腹透導管專業(yè)技術(shù)標準并發(fā)癥

1、腹膜透析導管技術(shù)的相關(guān)問題,王榮 于克洲山東省立醫(yī)院腎臟內(nèi)科,腹膜透析導管種類導管置入技術(shù)目前存在的問題腹膜透析早期與晚期失敗的原因,由無毒的惰性材料制成, 可彎曲, 質(zhì)量穩(wěn)定具備高的光潔度, 能夠有效避免微生物在其表面聚集而發(fā)生腹膜炎不透 X 線, 便于影像學檢查不受體溫、 透析液酸堿度、透析液成分及消毒劑的影響而發(fā)生質(zhì)量改變, 以防止長期使用過程中發(fā)生化學性腹膜炎和異物反應(yīng)導管應(yīng)在皮下和腹膜上兩個部位牢固地與組織結(jié)

2、合, 以有效防止漏液和皮下隧道感染具有良好的生物相容性, 不易被大網(wǎng)膜包裹。,理想的腹膜透析導管,? Silicone rubber (nearly all catheters)? Polyurethane (Cruz catheter),Two main materials,The Most Commonly Used Catheters, by Inner and Outer Shaft Shape,(A) Flex-Neck

3、Tenckhoff catheter, silicone (Medigroup, Oswego,IL, U.S.A.);(B) Cruz Tenckhoff catheter, polyurethane; (C) Standard Tenckhof f catheter, silicone; (D) One intraperitoneal limb of the T-fluted catheter (Ash Advantage:

4、Ash Advantage Technology, Lafayette, IN, U.S.A.), silicone. From S. Ash, with permission.,2.6 mm, the standard size of the Tenckhoff catheter, swan-neck catheter, Missouri swan-neck catheter, and TWH catheter3.1 mm (Cru

5、z catheter)3.5 mm [Flex-Neck (Medigroup, Oswego, IL, U.S.A.)and Ash Advantage catheters],BMI > 35,腹膜透析導管種類導管置入技術(shù)目前存在的問題腹膜透析早期與晚期失敗的原因,外科手術(shù)置管法腹腔鏡置管法X線透視下置管術(shù),導管置入技術(shù),腹膜透析導管種類導管置入技術(shù)目前存在的問題腹膜透析早期與晚期失敗的原因,PD置管過程中常見

6、的并發(fā)癥,內(nèi)臟損傷導管移位網(wǎng)膜包裹導管透析管出水不暢透析液滲漏疝腹膜炎及出口處感染麻醉意外,導管位置不良移位堵塞或包裹所致的腹膜透析液引流不暢腹膜透析液滲漏疝,機械并發(fā)癥,Chronic peritoneal dialysis in children: catheter related complications. A single centre experience,Pediatr Surg Int (2006)

7、 22: 524–528,Causes of catheter removal,血脂代謝紊亂與腹膜透析置管大網(wǎng)膜包裹的關(guān)系,中國血液凈化2008年3月第7卷第3期,選擇中南大學湘雅醫(yī)院腎內(nèi)科收集腹膜透析置管術(shù)后發(fā)生大網(wǎng)膜包裹病例15例，以同期未發(fā)生大網(wǎng)膜包裹病例30例為對照，對比二組發(fā)生血脂代謝紊亂的差異。 同時，以是否存在血脂代謝紊亂分組， 對比腹膜透析置管術(shù)后大網(wǎng)膜包裹的發(fā)生率。,,,血脂代謝紊亂組20例， 網(wǎng)膜包裹11例，網(wǎng)膜包裹

8、率55%血脂代謝正常組25例，網(wǎng)膜包裹4例，網(wǎng)膜包裹率16%前者較后者顯著升高，P ＜0.05，差異有統(tǒng)計學意義。,按照有無血脂代謝紊亂分組比較網(wǎng)膜包裹發(fā)生情況,PATIENT CHARACTERISTICS ASSOCIATED WITH DEFECTS OF THE PERITONEAL CAVITY BOUNDARY,Peritoneal Dialysis International, Vol. 25, pp. 367–3

