腹膜透析基础培训ppt课件.ppt
腹膜透析基础,How PD works 腹 透 原 理,腹膜透析的定义,腹膜透析（peritoneal dialysis，PD）是通过体内自身膜结构腹膜，作为滤器进行血液净化，清除多余的水份和废物腹膜透析主要是在家中进行治疗。腹膜透析前，先通过简单的手术，将约0.7厘米直径的软管（称为导管）通过腹壁置于腹腔。透析液可以通过此管道进入腹腔。,腹膜结构,腹膜是被覆于腹腔的光滑浆膜脏层腹膜壁层腹膜腹膜凹陷腹腔和腹膜腔,间皮间质巨噬细胞/单核细胞腹膜毛细血管在水和溶质的转换中起重要作用,腹膜组成,腹膜转运途径,Endothelium内皮,Capillaries 毛细血管,Peritoneal Cavity (Dialysate)腹腔（透析液）,Small solutes小分子溶质,Glucose葡萄糖,Macro molecules大分子溶质,Crystalloidosmosis晶体渗透压,Colloidosmosis胶体渗透压,Water水,Interstitium间质,Peritoneal tissue layer腹膜组织层,Ultrafiltration超滤,腹膜将下列两种液体分隔，水分和溶质进行跨膜转运腹膜毛细血管中的血液腹腔中的透析液,腹膜工作原理,PERITONEAL TISSUEBLOOD腹膜组织血液,Membrane腹膜,PERITONEAL CAVITY DIALYSATE腹腔透析液,Membrane model腹膜模型,腹膜转运机理,小分子依靠弥散作用从毛细血管进入腹膜间质，再进入透析液中透析液中的葡萄糖借助弥散作用从腹腔进入腹膜间质，加上弥散出来的小分子，使间质晶体渗透压升高，对毛细血管内水分形成超滤，水就从毛细血管移出；毛细血管中水分的超滤对毛细血管中大分子又产生对流作用，大分子就进入间质，使局部胶体渗透压升高，水被进一步超滤，这样，水和大分子然后分别进入透析液当中；葡萄糖不断进入间质和毛细血管使渗透梯度下降，水的超滤下降。 通过上述过程，毛细血管内的水被超滤出来，小分子和大分子毒素通过弥散和对流作用也被排出，从而实现水和毒素的清除，同时伴随着透析液葡萄糖被机体摄入。,4至6小时之后，代谢废物及多余的水分会停止移动至透析液中,然后你必须流出旧的透析液并灌入另一袋新的透析液,当透析液中的浓度相当于血液中的浓度时，水分和代谢废物则不会再移动。,当你注入新鲜的透析液，废物和多余的水分又会再度移动。,12,4,腹膜透析操作,Indications for dialysis initiation 开始透析的指征,GFR 10-15 ml /min /1.73mUremic symptomsMalnutritionGFR 10-15 ml /min /1.73m尿毒症症状营养不良,有计划地开始透析对于患者非常重要，应尽量避免“急诊透析”！,Indications for emergency dialysis initiation 急诊透析的指征,PericarditisHyperkaliemiaSevere acidosisLung oedemaIntractable hypertensionUremic coma,心包炎高钾血症严重酸中毒肺水肿难治性高血压尿毒症昏迷,Dialysis Process 透析替代作用,What Your Kidneys Do肾脏功能清除代谢产物体液平衡电解质平衡酸碱平衡产生激素PTHEPO维生素D,肾脏本身功能 XXXXXXXXXX,缺点内环境波动大血管通路 需要穿刺感染机会饮食限制需要到透析中心治疗费用高,Haemodialysis 血液透析,优点有效清除代谢产物专业人员实行操作提供病人社会化 一周仅需治疗3次 家庭不需要购置设备(除非家庭 HD),优点在家中自我管理自主性更高治疗计划可以更改饮食限制较少不需穿刺减少机体应激血压控制费用降低,Peritoneal Dialysis 腹膜透析,缺点每日透析植入腹透管体形改变感染机会体重可能增加需要一定的储物空间,Transplantation 移植,优点与自己的肾脏功能相似不需透析不需要通路正常饮食（钠）生活方式更接近正常,缺点手术风险排异反应药物的副作用抵抗力低下体形改变,病肾,移植肾,膀胱,Strong medical indication for PD腹膜透析绝对适应症,Difficulties with vascular accessLeft ventricular hypertrophyCongestive heart failureProsthetic vascular diseaseIntolerance of HDFrequent episodes of hypotensionHeadache and asthenia after HD sessionChildren,血管通路建立困难左心室肥厚充血性心衰人造血管病变不能耐受血液透析经常出现低血压事件血透后头痛和乏力儿童,PD preferred 适合PD,Bleeding diathesis (no need of heparinization)Diabetes (status of vessels, insulin i.p.)Chronic infections (prevention of the nosocomial spread hepatitis B, C, HIV)Future transplantation (improved initial graft function rate) Multiple myeloma (improves the chances of renal recovery, removes some light-chains proteins)出血倾向(不需要肝素化)糖尿病(血管条件，腹腔内使用胰岛素)慢性传染病(预防乙肝、丙肝及艾滋病的院内感染)将来准备肾移植(改善术后移植物成功率)多发性骨髓瘤(增加肾功能恢复机会，清除一些小的轻链蛋白),PD and HD equally preferred可以选择PD或HD,Polycystic