血液透析和腹膜透析之使用方法

血液透析與腹膜透析之用法小兒部腎臟科林廣彥醫師10/4/20231第1页血液透析(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

Renalreplacementtherapy10/4/20232PICUTrainingCourseSlide第2页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;CVVHD10/4/20233PICUTrainingCourseSlide第3页IndicationsforAcuteDialysis(1)SymptomaticfluidoverloadHyperkalemia(K+

≧7.0mEq/L)Symptomaticuremiaand/orBUN>150-175mg/dLSevereintractableacidosis(pH≦7.1)NonobstructiveanuriaOliguriawithrapidprogressionofrenalinsufficiencySeverehyponatremiaorhypernatremia10/4/20234PICUTrainingCourseSlide第4页IndicationsforAcuteDialysis(2)SeverehyperphosphatemiaandhypocalcemiaInadequateurineoutputwithobligatoryIVfluidrequirementsPotentiallyharmfullevelsoftoxins.poisons.ordrugs(hemodialysisorhemoperfusion)Tumorlysissyndrome(uricacid>20mg/dL)

Hyperammonemia

ininbornerrorsormetabolism(hemodialysis)10/4/20235PICUTrainingCourseSlide第5页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旳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10/4/20236PICUTrainingCourseSlide第6页AcutePeritonealDialysisinChildrenPDismoreefficientininfantsandchildrenPeritonealsurfaceareainchildren:twicethanthatofadultperkgbodyweightTheultrafiltrationrateperKgBW:higherinsmallerpediatricpatientsshortdialysatedewelltimesareusedPediatrichemodialysis:technicalchallengesandrequiresspeciallytrainedpersonnel10/4/20237PICUTrainingCourseSlide第7页TechnicalConsiderationofPDSingle(orTwo)cuffTenckhoffcatheterInsertion:SurgicalinsertionorPercutaneousinsertionInsertionSite:10/4/20238PICUTrainingCourseSlide第8页TenckhoffPDcatheter10/4/20239PICUTrainingCourseSlide第9页TenckhoffPDcatheter-2cuff10/4/202310PICUTrainingCourseSlide第10页10/4/202311PICUTrainingCourseSlide第11页10/4/202312PICUTrainingCourseSlide第12页10/4/202313PICUTrainingCourseSlide第13页10/4/202314PICUTrainingCourseSlide第14页10/4/202315PICUTrainingCourseSlide第15页該如何開立腹膜透析處方?10/4/202316PICUTrainingCourseSlide第16页AcuteperitonealdialysisorderDialysatesolution%(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,andglucoseqdatleast10/4/202317PICUTrainingCourseSlide第17页TheStandardperitonealdialysissolutionformulation(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/d1.51.3634650-1501.2-3.62.52.27396100-3002.4-7.24.253.86485300-4007.2-9.610/4/202318PICUTrainingCourseSlide第18页NotifyDoctorimmediatelyif:PoordialysateflowordrainageSevereabdominalpainordistensionBrightredbloodorcloudydialysatedrainageDialysateleakorpurulentdrainagearoundcatheterexitsiteTachypneiaorSOBFever

10/4/202319PICUTrainingCourseSlide第19页ComplicationsofPD(1)BleedingfromskinincisionIntestinalperforationBladderperforationLeakageofDialysateAirunderthediaphragmHypokalemiaHyperglycemiaHerniaandHydrocelePDtubemigrationandobstruction10/4/202320PICUTrainingCourseSlide第20页ComplicationsofPD(2)

Decreasedultrafiltration/IncreasingfluidretentionIncreasedultrafiltration/ExcessivefluidremovalHypotensionExitsiteinfectionTunnelinfectionPeritonitisPulmonarycomplicationsProteinlossandNutritionaldeficiencies10/4/202321PICUTrainingCourseSlide第21页AcuteHemodialysis(1)Dual-lumencatheterinsertion:femoralvein,subclavianvein,internaljugularveinSinglecatheterinumbilicalveinwiththeothercentralvenouscatheterAblood-flowrateofatleast2to3mL/Kg/minTheextracorporealbloodvolumeshouldnotexceed10%ofthepatient’sbloodvolume(orapproximately8ml/kgBW)Fluidremovalshouldgenerallynotexceed5%ofBWover4-6hrs10/4/202322PICUTrainingCourseSlide第22页Bloodflowrate(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)10/4/202323PICUTrainingCourseSlide第23页HemodialysisprescriptionDialyzer:dialyzermembrane;KUf;dialyzerefficiencyBloodflowrate:100~250ml/minsDialysissolutionflowrate:300~500ml/minsDialysissoultionTemp.:35-36℃

Anticoagulation:HeparinSessionlength:aspatient’scondition10/4/202324PICUTrainingCourseSlide第24页

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/dL10/4/202325PICUTrainingCourseSlide第25页ComplicationsduringHDHypotension:

N/Sbolusor5%albumin;mannitol(0.5-1.0g/kg);25%albumin(0.3-0.5gm/kg)↑dialysateNa(140mEq/Landhigher)UltrafiltrationinthefirsthourandthendialysisDialysisDise