Peritoneal dialysis for the un Peritoneal dialysis for the un-planned
Overview of peritoneal dialysis: From a surgeon’s point of view
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Transcript of Overview of peritoneal dialysis: From a surgeon’s point of view
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Overview of peritoneal dialysis: Overview of peritoneal dialysis: From a surgeon’s point of viewFrom a surgeon’s point of view
Chun-Nan Yeh, MD.
Department of SurgeryChang Gung Memorial Hospital, Chang Gung University
Taiwan
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腹膜透析
是利用人體本身的腹膜 -天然的半透膜來作為透析器 ,以排除血液內的多餘廢物及水份
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腹膜透析通路 永久性導管 (Tenckhoff Catheter)
材質 : 矽膠 (Silicon rubber) 種類 :
直型 Tenckhoff 導管 氈釦 (Dacron cuff) : 單氈釦 , 雙氈釦
由外科醫師植入
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腹膜透析導管
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CAPD 優點 無透析後不適症狀 可維持較理想的血壓和體液狀態 不需建立動靜脈廔管 不須扎針 , 無痛透析 貧血的程度較輕 , 輸血機會減少 殘餘腎功能的維持較久 經血液感染疾病的危險性低 (B,C 肝炎 ) 飲食限制極少 依作息和工作需求來調整透析時間 高度的獨立性和自主性 每月只需返院門診 1 至 2 次
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CAPD 的優點 醫療方面 -* 有穩定的血液生化值* 透析後不適應症狀* 血壓控制較好 , 體液狀態較穩定* 不需動靜脈瘻管 , 不需扎針* 貧血程度較輕* 殘餘腎功能維持時間較長* 對中大分子毒素的清除較好
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CAPD 的優點
社會心理方面 -
* 獨立自主性強* 較少的飲食限制* 彈性的調整自己的生活及治療時間* 較高的被僱用率* 社會心理調適較好
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CAPD 的注意事項
醫療方面 -
蛋白質的流失 體重增加 感染的可能性
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腹膜透析的適應症
有強烈意願要做腹膜透析者 有殘餘腎功能 (Residual Renal Function) 兒童 , 老年人 生活及工作型態活躍者 血管不良 , 無動靜脈瘻管可以供 HD 使用 血壓不穩定者 DM
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腹膜透析的禁忌症
不適當的腹膜 通透特性不良 腹膜有缺損或嚴重沾粘
腹膜腔和肋膜腔之間有相通
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Noninfectious Complications非感染性合併症
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Catheter related complication
導管周圍和皮下滲漏 Pericatheter and Subcutaneous leaks
導管阻塞 Peritoneal catheter obstruction 導管接頭鬆脫或導管破裂 Catheter adapter
disconnect of fracture of peritoneal catheter
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Pericatheter and Subcutaneous leaks
Assessments: Patient at risk
組織癒合不佳 Poor tissue healing
腹腔壓力增加 Increased intra-abdominal pressure
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Pericatheter and Subcutaneous leaks
Activities 1.External leaks 外在滲漏:
①使用葡萄糖試紙片確認導管出口處或傷口處的滲出液是否含有葡萄糖。②評估導管位置、傷口、導管出口處。③加強更換敷料
2.Subcutanous leaks 皮下滲漏 :①監測腹圍。②檢視斜腹區或背後是否有皮下
滲漏。③檢視生殖器是否有水腫情形。④ F/U CT
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Pericatheter and Subcutaneous leaks
Diagnostics ★ CT ★Peritoneal MRI
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Pericatheter Leak
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Pericatheter and Subcutaneous leaks
Therapeutics ★ ①採用平躺少量灌液 500-1500ml。
②必要時 1-2週先採 HD治療。 ★ 侵入性治療 ① 外科修補。 ② 復發性滲漏,評估是否要重新植管
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Pericatheter and Subcutaneous leaks
Patient education★偵測滲漏可能引起的導管出口處感染以及腹膜炎
★ 觀察潛在滲漏症狀★ 減少腹腔壓力★ 反覆性導管周圍滲漏需評估是否導管重植
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Pericatheter and Subcutaneous leaks
Outcomes Evaluation★Collect data to include:
導管形式及植入技術 導管出口處以及傷口的情形 滲漏的形式以及位置 診斷測試以及結果 改變透析處方 ( 劑量 , 次數 , 形式CAPD,APD)
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Catheter related complication
導管周圍和皮下滲露 Pericatheter and Subcutaneous leaks
導管阻塞 Peritoneal catheter obstruction 導管接頭鬆脫或導管破裂 Catheter adapter
disconnect of fracture of peritoneal catheter
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Peritoneal catheter obstruction
★灌注阻塞 Inflow obstruction
☆機械性操作不當 : 管夾未開
☆植管後血塊或纖維蛋白 ☆腹膜炎合併的纖維蛋白
