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

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

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

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 2017/4/16 PICU Training Course Slide

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

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

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

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

Tenckhoff PD catheter

Tenckhoff PD catheter-2 cuff

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

該如何開立腹膜透析處方 ?

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

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 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

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

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

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

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

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

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

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 2017/4/16 PICU Training Course Slide

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 2017/4/16 PICU Training Course Slide

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

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