腹膜透析导管大网膜包裹移位行开放性手术复位后的护理

[目的]总结腹膜透析导管大网膜包裹移位行开放性手术复位后的护理。[方法]对5例腹膜透析导管大网膜包裹移位行开放性手术复位,根据开放性手术行腹膜透析管复位术与首次置管术的不同,早期护理中密切观察术后血性透出液、腹透液渗漏的发生情况,在引流时间、灌入速度、灌入量等方面的护理措施上做出相应的调整;长期随访1年,观察病人是否有切口疝及导管功能再障的发生。[结果]5例病人积极配合治疗,术后恢复良好,顺利出院继续维持腹膜透析治疗;在随访过程中暂未发生切口疝及导管功能再障现象,其中1例病人在复位术半年后因难治性腹膜炎退出腹膜透析。[结论]加强腹膜透析导管大网膜包裹移位行开放性手术复位后的护理有利于病人康复。     

不同抗生素用药方案在预防腹膜透析置管术后腹膜炎中的比较

目的比较不同预防性用药方案在新置腹膜透析导管患者的使用情况,探讨抗生素用药在预防新置腹膜透析导管患者术后发生腹膜炎的重要性。方法回顾性分析2008年10月至2012年10月在北京大学深圳医院肾内科腹膜透析中心接受腹膜透析置管术开始行腹膜透析治疗的患者173例。按照预防性使用抗生素方法分为3组,A组:患者在腹膜透析置管术后3天内使用含有头孢唑啉0.25g/L的腹透液,共计101例次;B组:患者在腹膜透析置管术前3h静脉滴注头孢唑林0.5g,共计48例次;C组:患者术前及术后3天均未使用抗生素,共计24例次。比较3组患者术后14天内腹膜炎的发生率。结果 A组101例患者中1例出现腹膜炎,发生在术后第11天,占0.99%;B组48例患者中2例出现腹膜炎,均发生在术后第1天,占4.17%;C组24例患者中4例出现腹膜炎,3例发生在术后第1天,1例发生在术后第2天,占16.67%。对3组患者腹膜炎发生率进行两两比较,A组与C组比较,P=0.005,P<0.01,差异有统计学意义;B组与C组比较,P>0.05,差异无统计学意义;A组与B组比较,P>0.05,差异无统计学意义。结论腹膜透析置管术围手术期预防性抗生素用药十分有必要,术后腹腔内给药或术前一次静脉用药能有效预防术后腹膜炎发生。     

腹膜透析置管及并发症的护理

[目的]探讨腹膜透析置管及并发症的护理。[方法]回顾性分析2017年10月—2018年10月行腹膜透析置管术的46例肾衰竭病人的临床资料及护理措施。[结果]46例病人均手术成功,术后1例病人因腹膜炎并发真菌感染而拔管,2例病人发生透析管阻塞,3例病人出现腹痛,5例病人给予相应对症处理后均继续腹膜透析治疗,其余病人腹膜透析疗效满意。[结论]加强腹膜透析导管置入术的围术期护理是手术成功的保证。     

腹膜透析导管周围疖肿形成并出口隧道感染1例

正1临床资料患者女性,64岁,因"维持性腹膜透析5年、导管出口周围皮肤红肿、疼痛5天"于2015年7月22日就诊于腹膜透析门诊。5年前因"高血压良性小动脉肾硬化症、慢性肾脏病5期"行腹膜透析置管术,开始腹膜透析(peritoneal dialysis,PD)治疗,每月规律随诊。5天前患者家中洗澡后发现PD导管出口处皮肤原有瘢痕处红肿、疼痛,为进一步诊治来PD门诊。透析方案为2.5%PD液2L每日换液5次,超滤     

