血液透析与腹膜透析之使用方法

血液透析与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(Slowcontinuerenalreplacementtherapy):CVVH,CAVH,CVVHD,CAVHD,CVVHDF,CAVHDF

Renalreplacementtherapy3/20/20232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;CVVHD3/20/20233IndicationsforAcuteDialysis(1)SymptomaticfluidoverloadHyperkalemia(K+

≧7.0mEq/L)Symptomaticuremiaand/orBUN>150-175mg/dLSevereintractableacidosis(pH≦7.1)NonobstructiveanuriaOliguriawithrapidprogressionofrenalinsufficiencySeverehyponatremiaorhypernatremia3/20/20234IndicationsforAcuteDialysis(2)SeverehyperphosphatemiaandhypocalcemiaInadequateurineoutputwithobligatoryIVfluidrequirementsPotentiallyharmfullevelsoftoxins.poisons.ordrugs(hemodialysisorhemoperfusion)Tumorlysissyndrome(uricacid>20mg/dL)

Hyperammonemia

ininbornerrorsormetabolism(hemodialysis)3/20/20235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3/20/20236AcutePeritonealDialysisinChildrenPDismoreefficientininfantsandchildrenPeritonealsurfaceareainchildren:twicethanthatofadultperkgbodyweightTheultrafiltrationrateperKgBW:higherinsmallerpediatricpatientsshortdialysatedewelltimesareusedPediatrichemodialysis:technicalchallengesandrequiresspeciallytrainedpersonnel3/20/20237TechnicalConsiderationofPDSingle(orTwo)cuffTenckhoffcatheterInsertion:SurgicalinsertionorPercutaneousinsertionInsertionSite:3/20/20238TenckhoffPDcatheter3/20/20239TenckhoffPDcatheter-2cuff3/20/2023103/20/2023113/20/2023123/20/2023133/20/2023143/20/202315該如何開立腹膜透析處方?3/20/202316AcuteperitonealdialysisorderDialysatesolution%(1.5%,2.5%4.25%)Exchangevolume:initial20ml/kgandgraduallyupto40~50ml/kgduringoneweekWarmdialysatefluidto37℃(用bloodexchange之溫血環)Cycletime:inflow5~10minutesdwell30~40minutesoutflow15~20minutesAddheparin500~1000units/LofdialysatetilldialysatecelarAddK+4meq/Lofdialysate,ifserumK+<4meq/LTurnandpositionpatientp.r.n.foroptimumoutflow.BUN/Cre,ABG,Na,K,Cl,andglucoseqdatleast3/20/202317TheStandardperitonealdialysissolutionformulation(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/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.63/20/202318NotifyDoctorimmediatelyif:PoordialysateflowordrainageSevereabdominalpainordistensionBrightredbloodorcloudydialysatedrainageDialysateleakorpurulentdrainagearoundcatheterexitsiteTachypneiaorSOBFever

3/20/202319ComplicationsofPD(1)BleedingfromskinincisionIntestinalperforationBladderperforationLeakageofDialysateAirunderthediaphragmHypokalemiaHyperglycemiaHerniaandHydrocelePDtubemigrationandobstruction3/20/202320ComplicationsofPD(2)

Decreasedultrafiltration/IncreasingfluidretentionIncreasedultrafiltration/ExcessivefluidremovalHypotensionExitsiteinfectionTunnelinfectionPeritonitisPulmonarycomplicationsProteinlossandNutritionaldeficiencies3/20/202321AcuteHemodialysis(1)Dual-lumencatheterinsertion:femoralvein,subclavianvein,internaljugularveinSinglecatheterinumbilicalveinwiththeothercentralvenouscatheterAblood-flowrateofatleast2to3mL/Kg/minTheextracorporealbloodvolumeshouldnotexceed10%ofthepatient’sbloodvolume(orapproximately8ml/kgBW)Fluidremovalshouldgenerallynotexceed5%ofBWover4-6hrs3/20/202322Bloodflowrate(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)3/20/202323HemodialysisprescriptionDialyzer:dialyzermembrane;KUf;dialyzerefficiencyBloodflowrate:100~250ml/minsDialysissolutionflowrate:300~500ml/minsDialysissoultionTemp.:35-36℃

Anticoagulation:HeparinSessionlength:aspatient’scondition3/20/202324

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/dL3/20/202325ComplicationsduringHDHypotension:N/Sbolusor5%albumin;mannitol(0.5-1.0g/kg);25%albumin(0.3-0.5gm/kg)↑dialysateNa(140mEq/Landhigher)UltrafiltrationinthefirsthourandthendialysisDialysisDisequilibriumSyndromeArrthymia3/20/2023263/20/202327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