血液透析和腹膜透析之使用方法培训课件

1、血液透析和腹膜透析之使用方法血液透析和腹膜透析之使用方法血液透析 (H/D) 腹膜透析 (PD)慢性連續性腎臟替代療法(Slow continue renal replacement therapy): CVVH, CAVH, CVVHD, CAVHD, CVVHDF, CAVHDF Renal replacement therapy10/9/20222血液透析和腹膜透析之使用方法血液透析 (H/D) Renal replacement 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/D or CVVH; CVVHD10/9/20223血液透析和腹膜透析之使用方法何時該介

2、入腎臟替代療法?10/3/20223血液透析和腹膜透Indications for Acute Dialysis(1)Symptomatic 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 hypernatre

3、mia10/9/20224血液透析和腹膜透析之使用方法Indications for Acute DialysisIndications for Acute Dialysis (2)Severe hyperphosphatemia and hypocalcemiaInadequate urine output with obligatory IV fluid requirementsPotentially harmful levels of toxins. poisons. or drugs (hemodialysis or hemoperfusion)Tumor lysis syndrome

4、 (uric acid 20 mg/dL) Hyperammonemia in inborn errors or metabolism (hemodialysis)10/9/20225血液透析和腹膜透析之使用方法Indications for Acute Dialysis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hemodynamic unstable patient ( Shock; ICH; CAD ect.) 較適合P/D 水分與鉀離子之移除率: H/D 較 P/D 好10/9/20226血液透析和腹膜透析之使用方法血液透析與

5、腹膜透析之比較 溶質由腹膜清除率或體內生化環境較穩Acute Peritoneal Dialysis in ChildrenPD is more efficient in infants and children Peritoneal surface area in children: twice than that of adult per kg body weightThe ultrafiltration rate per Kg BW: higher in smaller pediatric patients short dialysate dewell times are usedPed

6、iatric hemodialysis: technical challenges and requires specially trained personnel10/9/20227血液透析和腹膜透析之使用方法Acute Peritoneal Dialysis in CTechnical Consideration of PDSingle (or Two) cuff Tenckhoff catheter Insertion: Surgical insertion or Percutaneous insertionInsertion Site:10/9/20228血液透析和腹膜透析之使用方法T

7、echnical Consideration of PDSTenckhoff PD catheter10/9/20229血液透析和腹膜透析之使用方法Tenckhoff PD catheter10/3/2022Tenckhoff PD catheter-2 cuff10/9/202210血液透析和腹膜透析之使用方法Tenckhoff PD catheter-2 cuff1010/9/202211血液透析和腹膜透析之使用方法10/3/202211血液透析和腹膜透析之使用方法10/9/202212血液透析和腹膜透析之使用方法10/3/202212血液透析和腹膜透析之使用方法10/9/202213血液

8、透析和腹膜透析之使用方法10/3/202213血液透析和腹膜透析之使用方法10/9/202214血液透析和腹膜透析之使用方法10/3/202214血液透析和腹膜透析之使用方法血液透析和腹膜透析之使用方法培训课件該如何開立腹膜透析處方 ?10/9/202216血液透析和腹膜透析之使用方法該如何開立腹膜透析處方 ?10/3/202216血液透析和腹Acute peritoneal dialysis orderDialysate solution %(1.5%,2.5%4.25%)Exchange volume: initial 20ml/kg and gradually up to 4050ml/

9、kg during one weekWarm dialysate fluid to 37 ( 用 blood exchange 之溫血環)Cycle time: inflow 510 minutes dwell 3040 minutes outflow 1520 minutes Add heparin 5001000 units/L of dialysate till dialysate celarAdd K+ 4meq/L of dialysate, if serum K+ 4meq/LTurn and position patient p.r.n. for optimum outflow.

10、BUN/Cre, ABG, Na, K, Cl, and glucose qd at least10/9/202217血液透析和腹膜透析之使用方法Acute peritoneal dialysis ordeThe Standard peritoneal 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/bagDextro

11、seGlucoseOsmolarityUltrafiltrate Volumeg/dLg/dLmOsm/LmL/exchange L/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.610/9/202218血液透析和腹膜透析之使用方法The Standard peritoneal dialysNotify Doctor immediately if:Poor dialysate flow or drainageSevere abdominal pain or distensionBright red

12、 blood or cloudy dialysate drainageDialysate leak or purulent drainage around catheter exit siteTachypneia or SOBFever 10/9/202219血液透析和腹膜透析之使用方法Notify Doctor immediately if:PComplications of PD (1)Bleeding from skin incisionIntestinal perforationBladder perforationLeakage of DialysateAir under the d

13、iaphragmHypokalemiaHyperglycemiaHernia and HydrocelePD tube migration and obstruction10/9/202220血液透析和腹膜透析之使用方法Complications of PD (1)BleedinComplications of PD (2) Decreased ultrafiltration/Increasing fluid retentionIncreased ultrafiltration/Excessive fluid removalHypotensionExit site infectionTunne

14、l infectionPeritonitisPulmonary complicationsProtein loss and Nutritional deficiencies10/9/202221血液透析和腹膜透析之使用方法Complications of PD (2) Acute Hemodialysis (1)Dual-lumen catheter insertion: femoral vein, subclavian vein, internal jugular veinSingle catheter in umbilical vein with the other central ven

15、ous catheterA blood-flow rate of at least 2 to 3 mL/Kg/min The extracorporeal blood volume should not exceed 10% of the patients blood volume ( or approximately 8 ml/kg BW) Fluid removal should generally not exceed 5% of BW over 4-6 hrs10/9/202222血液透析和腹膜透析之使用方法Acute Hemodialysis (1)Dual-lumBlood flo

16、w 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)10/9/202223血液透析和腹膜透析之使用方法Blood flow rate(BFR):Acute HemHemodialysis prescriptionDialyzer: dialyzer membrane; KUf; dialyzer efficiencyBlood flow rate: 100250ml/minsDialysis

17、solution flow rate: 300500 ml/minsDialysis soultion Temp.:35-36 Anticoagulation: HeparinSession length: as patients condition10/9/202224血液透析和腹膜透析之使用方法Hemodialysis prescriptionDialyDialysis solution compositionBicarbonate: 25mEq/LNa: 145 (135-145) mEq/L; K: 3.5(2-4) mEq/LCa: 3.5(2.5-3.5) mEq/L; Mg:0.

18、75(0.75-1.5) mEq/L; P: noneDextrose: 200mg/dL10/9/202225血液透析和腹膜透析之使用方法Dialysis solution compositionComplications during HDHypotension: N/S bolus or 5%albumin; mannitol (0.5-1.0g/kg);25% albumin(0.3-0.5gm/kg) dialysate Na (140mEq/L and higher) Ultrafiltration in the first hour and then dialysisDialysis Disequilibrium Syndrome Arrthymia10/9/202226血液透析和腹膜透析之使用方法Complications during HDHypoten10/9/202227血液透析和腹膜透析之使用方法10/3/202227血液透析和腹膜透析之使用方法小兒科血液透析交班單床號 姓名1. 血壓 : 透析前