改良经皮穿刺腹膜透析置管术在紧急起始腹膜透析中的应用

目的探讨改良经皮穿刺腹膜透析置管术在紧急起始腹膜透析中应用的安全性及有效性。方法选取76例行腹膜透析的终末期肾脏病患者,分别采用改良经皮穿刺法(A组34例)和常规开腹手术法(B组42例)完成置管后开始紧急起始腹膜透析,对2组患者的一般情况、原发病、手术时间、术后早期及远期并发症等进行对比分析。结果 A组在手术时间上短于B组(t=-6.142,P=0.009),术后早期渗漏的发生率、术后早期导管移位的发生率及术后远期导管移位的发生率均低于B组(χ~2值分别为8.341,7.523,11.724;P值分别为0.001,0.003,0.001),腹直肌出血发生率高于B组(χ~2=5.272,P=0.018);2组在网膜包裹、腹膜炎、疝、胸腹瘘方面的差异无统计学意义(χ~2值分别为0.659,0.091,0.148,0.148;P值分别为0.191,0.958,0.809,0.809)。结论在紧急起始腹膜透析中,改良经皮穿刺腹膜透析置管术是一种有效的、安全的、容易掌握的置管方式,与常规开腹手术法相比,手术时间更短,早期渗漏和导管移位的发生率低,值得临床推广。     

可调节式透气型腹带在腹膜透析术后导管固定中的应用

正腹膜透析(CAPD)简称腹透,是治疗急性肾损伤和慢性肾衰竭的有效肾替代治疗方法之一;腹膜透析患者需要永久留置腹透导管,外接短管长约23 cm,术后不易固定,处于游离状态时常常会不慎牵拉管道损伤出口处皮肤,导致皮肤红肿、出血、出口处炎症及隧道感染,甚至引起腹膜炎。由于传统的腹带宽大不透气,容易变松不容易妥善固定导管,且影响患者的舒适度。我们通过改良设计,并根据患者的实际腰围,充分考     

肛袋妙用

腹膜透析病人 ,由于腹部长期置有一根腹膜透析导管 ,病人不敢洗澡 ,害怕洗澡时水沿腹膜透析导管出口处渗入腹腔 ,造成腹透析导管出口处或隧道感染。因此 ,对腹膜透析置管术的病人 ,只能接受擦澡。我科为了解决病人洗澡问题 ,使用一次性肛袋 ,用于 5 7例腹膜透析病人 ,效果良好。现介绍如下。1　方法洗澡前 ,先将一次性肛袋的粘贴纸撕去 ,再将腹膜透析外管卷成一小团 ,塞进一次性肛袋中 ,然后将一次性肛袋粘贴在造瘘口周围即可。洗澡后 ,用生理盐水清洗腹膜透析管出口处周围的皮肤 ,并更换出口处周围的敷料即可。2　优点该法简单、方便 ,病人…     

腹腔镜下腹膜透析置管术对术后并发症的影响

目的 探讨腹腔镜下腹膜透析置管术对导管移位率等并发症的影响.方法 本研究为前瞻性、开放性临床研究.选取武汉市第一医院2007 年1 月至2010 年10 月诊断为尿毒症且愿意行腹膜透析的257 例患者,采取患者自愿选择方式,分为常规手术组(A 组)和腹腔镜手术组(B 组).比较近期、远期并发症如导管功能障碍、腹膜透析液引流不.、血性透出液、管周渗漏、引流疼痛、腹膜炎等方面差异.结果 A 组中有手术史的患者占11.9%,B 组中有手术史的患者占49.4 %,但两组的引流不.发生率分别为13.64 %、4.94 %,导管移位率分别为8.52 %、1.23%,均有显著性差异.在腹膜炎的发生率分别为1 /62.1 病人月、1 /59.7 病人月,两组差异无统计学意义.结论 腹腔镜置管较常规的腹膜透析置管技术发生导管移位率、引流不.率显著降低,且对于有过腹部手术史的患者建议腹腔镜置管.     

爱康肤银敷料与传统方法处理腹膜透析患者导管出口处感染的效果研究

目的比较爱康肤银敷料与传统方法处理腹膜透析导管出口处感染的效果。方法选择2014年1月~2015年3月在我院行腹膜透析置管术符合条件的导管出口处感染患者86例,按随机数字表法分为观察组和对照组,各43例。观察组给予爱康肤银敷料换药。对照组给予传统碘伏、庆大霉素、莫匹罗星软膏局部处理。比较两组导管出口处感染治愈率、愈合时间、再次感染率的差异。结果观察组导管出口处感染治愈率95.35%,较对照组81.39%显著升高(P0.05)。观察组愈合时间(13.27±5.14)d,显著短于对照组(20.05±4.76)d(P0.05)。两组再次感染率比较无显著性差异(P0.05)。结论爱康肤银敷料与传统换药方法比较,可明显提高腹膜透析导管出口处感染治愈率,缩短愈合时间及降低再次感染发生率。     