★ ★ 引流阻塞
Outflow obstruction
☆便秘 Constipation
☆尿液留置膀胱壓力過大
☆導管末端飄移離開骨盆腔
☆導管被勾住 : 腸子 , 網膜
☆腹腔網膜包腹 Omental wrap
☆沾黏
AssessmentsAssessments
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Catheter migration after insertion
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Omental wrap (entrapment)
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Peritoneal catheter obstruction
★Conservation noninvasive steps 非侵入性步驟 排除導管紐結或移除管夾 改變身體姿勢 矯正便秘 KUB★Invasive steps 侵入性步驟 重置導管或復位 切除部份網膜 腹腔鏡下使用 guided stiff wires or stylet 重新復位
ActivitiesActivities
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Peritoneal catheter obstruction
Therapeutics
纖維蛋白引起的阻塞 fibrin –related obstruction
★Add heparin 500 to 2000 U/L to dialysate each exchange
★ tissue plasminogen activator (tPA)
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Peritoneal catheter obstruction
Patient education ★導管正確固定以及防止迷你輸液管的紐結 ★ APD 使用時導管正確放置防止紐結 ★避免便秘 : 運動 , 飲食 , 軟便劑 ★病患應能報告引流液減少情況
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Peritoneal catheter obstruction
Outcomes evaluation★Collect data to include:
阻塞形式 (inflow / outflow)
診斷原因 , 預防措施
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Noninfectious Complications Non-catheter related非導管相關非感染性合併症
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Noninfectious Complications
Non-catheter related★疝氣 Hernia★灌注引流引起的腹部不適 Abdominal discomfort during infusion and
drain★血性透析液 Hemoperitoneum★水胸 Hydrothorax
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Hernia
任何形式的疝氣應於腹膜透析治療前 , 進行外科修補手術
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疝氣未治療 Hernias left untreated
1. 增加疝氣擴大的風險2. 疼痛 , 腸子陷入疝氣處3. 無法再繼續腹膜透析治療 .
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Hernia
最常見的疝氣手術切開處 Incisional: 正中植入法 臍疝氣 umbilical 腹股溝 inguinal.
Umbilical hernia Right inguinal hernia
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Hernia Key Assessment
凸出的部位 可縮小或還原 / 疼痛 / 大小 評估紅腫或者發炎情況 如果植管切開部位疝氣 , 檢視導管植入程序
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Hernia Key Activity
觀察檢查疑似部位 轉介外科 臍疝氣有可能沒有症狀 , 盡量避免大量的灌液
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Hernia THERAPEUTICS
Significant hernia requires surgical repair with prosthetic mesh techniques and watertight closure to minimize the high risk of recurrence
平躺 , 低劑量漸進式的增加灌液劑量 視狀況給予暫時血液透析
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Hernia PATIENT EDUCATION
減少腹腔壓力 通報如果疝氣面積增加或者疼痛復發等情形 教導病人換藥時應注意傷口以及導管傷口的換藥順序 , 避免交叉感染 ( 乾淨 髒 )
疝氣带的使用
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Hernia PATIENT EDUCATION
術後透析處方的調整 透析治療盡量採取平躺姿勢 漸進式增加劑量 , 兩週後回復原始處方 術後前兩週活動時可將腹部排空透析液
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Hernia OUTCOME EVALUATION
疝氣形式 預防措施 結果 透析處方的更改
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Noninfectious Complications
Non-catheter related★疝氣 Hernia★灌注引流引起的腹部不適 Abdominal discomfort during infusion and
drain★血性透析液 Hemoperitoneum★水胸 Hydrothorax
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Abdominal Discomfort During Infusion and Drain-Key Assessments
首先須先排除腹膜炎 評估現存症狀 , 次數 , 不適的等級以及灌注引流時不適的先關聯性
觀察透析液 , 引流液引流完畢所需的時間 ,顏色 , 清澈度以及透析液加熱溫度
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Abdominal Discomfort During Infusion and Drain-Key Activities
灌注疼痛 Inflow Pain: 物理性因素 : 透析液溫度或 PH 值 灌注疼痛通常伴隨著灌注完畢而改善
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Abdominal Discomfort During Infusion and Drain-Key Activities
改變灌注姿勢 CAPD, 改變灌注速率 APD, modified tidal (85–90%) 確定灌注的透析液溫度 重新檢視透析導管位置
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Abdominal Discomfort During Infusion and Drain-Key Activities
