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晁忙苗
5 years ago
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1 預先植管階段式開始之腹膜透析 Stepwise Initiation of PD by Using Subcutaneously Embedded PD Catheter Technique 張勝勛醫師成大醫院移植外科

6 Kidney international (2006) 70,S38~S43

8 11% of inserted catheters were never exteriorized : improved renal function died pre-emptive transplant Six catheters (2% of total) were removed for complications before being exteriorized Kidney international (2006) 70,S38~S43

9 Complications initial catheter function (85%) VS 23% malfunction rate (European catheter outcomes) primary non-function (7%) is low rate of exit-site leaks (3%) is also very low peritonitis rate during this period was one per 34 patient-months four incisional hernias no cases of serious abdominal wall hematomas Kidney international (2006) 70,S38~S43

10 PDI 2001,vol.21(3) ; p205~208

11 PDI 2002,vol.22(2) ; p211~219

12 Moncrief Popovich catheter : new method (B group; n = 30), (NB group; n = 30), randomized Standard Tenckhoff catheter : (NS group; : n = 65) start PD within 1 2 weeks after implantation Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection PDI 2002,vol.22(2) ; p211~219

13 埋放在皮下的導管可以放置多久? 導管可長時間埋放於皮下, 最好大於 4-5 週, 等到需要透析時再做出口製作術國外最久的埋放時間是 835 天 ( 平均 50 天 ) 2041 天

15 349 first PD were exteriorized and total observation period was 5624 patient-months Days between insertion of the catheter and exteriorization : early (group 1, days), mid (group 2, days) and late (group 3, days) exteriorization Nephrol Dial Transplant (2008) 23:

16 Mechanical complications and catheter loss are associated with the length of time a catheter is embedded. We recommend insertion 6 weeks to 5 months ahead of the need for PD to maximize catheter survival. Nephrol Dial Transplant (2008) 23:

17 How to tie the catheter? Tie-Band No import license in Taiwan? 替代品 (license OK): 2-0 suture line-nylon Clip (Johnson-Johnson LT-300) 1-0 Silk ( B Braun)-suture line The 2 nd wound location? Turn over wound Future exit site

18 Skin Design before Operation 2.Turn Over Wound Future Exit Site 1.Incision Wound 3.Ending Wound

19 surgery kit and accessories Blockade Catheter accessories a. Tie-Band tie on Future Exit Site

20 a. Tie-Band tie on Future Exit Site Benefits Blockade Catheter 效果佳製作導管出口時, 容易辨識 Exit Site 的位置製作導管出口時, 可保護導管不被手術刀劃傷 Shortcoming 無登記衛署輸入許可證 Tie-Band 材質堅硬, 植入皮下時, 病人會有異物感將 Catheter 植入皮下時, 比較困難 Moncrief JW, Popovich RP et al. ASAIO J. 39, 62-65, 1993

21 surgery kit and accessories Blockade Catheter accessories b. Clip LT 300 tie on Future Exit Site

22 b. Clip LT 300 tie on Future Exit Site Benefits 有登記衛署輸入許可證 Blockade Catheter 時, 操作容易製作導管出口時, 容易辨識 Exit Site 的位置 Shortcoming Blockade Catheter 效果不穩定, 曾有病人發生拉出導管時,Clip 鬆脫情形

23 surgery kit and accessories Blockade Catheter accessories c. 1-0 Silk or 2-0 Nylon suture linetie on Catheter Terminal Silk 綁在導管末端

24 c. 1 Silk or 2 Nylon suture line tie on Catheter Terminal Benefits 有登記衛署輸入許可證 Blockade Catheter 效果佳將 Catheter 植入皮下時, 操作容易 Silk 植入皮下時, 病人不會有異物感 Shortcoming 製作導管出口時, 不容易辨識 Exit Site 的位置先找出 Cuff 位置, 向下沿著 Catheter 2~3 cm 處, 定為 Exit Site 的位置

25 How I Do The Operation

26 Idea Reference from this paper :

27 Canada paper Exteriorization of the Embedded Catheter

28 surgery kit and accessories u Heparin in 5ml NS

36 Instill heparin (5ml/5000µ) into catheter. Tighten silk suture line. Confirm complete blockade. And, the catheter is automatically embedded.

42 健保批碼 :62009C 皮下異物取出術 2300 點

43 SMAP Exteriorization of the Embedded Catheter Removed Tie band tool 1 2 3

44 NCKUH Exteriorization of the Embedded Catheter

45 Why, Who and When? Shorter hospital stay and less healthcare costs Patients with expected problems of wound healing, such as diabetic, obese, or steroid therapy Prepare for peritoneal dialysis in a more stable condition of preuremia

46 腹膜透析部分 : 接受透析治療時機 ( 一 ) 植入腹膜透析導管 ( B) 之時機 : 預期開始長期腹膜透析前至少兩週或以上至少兩週或以上 ( 二 ) 糖尿病腎病變患者 : 肌酸酐清除率 (CCr CCr) 小於 15 ml/min, 或肌酸酐 (Cr) 大於 6 mg/dl, 且預期在三個月後需要透析者三個月後 ( 三 ) 非糖尿病腎病變患者 : 肌酸酐清除率 (CCr CCr) 小於 10 ml/min, 或肌酸酐 (Cr) 大於 8 mg/dl, 且預期在後需要透析者且預期在三個月後需要透析者 ( 四 ) 體重低於 30 公斤以下兒童 : 肌酸酐 (Cr) 大於 6 mg/dl 4 歲以下之兒童 : 肌酸酐 (Cr) 大於 5 mg/dl

47 Requirement for two procedures (insertion then exteriorization) : local anesthesia, short OP time no serious complications of exteriorization do not need a double-lumen

48 Mechanical complications one-way obstruction and omental entrapment Overall, 6% (21 of 349) of catheters were complicated by primary mechanical failure The proportion of catheters with primary failure varied significantly with time embedded Nephrol Dial Transplant (2008) 23:

49 預先植管能讓你適時準備透析通路減少緊急透析及其合併症並有時間學習腹膜透析的知識順利進入透析

50 50

67 chronic kidney disease, CKD glomerular filtration rate, GFR 60 ml/1.73 m 2 /min GFR CKD St. Peter, Schoolwerth, McGowan, & McClellan,

67 chronic kidney disease, CKD glomerular filtration rate, GFR 60 ml/1.73 m 2 /min GFR CKD St. Peter, Schoolwerth, McGowan, & McClellan, 66 * chronic kidney disease, CKD 2012 4 12 2012 8 6 2012 63,999 hemodialysis, HD 57,615 90 peritoneal dialysis, PD 6,384 10 2012 2002 * 103 4 23 103 12 23 104 1 15 100 18ES (07) 3121101 5564 wanchun0955@hotmail.com