Overview of peritoneal dialysis from a surgeon s point of view
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Overview of peritoneal dialysis: From a surgeon’s point of view. Chun-Nan Yeh, MD. Department of Surgery Chang Gung Memorial Hospital, Chang Gung University Taiwan. 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. 腹膜透析通路. 永久性導管 (Tenckhoff Catheter) 材質 : 矽膠 (Silicon rubber) 種類 :

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Overview of peritoneal dialysis from a surgeon s point of view

Overview of peritoneal dialysis: From a surgeon’s point of view

Chun-Nan Yeh, MD.

Department of Surgery

Chang Gung Memorial Hospital, Chang Gung University

Taiwan


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

腹膜透析導管


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Overview of peritoneal dialysis from a surgeon s point of view

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


Noninfectious complications

Noninfectious Complications非感染性合併症


Catheter related complication

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


Pericatheter and subcutaneous leaks

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


Pericatheter and subcutaneous leaks1

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。④F/U CT


Pericatheter and subcutaneous leaks2

Pericatheter and Subcutaneous leaks

Diagnostics

★ CT

★Peritoneal MRI


Pericatheter leak

Pericatheter Leak


Pericatheter and subcutaneous leaks3

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


Pericatheter and subcutaneous leaks4

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


Pericatheter and subcutaneous leaks5

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)


Catheter related complication1

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


Peritoneal catheter obstruction

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

Assessments

★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


Catheter migration after insertion

Catheter migration after insertion


Omental wrap entrapment

Omental wrap (entrapment)


Peritoneal catheter obstruction1

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

Activities


Peritoneal catheter obstruction2

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)


Peritoneal catheter obstruction3

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


Peritoneal catheter obstruction4

Peritoneal catheter obstruction

Outcomes evaluation

★Collect data to include:

阻塞形式(inflow / outflow)

診斷原因,預防措施


Noninfectious complications non catheter related

Noninfectious Complications Non-catheter related

非導管相關非感染性合併症


Noninfectious complications1

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


Hernia

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


Hernias left untreated

疝氣未治療Hernias left untreated

增加疝氣擴大的風險

疼痛,腸子陷入疝氣處

無法再繼續腹膜透析治療.


Hernia1

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


Hernia key assessment

HerniaKey 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


Hernia key activity

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


Hernia therapeutics

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


Hernia patient education

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


Hernia patient education1

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


Hernia outcome evaluation

Hernia OUTCOME EVALUATION

疝氣形式

預防措施

結果

透析處方的更改


Noninfectious complications2

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


Abdominal discomfort during infusion and drain key assessments

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


Abdominal discomfort during infusion and drain key activities

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


Abdominal discomfort during infusion and drain key activities1

Abdominal Discomfort During Infusion and Drain-KeyActivities

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


Abdominal discomfort during infusion and drain key activities2

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


Abdominal discomfort during infusion and drain key activities3

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%)


Abdominal discomfort during infusion and drain patient education

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


Abdominal discomfort during infusion and drain outcome evaluation

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


Noninfectious complications3

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


Hemoperitoneum

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


Hemoperitoneum key assessments

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)


Hemoperitoneum key assessments1

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


Hemoperitoneum key activities

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


Hemoperitoneum patient education

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


Hemoperitoneum outcome evalution

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


Noninfectious complications4

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


Hydrothorax key assessment

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


Hydrothorax key assessment1

Hydrothorax- Key Assessment


Hydrothorax key activities

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


Hydrothorax key activities1

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


Outcome of pleurodesis of hydrothrorax in capd

Outcome of Pleurodesis of hydrothrorax in CAPD

Mak et al. Ann Thorac Surg 2002;74:218-221


Hydrothorax

Hydrothorax

Thoracoscopy visualization of pleuroperitoneal communication and direct surgical obliteration

Video –Assisted Thoracic surgery (VATS)


Hydrothorax patient education

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


Hydrothorax outcome evaluation

Hydrothorax- Outcome Evaluation

滲漏形式

診斷評估及結果

處置,預後


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