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
2017/4/16

2. PICU Training Course Slide
Renal replacement therapy
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
2017/4/16
PICU Training Course Slide

3. 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

4. Indications for Acute Dialysis(1)
Symptomatic fluid overload
Hyperkalemia (K + ≧ 7.0 mEq/L)
Symptomatic uremia and/or BUN > mg/dL
Severe intractable acidosis (pH ≦ 7.1)
Nonobstructive anuria
Oliguria with rapid progression of renal insufficiency
Severe hyponatremia or hypernatremia
2017/4/16
PICU Training Course Slide

5. 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/dL)
Hyperammonemia in inborn errors or metabolism (hemodialysis)
2017/4/16
PICU Training Course Slide

6. PICU Training Course Slide
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
2017/4/16
PICU Training Course Slide

7. 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 used
Pediatric hemodialysis: technical challenges and requires specially trained personnel
2017/4/16
PICU Training Course Slide

8. Technical Consideration of PD
Single (or Two) cuff Tenckhoff catheter Insertion: Surgical insertion or Percutaneous insertion
Insertion Site:
2017/4/16
PICU Training Course Slide

9. Tenckhoff PD catheter

10. Tenckhoff PD catheter-2 cuff

13. PICU Training Course Slide
2017/4/16
PICU Training Course Slide

16. 該如何開立腹膜透析處方 ?

17. Acute peritoneal dialysis order
Dialysate solution %(1.5%,2.5%4.25%)
Exchange volume: initial 20ml/kg and gradually up to 40~50ml/kg during one week
Warm dialysate fluid to 37 ℃ ( 用 blood exchange 之溫血環)
Cycle time: inflow 5~10 minutes
dwell 30~40 minutes
outflow 15~20 minutes
Add heparin 500~1000 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
2017/4/16
PICU Training Course Slide

18. 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/bag
Dextrose
Glucose
Osmolarity
Ultrafiltrate Volume
g/dL
mOsm/L
mL/exchange
L/d
1.5
1.36
346
50-150
2.5
2.27
396
4.25
3.86
485

19. Notify Doctor immediately if:
Poor dialysate flow or drainage
Severe abdominal pain or distension
Bright red blood or cloudy dialysate drainage
Dialysate leak or purulent drainage around catheter exit site
Tachypneia or SOB
Fever
2017/4/16
PICU Training Course Slide

20. PICU Training Course Slide
Complications of PD (1)
Bleeding from skin incision
Intestinal perforation
Bladder perforation
Leakage of Dialysate
Air under the diaphragm
Hypokalemia
Hyperglycemia
Hernia and Hydrocele
PD tube migration and obstruction
2017/4/16
PICU Training Course Slide

21. PICU Training Course Slide
Complications of PD (2)
Decreased ultrafiltration/Increasing fluid retention
Increased ultrafiltration/Excessive fluid removal
Hypotension
Exit site infection
Tunnel infection
Peritonitis
Pulmonary complications
Protein loss and Nutritional deficiencies
2017/4/16
PICU Training Course Slide

22. PICU Training Course Slide
Acute Hemodialysis (1)
Dual-lumen catheter insertion: femoral vein, subclavian vein, internal jugular vein
Single catheter in umbilical vein with the other central 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
2017/4/16
PICU Training Course Slide

23. PICU Training Course Slide
Acute Hemodialysis(2)
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
2017/4/16
PICU Training Course Slide

24. Hemodialysis prescription
Dialyzer: dialyzer membrane; KUf; dialyzer efficiency
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
2017/4/16
PICU Training Course Slide

25. Dialysis solution composition
Bicarbonate: 25mEq/L
Na: 145 ( ) mEq/L; K: 3.5(2-4) mEq/L
Ca: 3.5( ) mEq/L; Mg:0.75( ) mEq/L; P: none
Dextrose: 200mg/dL
2017/4/16
PICU Training Course Slide

26. Complications during HD
Hypotension:
N/S bolus or 5%albumin; mannitol ( g/kg);25% albumin( gm/kg)
↑ dialysate Na (140mEq/L and higher)
Ultrafiltration in the first hour and then dialysis
Dialysis Disequilibrium Syndrome
Arrthymia
2017/4/16
PICU Training Course Slide

28. PICU Training Course Slide
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:
2017/4/16
PICU Training Course Slide

30. THE END