腹膜透析导管技术的相关问题.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,腹膜透析导管种类,导管置入技术,目前存在的问题,腹膜透析早期与晚期失败的原因,由无毒的惰性材料制成,可弯曲,质量稳定,具备高的光洁度,能够有效避免微生物在其表面聚集而发生腹膜炎,不透,X,线,便于影像学检查,不受体温、透析液酸碱度、透析液成分及消毒剂的影响而发生质量改变,以防止长期使用过程中发生化学性腹膜炎和异物反应,导管应在皮下和腹膜上两个部位牢固地与组织结合,以有效防止漏液和皮下隧道感染,具有良好的生物相容性,不易被大网膜包裹。,理想的腹膜透析导管,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 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: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 catheter,3.1 mm(Cruz catheter),3.5 mm Flex-Neck(,Medigroup,Oswego,IL,U.S.A.)and,Ash Advantage catheters,BMI 35,腹膜透析导管种类,导管置入技术,目前存在的问题,腹膜透析早期与晚期失败的原因,外科手术置管法,腹腔镜置管法,X,线透视下置管术,导管置入技术,腹膜透析导管种类,导管置入技术,目前存在的问题,腹膜透析早期与晚期失败的原因,PD置管过程中常见的并发症,内脏损伤,导管移位,网膜包裹导管,透析管出水不畅,透析液渗漏,疝,腹膜炎及出口处感染,麻醉意外,导管位置不良,移位,堵塞或包裹所致的腹膜透析液引流不畅,腹膜透析液渗漏,疝,机械并发症,Chronic peritoneal dialysis in children:catheter related complications.A single centre experience,Pediatr Surg Int(2006)22:524528,Causes of catheter removal,血脂代谢紊乱与腹膜透析置管大网膜包裹的关系,中国血液净化2008年3月第7卷第3期,选择中南大学湘雅医院肾内科收集腹膜透析置管术后发生大网膜包裹病例15例，以同期未发生大网膜包裹病例30例为对照，对比二组发生血脂代谢紊乱的差异。同时，以是否存在血脂代谢紊乱分组，对比腹膜透析置管术后大网膜包裹的发生率。,血脂代谢紊乱组20例，网膜包裹11例，网膜包裹率55%,血脂代谢正常组25例，网膜包裹4例，网膜包裹率16%,前者较后者显著升高，P 0.05，差异有统计学意义。,按照有无血脂代谢紊乱分组比较网膜包裹发生情况,PATIENT CHARACTERISTICS ASSOCIATED WITH DEFECTS OF THE PERITONEAL CAVITY BOUNDARY,Peritoneal Dialysis International,Vol.25,pp.367373,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.,Hernias 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%),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 hernias was 7%.,腹膜透析导管种类,导管置入技术,目前存在的问题,腹膜透析早期与晚期失败的原因,CONTRIBUTION OF EARLY FAILURE TO OUTCOME ON PERITONEAL DIALYSIS,Perit Dial Int 2008;28:259267,To analyze the importance of early treatment failure in PD and to compare 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 failures 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 first step to improving outcome by interventions(e.g.,improvement of catheter implantation technique,support to prevent psychosocial problems).,腹部和盆腔手术史对终末期肾病患者,腹膜透析导管置管的影响,有腹部和盆腔手术史,(A),组,25,例,无腹部和盆腔手术史,(B),组,86,例,其中,A,组具体手术如下,:,阑尾切除术,7,例、肾盂切开取石术,7,例、胆囊切除术,6,例、输卵管结扎术,1,例、剖宫产术,2,例、子宫切除术,1,例、胃大部切除术,2,例和脾脏切除术,1,例,其中,2,例曾接受,2,种手术治疗。,丁小强等内科理论与实践 2007 年第 2 卷第 6 期,对先前有腹部和盆腔手术史的 ESRD 患者,如腹部手术范围较小、估计腹腔内粘连较轻者,一般仍可选择 PD 治疗。既往腹部和盆腔手术史对 ESRD患者 PD导管放置后短期和长期并发症的发生率没有显著影响。,Tiong 等分析了 164例 CAPD置管手术患者,结果发现 43 例先前有腹部手术史的患者中有 18 例(41.9%)置管术后出现短期(30 d)并发症(如伤口出血或感染、导管移位、出口处出血或感染、早期腹膜炎、管周腹透液渗漏等),而 121 例无腹部手术史的患者中只有 32 例(26.4%)置管术后出现短期(30 d)并发症。作者认为先前腹部手术史是 CAPD 短期并发症的高危因素。,Tiong HY,et al.Singapore Med,2006,47(8):707-711.,回顾性分析上海长征医院1999年2008年由腹膜透析转血液透析治疗的39例患者,透析不充分：尿毒症症状和体征无明显改善和(或)血肌酐下降不明显；,技术失败：漂管、堵管、渗液；,感染：腹膜透析相关感染；,失超滤；,其他原因。,小 结,1.腹膜透析导管的选择对其预后很重要。,2.开放性手术置管术已经很成熟，若条件允许可以进一步探讨腹腔镜术式的使用。,3.完善术后护理与教育是预后良好的保障。,谢谢,