应用流程处理腹膜透析导管引流不畅

[目的]分析腹膜透析病人导管引流不畅的原因,探讨有效的预防和护理方法。[方法]采用追踪性研究方法．2007年11月-2008年3月在本科行腹膜透析置管术的病人120例,观察开始时间为病人腹膜透析置管术后当天,观察总时间为5个月。分析腹膜透析病人导管引流不畅的原因,制订腹膜透析导管引流不畅的预防和护理流程。对腹膜透析置管术后病人进行教育后,观察病人出现导管引流不畅的时间、运用流程处理后的效果。[结果]120例腹膜透析病人中,发生导管引流不畅13例．发生时间为术后3d～117d。引流不畅原因为导管移位8例,腹胀、便秘4例,大网膜包裹1例。运用流程进行处理后9例病人透析管11流恢复正常,4例病人重新手术后亦恢复了正常的透析。[结论]术后早期教育可预防腹膜透析导管引流不畅的发生,如导管发生引流不畅．早期发现并及时应用流程处理可减少重新手术的可能。     

A New Simplified One-Port Laparoscopic Technique for Peritoneal Dialysis Catheter Placement

♦ Background: Various techniques for laparoscopic insertion of a peritoneal dialysis catheter have been described. Usually 2 - 3 ports are required, and complications related to the port sites (such as abdominal wall hernia, leakage, and hemorrhage) cannot be avoided. To minimize the potential complications, we designed a simplified 1-port laparoscopic technique for peritoneal dialysis catheter placement.♦ Methods: We conducted a retrospective data review of 44 patients who underwent 1-port laparoscopic insertion of a Tenckhoff catheter from June 2009 to February 2011. All patient data, including postoperative complications, were analyzed.♦ Results: The mean follow-up period was 11.52 months. All catheters were working properly, except in 1 patient who developed peritonitis 3 months after catheter placement. (The catheter was removed.) No postoperative abdominal wall hemorrhage, early leaks, hernias, or catheter migration occurred. No exit-site or tunnel infections were observed.♦ Conclusions: Our 1-port laparoscopic technique provides excellent catheter fixation, avoids excessive port sites, and yields good cosmesis. The low complication rate and the simplicity of the method justify its standard use for Tenckhoff catheter placement.     

床旁经皮穿刺气管置管术在危重病人中的应用

目的探讨床旁经皮穿刺气管置管术（PDT）在危重病人中的应用。方法回顾性分析我院ICU实施PDT救治112例危重病人的临床资料。结果110例病人PDT操作均顺利完成,手术时间5～25min,平均（8.0±3.3）min;4例出现并发症,其中切口感染1例,出血1例,气管狭窄2例。结论对危重病人实施PDT,操作简便、快捷,手术成功率高,手术创伤小,并发症少。部分不能耐受传统开放式气管切开术的危重病人,仍可床旁进行PDT。     

联合检测尿NGAL、KIM-1对危重患儿急性肾损伤的临床意义

目的:探讨联合检测尿NGAL、KIM-1在判断重症患儿急性肾损伤(AKI)病情及预后中的作用。方法:以我院肾内科、PICU和健康体检儿童为观察对象,分为重症AKI组,重症非AKI组,CKD组和健康对照组,比较各组的血肌酐(sCr)和尿NGAL、尿KIM-1水平。结果:重症AKI组尿NGAL、KIM-1较重症非AKI组、CKD组、健康对照组明显升高(P0.05),重症非AKI组、CKD组、健康对照组各组间差别无统计学意义(P0.05)。尿KIM-1联合尿NGAL的峰值升高倍数和肾预后呈正相关,和CCr呈负相关关系。结论:尿NGAL和尿KIM-1水平与重症患儿AFI严重程度及肾预后有关。     

Management of refractory peritonitis to maintain the peritoneum for subsequent dialysis.

