血液透析与腹膜透析之使用方法PP小儿肾脏科.ppt

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 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 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 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) 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 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 Technical Consideration of PD Single (or Two) cuff Tenckhoff catheter Insertion: Surgical insertion or Percutaneous insertion Insertion Site: Tenckhoff PD catheter 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 Notify Doctor immediately if