腹膜透析基礎(chǔ)課件

腹膜透析－ESRD治療寧建平HowPDworks

腹透原理

Whatistheperitonealmembrane?

腹膜是被覆于腹腔的光滑漿膜臟層腹膜壁層腹膜腹膜凹陷腹腔和腹膜腔Roleoftheperitoneum

腹膜的功能ProtectperitonealorgansPreventfrictionofmovingorgansHostdefensemechanisms:Mesothelialcells,monocytesmacrophages,opsonins支持、保護(hù)腹腔臟器分泌滑液防止臟器移動時(shí)的摩擦宿主的防御機(jī)制:間皮細(xì)胞、單核巨噬細(xì)胞、調(diào)理素Componentsoftheperitoneumasadialysismembrane

腹膜（做為透析膜）的組成ThemesotheliumThestagnantfluidfilmTheinterstitiumPeritonealcapillariesStagnantcapillaryfluidThecapillaryendotheliumitselfTheendothelialbasementmembrane間皮滯留液體層（阻力）間質(zhì)腹膜毛細(xì)血管毛細(xì)血管滯留液體毛細(xì)血管內(nèi)皮內(nèi)皮基底膜Thetransportofsolutesandwateracrossa“membrane”thatseparatestwofluidcontainingcompartments.ThebloodintheperitonealcapillariesDialysissolutionintheperitonealcavity腹膜將下列兩種液體分隔，水分和溶質(zhì)進(jìn)行跨膜轉(zhuǎn)運(yùn)腹膜毛細(xì)血管中的血液腹腔中的透析液ABasicConceptofPeritonealDialysis腹透基本概念PERITONEALTISSUEBLOOD腹膜組織血液Membrane腹膜PERITONEALCAVITYDIALYSATE腹腔透析液Membranemodel腹膜模型Diffusion

彌散Definition:Solutemovementduetoconcentrationgradientoftwosolutesbetweencomponentsacrossasemi-permeablemembraneMaindrivingforceforsmallsoluteremovalFactorsinvolvedindiffusionSizeofsolutePeritonealsurfaceareaHydrostaticpressureElectricalchargeofsolutes定義:溶質(zhì)依靠溶液之間濃度梯度透過半透膜（腹膜）進(jìn)行的轉(zhuǎn)運(yùn)彌散是小分子溶質(zhì)清除的主要機(jī)制影響彌散的因素

溶質(zhì)分子的大小

腹膜表面積

靜水壓

溶質(zhì)的電負(fù)荷Convectivetransport

對流轉(zhuǎn)運(yùn)

SolutetransportalongwithfluidmovementHighduringactiveultrafiltrationTermsusedinconvectivetransportSievingcoefficient:RatioofsolutebeingpassedthebarrierReflectioncoefficientRatioofsolutebeingrejectedbythebarrierSievingcoefficient=1-reflectioncoefficientFactorsinvolvedinconvectivetransportSizeofsoluteElectricalchargeofsolutes定義：水分轉(zhuǎn)運(yùn)時(shí)伴隨的溶質(zhì)清除

高效超濾過程中對流作用大

對流轉(zhuǎn)運(yùn)應(yīng)用的參數(shù)

篩選系數(shù)（Sievingcoefficient）：溶質(zhì)通過膜屏障的比例

反射系數(shù)（Reflectioncoefficient）：溶質(zhì)被膜屏障阻擋的比例

篩選系數(shù)＝1－反射系數(shù)

影響對流轉(zhuǎn)運(yùn)的因素

溶質(zhì)分子的大小

溶質(zhì)的電負(fù)荷OsmoticUltrafiltrationMovementofwaterfromachamberwithlowerosmoticpressuretohigheroneacrossasemi-permeablemembrane滲透超濾水分通過半透膜從低滲透壓的腔室轉(zhuǎn)移到高滲透壓的腔室，靜水壓和滲透壓的矢量和決定水分滲透的方向。RemovalofWaterinPD:CrystalloidOsmosisPD水分清除：晶體滲透壓H2OHighglucose-HighosmolalityPeritonealSpace高糖－高滲腹膜部位Capillaryspace毛細(xì)血管Normalosmolality正常滲透壓Smallpore:50%小孔：50％Aquaporinmediated:50%水孔蛋白介導(dǎo)：50％，（只能使水通過，也叫水通道）腹膜轉(zhuǎn)運(yùn)機(jī)理小分子依靠彌散作用從毛細(xì)血管進(jìn)入腹膜間質(zhì)，再進(jìn)入透析液中透析液中的葡萄糖借助彌散作用從腹腔進(jìn)入腹膜間質(zhì)，加上彌散出來的小分子，使間質(zhì)晶體滲透壓升高，對毛細(xì)血管內(nèi)水分形成超濾，水就從毛細(xì)血管移出；毛細(xì)血管中水分的超濾對毛細(xì)血管中大分子又產(chǎn)生對流作用，大分子就進(jìn)入間質(zhì)，使局部膠體滲透壓升高，水被進(jìn)一步超濾，這樣，水和大分子然后分別進(jìn)入透析液當(dāng)中；葡萄糖不斷進(jìn)入間質(zhì)和毛細(xì)血管使?jié)B透梯度下降，水的超濾下降。通過上述過程，毛細(xì)血管內(nèi)的水被超濾出來，小分子和大分子毒素通過彌散和對流作用也被排出，從而實(shí)現(xiàn)水和毒素的清除，同時(shí)伴隨著透析液葡萄糖被機(jī)體攝入。Solutesfromthecirculationtodialysissolutions從血循環(huán)到透析液中的溶質(zhì)Solutesfromdialysissolutionstothecirculation從透析液到血循環(huán)的溶質(zhì)ProteinWhatisPET?Basedonequilibrationofsoluteconcentrationindialysatetoplasmaandperitonealglucoseabsorption.Dialysatetoplasmaconcentrationratioofsolutessuchascreatinine,urea,potassium(D/Psolutes):Dialysate