Peritonitis and its sequelae remain major clinical problems in treating peritoneal dialysis (PD) patients. One of these sequelae is the formation of intra-abdominal adhesions, preventing a patient from returning to peritoneal dialysis after a Tenckhoff catheter is removed for refractory peritonitis. We have recently applied a technique that appears to reduce the incidence of this severe complication. When it is determined that a catheter will be removed for refractory peritonitis, hourly peritoneal dialysis exchanges are performed for 12 hr prior to surgery. Postoperatively, the abdomen is rested for 48 hr, after which a temporary peritoneal dialysis catheter is placed at the bedside and hourly exchanges (with antibiotics) are performed for 2-3 days or until the dialysis fluid white blood cell count improves. Then the temporary catheter is removed and the abdomen is rested until the Tenckhoff catheter is replaced in 10-14 days. We treated 5 consecutive patients with refractory peritonitis (2 Pseudomonas, 1 Proteus, 1 Candida, 1 S. aureus) with this technique. All 5 patients were able to return successfully to peritoneal dialysis. At our institution over the past five years, 9 patients with refractory peritonitis due to the same organisms have had their catheters removed. Only 5 (56%) were able to return to PD. Although preliminary, our technique holds promise for those patients wishing to return to peritoneal dialysis after having a catheter removed for refractory peritonitis.     

Toxic shock syndrome in two CAPD patients with Staphylococcus aureus exit-site infection.

Toxic shock syndrome (TSS) is an illness defined by the occurrence of fever, rash, hypotension, multiple organ system dysfunction, and desquamation. Nonmenstrual TSS is often associated with surgical or nonsurgical cutaneous infections, which are rarely purulent or inflamed (Reingold AL, et al. Nonmenstrual toxic shock syndrome: a review of 130 cases. Ann Intern Med 1982; 96:871-4). Toxic shock syndrome associated with peritoneal exit-site infection but without peritonitis is extremely unusual (Sherbotie JR, et al. Toxic shock syndrome with Staphylococcus aureus exit-site infection in a patient on peritoneal dialysis. Am J Kidney Dis 1990; 15:80-3). We describe 2 patients that met the Centers for Disease Control case definition of TSS secondary to a peritoneal dialysis catheter exit-site infection with signs of mild inflammation and growth of Staphylococcus aureus, but with no evidence of peritonitis.     

A simple method to prevent peritoneal dialysis catheter tip migration.

BACKGROUND: We report here a one-stitch fixation method that prevents catheter tip migration during implantation of the double-cuffed straight Tenckhoff catheter. METHODS: From July 2003 to September 2005, 38 patients with end-stage renal disease underwent implantation of the double-cuff straight Tenckhoff catheter for peritoneal dialysis by this method. RESULTS: No patient had catheter tip migration out of the true pelvis. No patient had pericatheter dialysate leakage or developed incisional hernia. Two patients (5.3%) experienced exit-site infection during the 2- and 5-month follow-up and they recovered well after wound care. Three patients (7.9%) developed peritonitis during the 3-day and 2- and 6-month follow-up; the conditions were controlled after antibiotic care. One patient (2.6%) experienced mechanical catheter obstruction during the 10-day follow-up due to omental wrapping; surgical revision was necessitated. CONCLUSIONS: We believe that the method is an easy, safe, and effective technique for preventing catheter tip migration.     

Immediate initiation of CAPD following percutaneous catheter placement without break-in procedure.

OBJECTIVE: To evaluate the effect of a modified method of percutaneous catheter placement without a break-in procedure on the development of catheter-related complications in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: A prospective, observational clinical study. SETTING: Peritoneal dialysis (PD) units of two university-based hospitals. PATIENTS AND METHODS: This study included 51 consecutive patients on CAPD. A straight double-cuffed Tenckhoff catheter with a straight intraperitoneal segment was used, and all catheters were inserted using a modified percutaneous placement method under local anesthesia. The catheter was introduced directly into the deep pelvis through an intramuscular tract, which had been created by tapered dilators. Peritoneal dialysis was initiated immediately after catheter insertion without a break-in procedure. Catheter-related complications were surveyed during the 12 months after initiation of CAPD. RESULTS: Within the first month, only 1 pericatheter leakage (1.9%) was detected. There were no cases of visceral perforation or severe hemorrhage during catheter insertions. Catheter malfunction due to catheter tip migration, exit-site infection, and peritonitis developed in only 1.9%, 3.9%, and 3.9% of patients, respectively. After 1 month following catheter insertion, no further incidences of pericatheter leakage occurred during the follow-up period. All catheters, except one that was reinserted due to tip migration, survived throughout the study period. CONCLUSION: The rates of pericatheter leakage and other catheter-related complications are relatively low in CAPD patients using our percutaneous catheter placement method without a break-in procedure. This procedure is comparatively simple and less invasive than other catheter placement methods, and allows for immediate start of PD after catheter insertion, without a break-in procedure.     