kidney diseaseScleroderma, other conective tissue diseases (e.g. SLE)Patients living in nursing homes多囊肾疾病硬皮病及其他结缔组织疾病（系统性红斑狼疮等）居住在护理院的患者,Theoretically not to choose PD initially BUT PD may be feasible with added adjustments 理论上不宜首选腹透治疗，但是进行某些改进后腹透也可以实行的情况,Large body sizeDiverticulosis / diverticulitisSevere backacheNIPDHerniasNIPDMultiple abdominal surgeryPoor manual dexterityBlindnessNo compliance,体形较大(肠)憩室病/憩室炎重度背痛NIPD疝气NIPD腹部多次手术史操作不便失明依从性差,Psychosocial situations in which PD is more appropriate更适合腹透的心理状态,PD preferred Independent LifeFrequent travelsTendency towards PD Great need of independence by the patient Need to maintain workDistance to the HD center,独立生活经常旅行优先选腹透倾向于腹透患者有强烈独立生活的愿望需要继续工作远离血透中心,Empiric prescription 经验处方,3-5 exchanges of 2 L dialysis bagConsidering mainly fluid balance2升袋装透析液交换3-5次注意保持大致液体平衡,The weights at which the weekly Kt/Vurea equals the minimum target of 1.7 每周尿素Kt/V最少达到1.7的患者体重水平 Nolph Kd et al. Perit Dial Int 1994. 14: 261-264,Different PD catheters 不同 腹透管路,Straight 1 cuff,Straight 2 cuffs,Coiled Tenckhoff catheters 卷曲管,Coiled 1 cuff,Coiled 2 cuffs,Swan Neck Tenckhoff catheters 鹅颈管,Straight,Coiled,Downwards directed exit sitePermanent bend between 2 cuffs (180)Right or left,Swan Neck Missouri 鹅颈Missouri管,Straight,Coiled,Bead placed IP, Flange extraP,Straight Tenckhoff catheters 直管,PD Catheter implantation 腹透置管术,Peritoneal Catheter implantation must be performed by a competent and experienced surgeon or nephrologist. Optimal long term peritoneal catheter function and exit site healing are directly related to the skills and the competence of the catheter insertion team.腹透导管埋置术必需由熟练有经验的外科医生或肾病专科医师施行。腹透导管长期保持最佳功能及体外段的愈合，直接与手术医生的技术和能力相关,Gokal et al. Peritoneal catheter and exit site practices.Toward optimal peritoneal access,Perit Dial Int, 1998;18:11-33,Peritoneal Dialysis Technique 腹透技术,Basic proceduresInfusionDwell time (variable)Drainage of dialysis solution (effluent)Volume describes the amount of dialysis solution used in each exchangeDose depicts the amount of solution used over a specified time periodIntermittent PD and continuous PD describe the regimens or plans of the therapy over a period of time基本操作灌注留腹时间（可变）引流腹透液 (流出液)容量每次交换所用的腹透液的量剂量某一时间段内用的透析液总量间歇性腹透及连续性腹透一段时期内用的腹透方案或用法,“Flush before Fill” DesignUltra transfer set. With roller clampDisconnect systemUsing standard spike Solution.Prefilled Minicap Disconnect cap.“灌注前冲洗”的设计带有滚轴夹子的体外导管设置分离系统使用标准接口溶液.预备分离小帽,Drain Flush Fill-Dwell引流冲洗灌注留腹,Common complications in PD 腹透并发症,PeritonitisExit site infectionFluid overload,腹膜炎出口感染容量过多,谢谢！,
