112/04/18 1

血液透析與腹膜透析之使用方法

小兒部腎臟科 林廣彥醫師

112/04/18 PICU Training Course Slide 2

血液透析 (H/D) 腹膜透析 (PD) 慢性連續性腎臟替代療法 (Slow continue r

enal replacement therapy): CVVH, CAVH, CVVHD, CAVHD, CVVHDF, CAV

HDF

Renal replacement Renal replacement therapytherapy

1.1. 何時該介入腎臟替代療法何時該介入腎臟替代療法 ??

2.2. 該如何選擇何種腎臟替代療法 該如何選擇何種腎臟替代療法 ?? H/D; P/D or CVVH; CVVHD H/D; P/D or CVVH; CVVHD

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Indications for Acute Dialysis(1)

1. Symptomatic fluid overloadfluid overload

2. Hyperkalemia (K (K ++ 7.0≧ 7.0≧ mEq/L mEq/L)

3. Symptomatic uremia and/or BUN >150-175 mg/dL

4. Severe intractable acidosis (pH 7.1)≦5. Nonobstructive anuria

6. Oliguria with rapid progression of renal insufficiency

7. Severe hyponatremia or hypernatremia

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Indications for Acute Dialysis (2)

8. Severe hyperphosphatemia and hypocalcemia

9.9. Inadequate urine outputInadequate urine output with obligatory IV flui with obligatory IV fluid requirementsd requirements

10. Potentially harmful levels of toxins. poisons. or drugs (hemodialysis or hemoperfusion)

11.11. Tumor lysis syndrome Tumor lysis syndrome (uric acid >20 mg/dL(uric acid >20 mg/dL)

12.12. HyperammonemiaHyperammonemia in inborn errorsin inborn errors or metabolism (hemodialysis)

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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 ( S

hock; ICH; CAD ect.) 較適合 P/D 水分與鉀離子之移除率 : H/D 較 P/D 好

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Acute Peritoneal Dialysis in Children

PD is more efficient in infants and children Peritoneal surface area in children: twice th

an that of adult per kg 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 personnel

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Technical Consideration of PD

Single (or Two) cuff Tenckhoff catheter Insertion: Surgical insertion or Percutaneous insertion

Insertion Site:

Tenckhoff PD catheter

Tenckhoff PD catheter-2 cuff

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該如何開立該如何開立腹膜透析處方 腹膜透析處方 ??

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Acute peritoneal dialysis order

1. Dialysate solution %(1.5%,2.5%4.25%)2. Exchange volume: initial 20ml/kg and gradually up to 40~50m

l/kg during one week3. Warm dialysate fluid to 37 ℃ ( 用 blood exchange 之溫血環 )4. Cycle time: inflow 5~10 minutes

dwell 30~40 minutes outflow 15~20 minutes

5. Add heparin 500~1000 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 optimum outflow.8. BUN/Cre, ABG, Na, K, Cl, and glucose qd at least

The Standard peritoneal dialysis solution formulation(mEq/L)

Na: 132; K:0; Mg:0.5; Ca:3.5; Cl:96; Lactate:40

Dextrose (glucose monohydrate): 1.5%; 2.5%; 4.25%

Package: 1L(1.5%); 2L; 2.5L; 5L/bagDextrose Glucose Osmolarity Ultrafiltrate Volume

g/dL g/dL mOsm/L mL/exchange

L/d

1.5 1.36 346 50-150 1.2-3.6

2.5 2.27 396 100-300 2.4-7.2

4.25 3.86 485 300-400 7.2-9.6

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Notify Doctor immediately if:

1. Poor dialysate flow or drainage2. Severe abdominal pain or distension3. Bright red blood or cloudy dialysate drainag

e4. Dialysate leak or purulent drainage around

catheter exit site5. Tachypneia or SOB6. Fever

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Complications of PD (1) Bleeding from skin incisionBleeding from skin incision Intestinal perforationIntestinal perforation Bladder perforation Leakage of DialysateLeakage of Dialysate Air under the diaphragm HypokalemiaHypokalemia Hyperglycemia Hernia and Hydrocele PD tube migration and obstructionPD tube migration and obstruction

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Complications of PD (2)

Decreased ultrafiltration/Increasing fluid retentionDecreased ultrafiltration/Increasing fluid retention Increased ultrafiltration/Excessive fluid removal Hypotension Exit site infection Tunnel infection PeritonitisPeritonitis Pulmonary complications Protein loss and Nutritional deficiencies

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Acute Hemodialysis (1) Dual-lumen catheter insertion: femoral vein, subcla

vian vein, internal jugular vein Single catheter in umbilical vein with the other centr

al venous catheter A blood-flow rate of at least 2 to 3 mL/Kg/min The extracorporeal blood volume should not exceed

10% of the patient’s blood volume ( or approximately 8 ml/kg BW)

Fluid removal should generally not exceed 5% of BW over 4-6 hrs

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Blood flow rate(BFR):BFR=2.5xBW(kg)+100 ml/min (p’t BW:10-40kg)BFR<100 ml/min (p’t BW<10 kg)BFR=100~250 ml/min (p’t

BW>40kg)Urea clearance: <3-5 ml/min/kg

Acute Hemodialysis(2)

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Hemodialysis prescription Dialyzer: dialyzer membrane; KUf; dialyzer ef

ficiency Blood flow rate: 100~250ml/mins Dialysis solution flow rate: 300~500 ml/mins Dialysis soultion Temp.:35-36℃ Anticoagulation: Heparin Session length: as patient’s condition

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Dialysis solution composition

Bicarbonate: 25mEq/L Na: 145 (135-145) mEq/L; K: 3.5(2-4) mEq

/L Ca: 3.5(2.5-3.5) mEq/L; Mg:0.75(0.75-1.5)

mEq/L; P: none Dextrose: 200mg/dL

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Complications during HD Hypotension:

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 dialy

sis Dialysis Disequilibrium Syndrome Arrthymia

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小兒科血液透析交班單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 , 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:

THE END