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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. 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

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  1. 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

  2. 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

  3. 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

  4. 腹膜透析導管

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Noninfectious Complications非感染性合併症

  12. 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

  13. 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

  14. 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

  15. Pericatheter and Subcutaneous leaks Diagnostics ★ CT ★Peritoneal MRI

  16. Pericatheter Leak

  17. 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

  18. 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

  19. 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)

  20. 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

  21. 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

  22. Catheter migration after insertion

  23. Omental wrap (entrapment)

  24. 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

  25. 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)

  26. 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

  27. Peritoneal catheter obstruction Outcomes evaluation ★Collect data to include: 阻塞形式(inflow / outflow) 診斷原因,預防措施

  28. Noninfectious Complications Non-catheter related 非導管相關非感染性合併症

  29. 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

  30. 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

  31. 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.

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. Hernia OUTCOME EVALUATION 疝氣形式 預防措施 結果 透析處方的更改

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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%)

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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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