creatinineconcentrationincreasesascreatininediffusesintotheperitonealcavityduetotheconcentrationgradient.Dialysateglucoseconcentrationdecreasesasperitonealglucoseabsorbsduringadwelltime.Drainvolumeisinverselycorrelatedtosolutetransportrate.PET建立在血漿與透析液中溶質(zhì)濃度的平衡以及腹膜對葡萄糖吸收作用的基礎(chǔ)上.透析液和血漿中溶質(zhì)濃度的比值(D/P)如肌酐、尿素、鉀離子：隨著血液中肌酐順著濃度梯度彌散入腹腔內(nèi)，透析液中肌酐濃度逐漸增加.留腹期間透析液中葡萄糖的濃度隨著腹膜對葡萄糖的吸收而降低.引流量和溶質(zhì)轉(zhuǎn)運(yùn)率負(fù)相關(guān).IntraperitonealVolumeinDifferentTransportGroups不同轉(zhuǎn)運(yùn)的腹膜在腹透時(shí)超濾量的變化Wangetal.NephrolDialTransplant13:1242-49,199822502500275030003250Intraperitonealvolume,ml腹腔內(nèi)液體容量060120180240300360Time,minL低轉(zhuǎn)運(yùn)L-A低平均H-A高平均H高轉(zhuǎn)運(yùn)1.Drainforatleast20min,ideallyafteran8-to12-hourovernightdwellusing2Lof2.5%dextrosesolution2.Weigh2-Lbagofwarmed2.5%dextrosesolution3.Infuseover10min(atarateof200ml/min). Aftereach400-mlinfused,rollthepatientfromsidetoside.4.Indwellfor4hours.Ambulatoryduringdwelltime.5.Drainover20min.6.Afterdrainage,thebagisagainweighed.最好在使用2.5％葡萄糖腹透液留腹過夜8－12小時(shí)后，充分排放透析液至少20分鐘秤量袋裝2升規(guī)格的已加溫的2.5％葡萄糖腹膜透析液3.十分鐘以上灌入腹內(nèi)(速度200ml/min),每灌入400ml時(shí)讓患者翻轉(zhuǎn)身體.4.留腹4小時(shí)，留腹期間要求不臥床.5.排液時(shí)間20分鐘以上.6.排液后再次秤量腹透液袋.PET:Protocol

PET：操作程序Bloodsample:0,2,4hourDialysatesample:200mlofdialysissolutionisdrainedintothebag,mixedwell,a10mlsampleistaken,andtheremaining190mlisreinfusedbackafter2and4hours,anothersampleistaken.CalculateD/Pcreatitineat2and4hoursD/D0glucoseat2and4hoursthevolumeofUFinthedrainagebag血標(biāo)本:0,2,4小時(shí)透析液標(biāo)本:將200ml的透析液排至袋中，充分混勻，取10ml樣本，剩下的190ml液體重新灌入腹腔.計(jì)算2h、4h的肌酐濃度透析液/血漿(D/Pcr)

2h、4h的葡萄糖濃度透析液/血漿(D/D0)

引流袋凈超濾量PET:Sampling

PET：取樣PET:Interpretation

PET評估

D/PforUr,CrandNaandD/DoforGluat0,2,and4hrsarecalculatedPatientsareclassifiedonbasisof4hrD/PCraslow,lowaverage,highaverageorhightransportersIngeneral,hightransportersdialyzewell,butabsorbGlurapidly,havelessUF,greaterdialysateproteinlossesandlowerserumalbuminLowtransportersaretheoppositeandaveragetransportersareinbetween計(jì)算0、2、4小時(shí)的尿素、肌酐、鈉的透析液濃度/血漿濃度(D/PUr,D/PCr

,D/PNa)以及葡萄糖透析液濃度/血漿濃度(D/Do)按照4h時(shí)肌酐透析液濃度/血漿濃度(D/PCr)分為低、低平均、高平均或高轉(zhuǎn)運(yùn)患者總的來說，高轉(zhuǎn)運(yùn)患者透析好但是葡萄糖的吸收快，超濾量少，透析液丟失蛋白多，血清白蛋白也較低低轉(zhuǎn)運(yùn)患者與上述相反，平均轉(zhuǎn)運(yùn)者在兩者之間CategorizationofperitonealtransportinPET