Prevention of peritonitis in children on peritoneal dialysis.

We reviewed methods of preventing peritonitis in children. A considerable body of evidence indicates that peritonitis rates are lowest with the use of a double-cuffed catheter, with a downward directed tunnel, placed by an experienced surgeon. Evidence in adults, but lacking in children, suggests that exit-site mupirocin will lower Staphylococcus aureus exit-site infections and thus peritonitis rates. The risk of peritonitis due to contamination can be diminished by the avoidance of spiking and by the provision of a long training period. Catheter removal and replacement for catheter-related peritonitis may be done simultaneously in certain circumstances and is useful in decreasing the risk of recurrent peritonitis. Antibiotic prophylaxis at the time of catheter insertion, for contamination, during dialysate leaks, and for invasive procedures appears to be useful in diminishing peritonitis risk.     

Percutaneous Peritoneal Dialysis Catheter Insertion by a Nephrologist: A New,Simple, and Safe Technique

♦ Background: Insertion of the peritoneal dialysis (PD) catheter by a nephrologist has been encouraged by several studies. The ultimate goal is to provide safe, timely, and effective catheter insertion without an unduly long wait time or delay. The success of PD depends partly on the ease of catheter insertion. We developed a new technique for percutaneous PD catheter insertion by nephrologists. Our new technique, in addition to being easy, proved to be safe and to eliminate the need for the peel-away sheath.♦ Methods: Data were collected prospectively on all patients having a PD catheter inserted by a nephrologist using our new technique (40 catheters in 38 patients). All catheters were evaluated for infectious and mechanical complications.♦ Results: The mean duration of the procedure from skin sterilization to the end of insertion was 24 ± 3 minutes. No bowel perforation or serious hemorrhage was recorded. Poor initial drainage was recorded in 12.5% of the catheters (n = 5) during the 4 weeks after insertion. The incidence of early exit-site leakage was 2.5% (1 catheter). Episodes of exit-site infection occurred in 5.0% and 12.5% of catheters (within 1 month and by the end of study period respectively). Two episodes of peritonitis were reported by the end of the 12-month period. Catheter survival was 95.0% and 87.5% at 6 months and 12 months respectively.♦ Conclusions: Percutaneous bedside placement of PD catheters using our new technique is safe and carries less morbidity in terms of bowel perforation, catheter-related infection, and exit-site leak. In addition, our new technique appears to have a high success rate and to offer considerable savings in terms of operating time.     

Fibrin glue used successfully in peritoneal dialysis catheter leakage in children.

BACKGROUND: Acute renal failure in infants and small children is generally treated with peritoneal dialysis (PD). Dialysis has to be started immediately after catheter implantation. Early dialysate leakage can complicate the effectiveness of dialysis. Fibrin glue applied to the external part of the tunnel may stop dialysate leakage and eliminate the need for surgical intervention. The use of fibrin glue in the treatment of PD catheter leakage in children was studied. METHODS: Fibrin glue was used in 8 children (age 0.8 - 57 months) on PD in whom dialysate leakage was seen during the first 24 to 48 hours after catheter insertion.The dialysis volume initially administered was 20 mL/kg body weight. Fibrin glue (1 mL) was applied to the external part of the subcutaneous catheter tunnel through the exit site, as close to the cuff as possible. The occurrence of dialysate leakage and complications such as exit-site or tunnel infection and peritonitis were evaluated. RESULTS: Nine single-cuff straight Tenckhoff catheters were implanted in 8 children. In 5 cases, no subcutaneous tunnel was created. One child had catheter replacement due to obstruction of the catheter; on both occasions, catheter leakage was seen and treated with fibrin glue. In all 8 patients, no relapse of dialysate leakage was seen after application of the fibrin glue. During the time of PD, exit-site infections, tunnel infections, and peritonitis did not occur. CONCLUSION: Fibrin glue is a successful, simple, and safe substance for the treatment of peritoneal dialysate leakage in infants and small children with acute renal failure treated with PD.