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1、2019/1/20,PICU Training Course Slide,1,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 therapy,2019/1/20,PICU Training Course Slide,2,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; CVVHD,2019/1/20,PICU Training Cou
2、rse Slide,3,Indications for Acute Dialysis(1),Symptomatic fluid overload Hyperkalemia (K + 7.0 mEq/L) Symptomatic uremia and/or BUN 150-175 mg/dL Severe intractable acidosis (pH 7.1) Nonobstructive anuria Oliguria with rapid progression of renal insufficiency Severe hyponatremia or hypernatremia,201
3、9/1/20,PICU Training Course Slide,4,Indications for Acute Dialysis (2),Severe hyperphosphatemia and hypocalcemia Inadequate urine output with obligatory IV fluid requirements Potentially harmful levels of toxins. poisons. or drugs (hemodialysis or hemoperfusion) Tumor lysis syndrome (uric acid 20 mg
4、/dL) Hyperammonemia in inborn errors or metabolism (hemodialysis),2019/1/20,PICU Training Course Slide,5,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,2019/1/20,PICU Training Course Slide,6,Acute Peritoneal D
5、ialysis 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 used Pediatric hemodialysis: technical challenge
6、s and requires specially trained personnel,2019/1/20,PICU Training Course Slide,7,Technical Consideration of PD,Single (or Two) cuff Tenckhoff catheter Insertion: Surgical insertion or Percutaneous insertion Insertion Site:,2019/1/20,PICU Training Course Slide,8,Tenckhoff PD catheter,2019/1/20,PICU
7、Training Course Slide,9,Tenckhoff PD catheter-2 cuff,2019/1/20,PICU Training Course Slide,10,2019/1/20,PICU Training Course Slide,11,2019/1/20,PICU Training Course Slide,12,2019/1/20,PICU Training Course Slide,13,2019/1/20,PICU Training Course Slide,14,2019/1/20,PICU Training Course Slide,15,該如何開立腹膜
8、透析處方 ?,2019/1/20,PICU Training Course Slide,16,Acute peritoneal dialysis order,Dialysate solution %(1.5%,2.5%4.25%) Exchange volume: initial 20ml/kg and gradually up to 4050ml/kg during one week Warm dialysate fluid to 37 ( 用 blood exchange 之溫血環) Cycle time: inflow 510 minutes dwell 3040 minutes out
9、flow 1520 minutes Add heparin 5001000 units/L of dialysate till dialysate celar Add K+ 4meq/L of dialysate, if serum K+ 4meq/L Turn and position patient p.r.n. for optimum outflow. BUN/Cre, ABG, Na, K, Cl, and glucose qd at least,2019/1/20,PICU Training Course Slide,17,The Standard peritoneal dialys
10、is 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/bag,2019/1/20,PICU Training Course Slide,18,Notify Doctor immediately if:,Poor dialysate flow or drainage Severe abdominal pain or distensi
11、on Bright red blood or cloudy dialysate drainage Dialysate leak or purulent drainage around catheter exit site Tachypneia or SOB Fever,2019/1/20,PICU Training Course Slide,19,Complications of PD (1),Bleeding from skin incision Intestinal perforation Bladder perforation Leakage of Dialysate Air under
12、 the diaphragm Hypokalemia Hyperglycemia Hernia and Hydrocele PD tube migration and obstruction,2019/1/20,PICU Training Course Slide,20,Complications of PD (2),Decreased ultrafiltration/Increasing fluid retention Increased ultrafiltration/Excessive fluid removal Hypotension Exit site infection Tunne
13、l infection Peritonitis Pulmonary complications Protein loss and Nutritional deficiencies,2019/1/20,PICU Training Course Slide,21,Acute Hemodialysis (1),Dual-lumen catheter insertion: femoral vein, subclavian vein, internal jugular vein Single catheter in umbilical vein with the other central venous
14、 catheter A 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 hrs,2019/1/20,PICU Training Course Slide,22,Blood flow rate(BFR): BFR
15、=2.5xBW(kg)+100 ml/min (pt BW:10-40kg) BFR40kg) Urea clearance: 3-5 ml/min/kg,Acute Hemodialysis(2),2019/1/20,PICU Training Course Slide,23,Hemodialysis prescription,Dialyzer: dialyzer membrane; KUf; dialyzer efficiency Blood flow rate: 100250ml/mins Dialysis solution flow rate: 300500 ml/mins Dialy
16、sis soultion Temp.:35-36 Anticoagulation: Heparin Session length: as patients condition,2019/1/20,PICU Training Course Slide,24,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,20
17、19/1/20,PICU Training Course Slide,25,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 dialysis Dialysis Disequilibrium Syndrome Arrthymia,2019/1/20,PICU Trainin
18、g Course Slide,26,2019/1/20,PICU Training Course Slide,27,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:,2019/1/20,PICU Training Course Slide,28,2019/1/20,PICU Training Course Slide,29,THE END,