血液透析和腹膜透析之使用方法培训课件.ppt

1、血液透析和腹膜透析血液透析和腹膜透析之使用方法之使用方法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 replacement therapy):CVVH,CAVH,CVVHD,CAVHD,CVVHDF,CAVHDF 11/5/20222血液透析和腹膜透析之使用方法11/5/20223血液透析和腹膜透析之使用方法Indications for Acute Dialysis(1)1.Symptomatic 2.Hyperkalemia)3.Symptomatic uremia and/

2、or BUN 150-175 mg/dL4.Severe intractable acidosis(pH 7.1)5.Nonobstructive anuria6.Oliguria with rapid progression of renal insufficiency7.Severe hyponatremia or hypernatremia11/5/20224血液透析和腹膜透析之使用方法Indications for Acute Dialysis(2)8.Severe hyperphosphatemia and hypocalcemia10.Potentially harmful lev

3、els of toxins.poisons.or drugs(hemodialysis or hemoperfusion)or metabolism(hemodialysis)11/5/20225血液透析和腹膜透析之使用方法血液透析與腹膜透析之比較 n溶質由腹膜清除率或體內生化環境較穩定溶質由腹膜清除率或體內生化環境較穩定n中分子及大分子清除率較每週三次的中分子及大分子清除率較每週三次的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11/

4、5/20226血液透析和腹膜透析之使用方法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 body weight The ultrafiltration rate per Kg BW:higher in smaller pediatric patients short dialysate dewell times are usedPediatr

5、ic hemodialysis:technical challenges and requires specially trained personnel11/5/20227血液透析和腹膜透析之使用方法Technical Consideration of PDSingle(or Two)cuff Tenckhoff catheter Insertion:Surgical insertion or Percutaneous insertionInsertion Site:11/5/20228血液透析和腹膜透析之使用方法Tenckhoff PD catheter11/5/20229血液透析和腹膜透

6、析之使用方法Tenckhoff PD catheter-2 cuff11/5/202210血液透析和腹膜透析之使用方法11/5/202211血液透析和腹膜透析之使用方法11/5/202212血液透析和腹膜透析之使用方法11/5/202213血液透析和腹膜透析之使用方法11/5/202214血液透析和腹膜透析之使用方法11/5/202216血液透析和腹膜透析之使用方法Acute peritoneal dialysis order1.Dialysate solution%(1.5%,2.5%4.25%)2.Exchange volume:initial 20ml/kg and gradually

7、up to 4050ml/kg during one week3.Warm dialysate fluid to 37 (用 blood exchange 之溫血環)4.Cycle time:inflow 510 minutes dwell 3040 minutes outflow 1520 minutes 5.Add heparin 5001000 units/L of dialysate till dialysate celar6.Add K+4meq/L of dialysate,if serum K+4meq/L7.Turn and position patient p.r.n.for

8、 optimum outflow.8.BUN/Cre,ABG,Na,K,Cl,and glucose qd at least11/5/202217血液透析和腹膜透析之使用方法The 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/bagDextroseGlucoseOsmolarityUltrafiltra

9、te Volumeg/dLg/dLmOsm/LmL/exchange L/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.611/5/202218血液透析和腹膜透析之使用方法Notify Doctor immediately if:1.Poor dialysate flow or drainage2.Severe abdominal pain or distension3.Bright red blood or cloudy dialysate drainage4.Dialysate leak or

10、 purulent drainage around catheter exit site5.Tachypneia or SOB6.Fever 11/5/202219血液透析和腹膜透析之使用方法Complications of PD(1)nBladder perforationnAir under the diaphragmnHyperglycemianHernia and Hydrocele11/5/202220血液透析和腹膜透析之使用方法Complications of PD(2)nIncreased ultrafiltration/Excessive fluid removalnHypot

11、ensionnExit site infectionnTunnel infectionnPulmonary complicationsnProtein loss and Nutritional deficiencies11/5/202221血液透析和腹膜透析之使用方法Acute Hemodialysis(1)nDual-lumen catheter insertion:femoral vein,subclavian vein,internal jugular veinnSingle catheter in umbilical vein with the other central venous

12、 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 volume(or approximately 8 ml/kg BW)nFluid removal should generally not exceed 5%of BW over 4-6 hrs11/5/202222血液透析和腹膜透析之使用方法Blood flow rate(BFR):BFR=2.5xBW(kg)+100 ml/m

13、in (pt BW:10-40kg)BFR100 ml/min (pt BW40kg)Urea clearance:3-5 ml/min/kgAcute Hemodialysis(2)11/5/202223血液透析和腹膜透析之使用方法Hemodialysis prescriptionnDialyzer:dialyzer membrane;KUf;dialyzer efficiencynBlood flow rate:100250ml/minsnDialysis solution flow rate:300500 ml/minsnDialysis soultion Temp.:35-36 nAn

14、ticoagulation:HeparinnSession length:as patients condition11/5/202224血液透析和腹膜透析之使用方法Dialysis solution compositionnBicarbonate:25mEq/LnNa:145(135-145)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/dL11/5/202225血液透析和腹膜透析之使用方法Complications during HDnHypotension:n

15、N/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 dialysisnDialysis Disequilibrium Syndrome nArrthymia11/5/202226血液透析和腹膜透析之使用方法11/5/202227血液透析和腹膜透析之使用方法床號 姓名1.血壓:透析前 ,透析後 2.心跳:透析前 ,透析後_;呼吸:透析前 ,透析後_ 3.體重:透析前 ,透析後_ 4.輸血:PRBC U,WB U,PLT U,FFP U領血單位:病房();PICU()5.Complications during H/D:11/5/202228血液透析和腹膜透析之使用方法11/5/202229血液透析和腹膜透析之使用方法THE END11/5/202230血液透析和腹膜透析之使用方法