若病人深感不適 : (IP) lidocaine or bicarbonate Adding sodium bicarbonate (2–5 meq/L) or
lidocaine 2% (3–5 mL) to the dialysate solution may offer some relief
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Abdominal Discomfort During Infusion and Drain-Key Activities
引流不適 : CAPD 引流時留些許透析液在腹腔中 APD, program cycler to deliver modified tidal
PD (85-90%)
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Abdominal Discomfort During Infusion and Drain-Patient Education
減慢灌注速度 , 避免快速增加大量的劑量 避免透析液溫度過冷或過熱 避免導管移位 預防腹膜炎 藥物的使用 Training for APD
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Abdominal Discomfort During Infusion and Drain -Outcome evaluation
不適的程度和時間長度 調整處方 , 藥物 病人適應度 , 診斷以及結果
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Noninfectious Complications
Non-catheter related★疝氣 Hernia★灌注引流引起的腹部不適 Abdominal discomfort during infusion and
drain★血性透析液 Hemoperitoneum★水胸 Hydrothorax
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Hemoperitoneum 血性透析液
常見於女性月經或排卵期 . 輕微出血可能原因 : 導管引起 , 劇烈運動 ,腹膜沾黏
任何形式的出血都需密切觀察 , 探討潛在因素
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Hemoperitoneum- Key Assessments
觀察透析液顏色清澈度以及排除腹膜炎 觀察病人過去情況 , 評估可能原因 是否發生於植管後 Retrograde menstruation/ovulation in
females (評估頻率和發生時間 )
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Hemoperitoneum- Key Assessments
Surgical causes: cholecystitis, rupture of the spleen or pancreatitis
Medical causes: coagulation disorders, PKD, leakage,hematoma ESWL, rupture of ovarian or hepatic cysts, EPS
Recent Exam: enema, colonoscopy Recent use of IP tPA
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Hemoperitoneum- Key Activities
THERAPEUTICS: 植管後
200–1500 mL volume flush with heparinized (500–1,000 U/L) dialysis fluid 直到透析液清澈
觀察引留液顏色 , 若需要可以評估 Hct 如果症狀持續觀察是否有腹膜炎或其他急性腹部疾病
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Hemoperitoneum- Patient Education
教導女性患者 , 仍有月經週期者衛教 , 相關經期排卵相關性之血性透析衛教資訊
增加透析液換液沖洗以降低血性透析液之情形 避免提重物以及外力重擊 紀錄發生頻率 , 週期 , 治療 , 出血狀況 , 是否為自發性的出血
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Hemoperitoneum- Outcome Evalution
預防措施包含藥物 治療後的預後 更改透析處方以及透析時間
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Noninfectious Complications
Non-catheter related★疝氣 Hernia★灌注引流引起的腹部不適 Abdominal discomfort during infusion and
drain★血性透析液 Hemoperitoneum★水胸 Hydrothorax
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Hydrothorax- Key Assessment
Signs and symptoms of pleural effusion: 咳嗽或者呼吸困難 胸痛 , 急性呼吸窘迫 體重增加 透析引流液減少 少量的肋膜積水有可能完全沒有症狀
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Hydrothorax- Key Assessment
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Hydrothorax- Key Activities
Diagnostic: 肺部呼吸音減弱 ( 好發右側 ) 呼吸短促 , 平躺時咳嗽加劇 若引流液減少 , 須注意是否使用高濃度藥水後呼吸短促情形加劇
Exam: Chest X-ray-pleural effusion 核醫 -pleural-peritoneal communication
胸腔引流液呈現高葡萄糖 , 低蛋白
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Hydrothorax- Key Activities
THERAPEUTICS 保守性療法 (peritoneal rest and
intermittent low volume dialysis) 鮮少有成功的機率
胸管引流以及胸腔灑粉法 (talc slurry, autologous blood, OK-432 (Picibanil), minocycline) 成功機率有限
在外科手術之後 , 短暫使用血液透析 3-4 週 , 有助於腹膜橫隔相通處的黏合
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Outcome of Pleurodesis of hydrothrorax in CAPD
Mak et al. Ann Thorac Surg 2002;74:218-221
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Hydrothorax
Thoracoscopy visualization of pleuroperitoneal communication and direct surgical obliteration
Video –Assisted Thoracic surgery (VATS)
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Hydrothorax- Patient Education
偵測患者臨床狀況 , 預防淺在的滲漏情況
視情況給予透析處方改變 增加回診觀察次數
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Hydrothorax- Outcome Evaluation
滲漏形式 診斷評估及結果 處置 , 預後