catheters,C J Stefanidis 2002,Seldinger (Acta Radiologica, 38, 1953, 368-376),3-4 mm incision around the wire. In newborns is not recommended ,The wire is removed,The catheter is taped to the skin,Percutaneus guidewire inserted catheters,C J Stefanidis 2002,Femoral vein catheter for neonates,14 G 13.5 cm 3 sideports,Guide wire-inserted femoral vein polyurethane catheter (Medcomp-pediatric),C J Stefanidis 2002,Cook catheter 8.5 French 8 cm 44 sideports,Percutaneus guidewire inserted catheter,/cook_incorporated/pdf/CDB11.pdf,C J Stefanidis 2002,5 French Cook PD catheter,29 infants age 4.5 +/- 1.3 months weight 4.8 +/- 0.5 kg Complications: inadequate inflow in one case bleeding in one case accidental removal in one case,Bunchman TE. Acute peritoneal dialysis access in infant renal failure Perit Dial Int 1996;16 Suppl 1:S509-11.,Duration of the placed catheters was 9.9 +/- 2.7 days, without the problems associated with the use of a stiff catheter,5 French 5.5 cm,C J Stefanidis 2002,8.5 French 15 cm 6 sideports,/cook_incorporated/pdf/CADB14.pdf,Cook (pleuropericardial) pig tail catheter,C J Stefanidis 2002,Cook (pleuropericardial) pig tail catheter,Retrospective study (1992-1995) in 46 patients Complications of the Seldinger-placed Cook (pleuropericard) catheter were limited: leakage (1/44) bleeding: n = 0 obstruction or dislocation: n = 4 peritonitis: n = 1 (Candida),Vande Walle J et al New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Perit Dial 1997;13:190-4,C J Stefanidis 2002,Tenckhoff catheters,9.5 French,Introducer 11 French,Lewis MA, Nycyk JA.Practical peritoneal dialysis-the Tenckhoff catheter in acute renal failure. Pediatr Nephrol 1992 Sep;6(5):470-5,C J Stefanidis 2002,Tenckhoff catheters implanted under general anesthesia,16 French,C J Stefanidis 2002,Tenckhoff catheters (TC) implanted under general anesthesia compaired with Cook catheters (CC),Chadha V et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis. 2000;35(6):1111-6.,TC in 22 patients and a CC in 37 patients The duration of use of TCs (16 days) was significantly greater than the duration of CC use (5 days; P 0.001). By day 6 of dialysis, 90% of TCs were functioning without complications compared with 46% of CCs,Only 2 patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%).,C J Stefanidis 2002,Laparoscopic Tenckhoff catheter implantation,Daschner M et al Perit Dial Int 2002 Jan-Feb;22(1):22-6,In 25 children laparoscopic TCIs and in 23 conventional TCIs The inner cuff was placed adjacent to the peritoneum, without sutures leakage: n =1, bleeding: n = 0 ,obstruction : n = 2,Laparoscopic TCI is feasible in children of all age groups, with equivalent functional results compared to conventional TCI,An additional advantage is the option to identify and eliminate anatomical risk factors, such as intra-abdominal adhesions or preformed inguinal hernias in male infants,C J Stefanidis 2002,Acute PD catheters,A Tenckhoff catheter implanted under general anesthesia is recommended,If the patient can not undergo surgery, a percutaneus guidewire inserted PD catheter should be placed,C J Stefanidis 2002,Acute PD in the PICU,PD catheters for ARF,Choice of dialysis treatment,Prescription of PD in ARF,C J Stefanidis 2002,The patient should be connected and start automated PD immediately after surgical catheter implantation.,Prescription of acute PD,If APD is not available a closed-drainage system PD system with disconnection should be used. The use of a closed-drainage system reduced the incidence of system-related peritonitis Valeri A et al Am J Kidney Dis 1993,Complications (peritonitis and hypothermia) are significantly reduced with the use of a cycler compared with the manual method. Kohli HS et al Ren Fail 1995,C J Stefanidis 2002,Cefazoline (250 mg/liter) and Heparin 500 U/liter should be added to the dialysis solution for first two days,Initial prescription of acute PD,Dialysate with a glucose concentration of 1.36% for volume of urine 1.5 ml/kg/hr and UF is not required Otherwise a dialysate with a higher glucose concentration 2.27% (or even higher) should be prescribed,For children with severe lactic acidosis or hepatic failure a bicarbonate-based dialysate can be prepared in the hospital pharmacy,C J Stefanidis 2002,Initially the exchange volume is kept low (20 ml/kg, 100-200 ml/m) to reduce the risk of dialysate leakage,Initial prescription of acute PD,After 24 hours the volume is increased by 100-200 ml/m/day up to 800-1000 ml/m as tolerated by the patient,The first day one-hour dwells are prescribed and usually two-hour dwells are recommended on the second day,C J Stefanidis 2002,Prescription of PD should be individually adjusted in the next days according to the needs of ultrafiltration and the parameters of adequacy (bl. urea and s. creatinine levels),Adapted prescription of acute PD,Usually after the stabilization period 5 to 8 exchanges daily are effective in most children with ARF. The aim is to deliver a maximum clearance to compensate the catabolic stress,C J Stefanidis 2002,Messages to take home,1. Early referral and early initiation of PD is very important for the outcome of children with ARF,2. PD should not be used in children with severe life-threatening hyperkalemia or