9、73,Other complications included pericatheter or subcutaneous leak, hydrothorax, and miscellaneous.,200 of these patients experienced a total of 217 anatomic complications 16 patients had more than 1 complication. Herni

10、as comprised 60.4% of all complications: 24.9% inguinal, 18.9% umbilical, 13.8% ventral, 2.3% femoral, and 0.5% intrathoracic. Other complications included pericatheter or subcutaneous leak (25.3%), hydrothorax (6.0%),

11、 and miscellaneous (8.3%). Peritoneal dialysis modalities in use at the time of complication were automated PD (52.3%), continuous ambulatory PD (38.6%), and nocturnal intermittent PD (9.1%). The overall incidence of he

12、rnias was 7%.,腹膜透析導管種類導管置入技術(shù)目前存在的問題腹膜透析早期與晚期失敗的原因,CONTRIBUTION OF EARLY FAILURE TO OUTCOME ON PERITONEAL DIALYSIS,Perit Dial Int 2008; 28:259–267,To analyze the importance of early treatment failure in PD and to compa

13、re early with late failures with respect to reasons and predictors of risk for failure.,Early failure of PD is frequent and makes an important contribution to overall PD outcome. In our population, one third of all PD f

14、ailures and 40% of all technique failures occurred within the first 6 months following catheter implantation. Identification of the main causes of early PD failure (catheter implantation, psychosocial problems) is the f

15、irst step to improving outcome by interventions (e.g., improvement of catheter implantation technique, support to prevent psychosocial problems).,腹部和盆腔手術(shù)史對終末期腎病患者腹膜透析導管置管的影響,有腹部和盆腔手術(shù)史(A)組 25 例無腹部和盆腔手術(shù)史(B)組 86 例其中 A組具體

16、手術(shù)如下: 闌尾切除術(shù) 7 例、 腎盂切開取石術(shù) 7 例、 膽囊切除術(shù) 6 例、 輸卵管結(jié)扎術(shù) 1 例、剖宮產(chǎn)術(shù) 2 例、 子宮切除術(shù) 1 例、 胃大部切除術(shù) 2例和脾臟切除術(shù) 1 例, 其中 2 例曾接受 2 種手術(shù)治療。,丁小強等內(nèi)科理論與實踐 2007 年第 2 卷第 6 期,對先前有腹部和盆腔手術(shù)史的 ESRD 患者, 如腹部手術(shù)范圍較小、 估計腹腔內(nèi)粘連較輕者, 一般仍可選擇 PD 治療。既往腹部和盆腔手術(shù)史對 ESRD患者

17、PD導管放置后短期和長期并發(fā)癥的發(fā)生率沒有顯著影響。,Tiong 等分析了 164例 CAPD置管手術(shù)患者, 結(jié)果發(fā)現(xiàn) 43 例先前有腹部手術(shù)史的患者中有 18 例( 41.9%)置管術(shù)后出現(xiàn)短期(≤30 d)并發(fā)癥(如傷口出血或感染、 導管移位、 出口處出血或感染、 早期腹膜炎、 管周腹透液滲漏等) ,而 121 例無腹部手術(shù)史的患者中只有 32 例( 26.4%)置管術(shù)后出現(xiàn)短期( >30 d)并發(fā)癥。作者認為先前腹部手術(shù)史是

18、 CAPD 短期并發(fā)癥的高危因素。,Tiong HY, et al. Singapore Med ,2006,47 (8):707- 711.,回顧性分析上海長征醫(yī)院1999年～2008年由腹膜透析轉(zhuǎn)血液透析治療的39例患者,①透析不充分：尿毒癥癥狀和體征無明顯改善和(或)血肌酐下降不明顯；②技術(shù)失?。浩?、 堵管、 滲液；③感染：腹膜透析相關(guān)感染；④失超濾；⑤其他原因。,小 結(jié),1.腹膜透析導管的選擇對其預(yù)后