血液透析和腹膜透析之使用方法PP_小儿肾脏科ppt课件

1、血液透析與腹膜透析之运用方法小兒部腎臟科 林廣彥醫師n血液透析血液透析 (H/D) (H/D) n腹膜透析腹膜透析 (PD)(PD)n慢性連續性腎臟替代療法慢性連續性腎臟替代療法(Slow continue renal (Slow continue renal replacement therapy):replacement therapy):n CVVH, CAVH, CVVHD, CAVHD, CVVHDF, CVVH, CAVH, CVVHD, CAVHD, CVVHDF, CAVHDFCAVHDF Indications for Acute Dialysis(1)Symptomatic

2、 fluid overloadHyperkalemia (K + 7.0 mEq/L)Symptomatic uremia and/or BUN 150-175 mg/dLSevere intractable acidosis (pH 7.1)Nonobstructive anuriaOliguria with rapid progression of renal insufficiencySevere hyponatremia or hypernatremiaIndications for Acute Dialysis (2)Severe hyperphosphatemia and hypo

3、calcemiaInadequate urine output with obligatory IV fluid requirementsPotentially harmful levels of toxins. poisons. or drugs (hemodialysis or hemoperfusion)Tumor lysis syndrome (uric acid 20 mg/dL) Hyperammonemia in inborn errors or metabolism (hemodialysis)血液透析與腹膜透析之比較 n溶質由腹膜去除率或體內生化環境較穩定溶質由腹膜去除率或體

4、內生化環境較穩定n中分子及大分子去除率較每週三次的中分子及大分子去除率較每週三次的HD好好n對於對於hemodynamic unstable patient ( Shock; ICH; CAD ect.) 較適合較適合P/D n水分與鉀離子之移除率水分與鉀離子之移除率: H/D 較較 P/D 好好Acute Peritoneal Dialysis in Children PD is more efficient in infants and children Peritoneal surface area in children: twice than that of adult per kg

5、 body weight The ultrafiltration rate per Kg BW: higher in smaller pediatric patients short dialysate dewell times are used Pediatric hemodialysis: technical challenges and requires specially trained personnelTechnical Consideration of PDSingle (or Two) cuff Tenckhoff catheter Insertion: Surgical in

6、sertion or Percutaneous insertionInsertion Site:Tenckhoff PD catheterTenckhoff PD catheter-2 cuffAcute peritoneal dialysis ordernDialysate solution %(1.5%,2.5%4.25%)nExchange volume: initial 20ml/kg and gradually up to 4050ml/kg during one weeknWarm dialysate fluid to 37 ( 用 blood exchange 之溫血環)nCyc

7、le time: inflow 510 minutesn dwell 3040 minutesn outflow 1520 minutes nAdd heparin 5001000 units/L of dialysate till dialysate celarnAdd K+ 4meq/L of dialysate, if serum K+ 4meq/LnTurn and position patient p.r.n. for optimum outflow.nBUN/Cre, ABG, Na, K, Cl, and glucose qd at leastThe Standard perit

8、oneal dialysis solution formulation(mEq/L)Na: 132; K:0; Mg:0.5; Ca:3.5; Cl:96; Lactate:40Dextrose (glucose monohydrate): 1.5%; 2.5%; 4.25%Package: 1L(1.5%); 2L; 2.5L; 5L/bagDextroseGlucoseOsmolarityUltrafiltrate Volumeg/dLg/dLmOsm/LmL/exchange L/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.

9、86485300-4007.2-9.6Notify Doctor immediately if:nPoor dialysate flow or drainagenSevere abdominal pain or distensionnBright red blood or cloudy dialysate drainagenDialysate leak or purulent drainage around catheter exit sitenTachypneia or SOBnFever Complications of PD (1)Complications of PD (2) Acut

10、e Hemodialysis (1)nDual-lumen catheter insertion: femoral vein, subclavian vein, internal jugular veinnSingle catheter in umbilical vein with the other central venous catheternA blood-flow rate of at least 2 to 3 mL/Kg/min nThe extracorporeal blood volume should not exceed 10% of the patients blood

11、volume ( or approximately 8 ml/kg BW) nFluid removal should generally not exceed 5% of BW over 4-6 hrsBlood flow rate(BFR):BFR=2.5xBW(kg)+100 ml/min (pt BW:10-40kg)BFR100 ml/min (pt BW40kg)Urea clearance: 3-5 ml/min/kgAcute Hemodialysis(2)Hemodialysis prescriptionnDialyzer: dialyzer membrane; KUf; d

12、ialyzer efficiencynBlood flow rate: 100250ml/minsnDialysis solution flow rate: 300500 ml/minsnDialysis soultion Temp.:35-36 nAnticoagulation: HeparinnSession length: as patients conditionDialysis solution compositionnBicarbonate: 25mEq/LnNa: 145 (-145) mEq/L; K: 3.5(2-4) mEq/LnCa: 3.5(2.5-3.5) mEq/L; Mg:0.75(0.75-1.5) mEq/L; P: nonenDextrose: 200mg/dLComplications during HDnHypotension: nN/S bolus or 5%albumin; mannitol (0.5-1.0g/kg);25% albumin(0.3-0.5gm/kg) n dialysate Na (140mEq/L and higher) nUltrafiltration in the first hour and then dialysisnDialys