PET中腹膜轉(zhuǎn)運(yùn)特性的分類D/Pcreatinine肌酐D/D0glucose葡萄糖Drainvolume引流量High高轉(zhuǎn)運(yùn)Mean+1SDandaboveMean-1SDandbelowMean-1SDandbelowHighaverage高平均Mean+<1SDMean->1SDMean->1SDLowaverage低平均Mean->1SDMean+>1SDMean+>1SDLow低轉(zhuǎn)運(yùn)Mean-1SDandbelowMean+1SDandaboveMean+1SDandabove患者比例％膜的類型4h時(shí)肌酐腹透液血清比(D/P)特性10%高轉(zhuǎn)運(yùn)0.82－1.03膜效率很高溶質(zhì)轉(zhuǎn)運(yùn)快葡萄糖的吸收快達(dá)到超濾目標(biāo)可能較難有低白蛋白血癥的危險(xiǎn)53%高平均0.65－0.81膜效率高溶質(zhì)轉(zhuǎn)運(yùn)好超濾好31%低平均0.50－0.64膜的效率較低溶質(zhì)轉(zhuǎn)運(yùn)有點(diǎn)慢超濾好6%低轉(zhuǎn)運(yùn)0.34－0.49膜的效率很低溶質(zhì)轉(zhuǎn)運(yùn)慢沒有殘腎功能時(shí)很難達(dá)到目標(biāo)肌酐清除率超濾非常好我國患者腹膜轉(zhuǎn)運(yùn)功能分布有所不同：H15％，HA50％，LA40％，L6％TwardowskiZJ,ASAIOTrans1990;36:8Rapid(high)vsslow(low)transportersinPD高轉(zhuǎn)運(yùn)與低轉(zhuǎn)運(yùn)比較由于病人的轉(zhuǎn)運(yùn)功能不同，應(yīng)進(jìn)行個(gè)體化處方。Importantfactorsdeterminingsoluteandfluidremoval

決定水和溶質(zhì)清除的重要因素Dialysatetoplasmaconcentrationratio(D/P):PeritonealtransportcharacteristicsDiffusionConvectivetransport:MainlydependsonultrafiltrationDialysatevolumeTotalinfusionvolumeUltrafiltrationvolumePeritonealabsorptionBodysize透析液血漿濃度比值(D/P):腹膜轉(zhuǎn)運(yùn)特點(diǎn)：彌散對流轉(zhuǎn)運(yùn)：主要依賴超濾透析液劑量:灌腹總量超濾量腹膜吸收量體形大小DialysisProcess

透析替代作用WhatYourKidneysDo腎臟功能清除代謝產(chǎn)物體液平衡電解質(zhì)平衡酸堿平衡產(chǎn)生激素PTHEPO維生素D

腎臟本身功能XXXXXXXXXX缺點(diǎn)內(nèi)環(huán)境波動大血管通路需要穿刺感染機(jī)會飲食限制需要到透析中心治療費(fèi)用高Haemodialysis

血液透析優(yōu)點(diǎn)有效清除代謝產(chǎn)物專業(yè)人員實(shí)行操作提供病人社會化一周僅需治療3次家庭不需要購置設(shè)備 (除非家庭HD)優(yōu)點(diǎn)在家中自我管理自主性更高治療計(jì)劃可以更改飲食限制較少不需穿刺減少機(jī)體應(yīng)激血壓控制費(fèi)用降低PeritonealDialysis

腹膜透析缺點(diǎn)每日透析植入腹透管體形改變感染機(jī)會體重可能增加需要一定的儲物空間Transplantation

移植優(yōu)點(diǎn)與自己的腎臟功能相似不需透析不需要通路正常飲食（鈉）生活方式更接近正常缺點(diǎn)手術(shù)風(fēng)險(xiǎn)排異反應(yīng)藥物的副作用抵抗力低下體形改變Patient's

KidneyTransplant

Kidney(extra-peritoneally)Bladder病腎移植腎膀胱StrongmedicalindicationforPD

腹膜透析絕對適應(yīng)癥DifficultieswithvascularaccessLeftventricularhypertrophyCongestiveheartfailureProstheticvasculardiseaseIntoleranceofHDFrequentepisodesofhypotensionHeadacheandastheniaafterHDsessionChildren血管通路建立困難左心室肥厚充血性心衰人造血管病變不能耐受血液透析經(jīng)常出現(xiàn)低血壓事件血透后頭痛和乏力兒童PDpreferred

適合PDBleedingdiathesis(noneedofheparinization)Diabetes(statusofvessels,insulini.p.)Chronicinfections(preventionofthenosocomialspread–hepatitisB,C,HIV)Futuretransplantation(improvedinitialgraftfunctionrate)Multiplemyeloma(improvesthechancesofrenalrecovery,removessomelight-chainsproteins)出血傾向(不需要肝素化)糖尿病(血管條件，腹腔內(nèi)使用胰島素)慢性傳染病(預(yù)防乙肝、丙肝及艾滋病的院內(nèi)感染)將來準(zhǔn)備腎移植(改善術(shù)后移植物成功率)多發(fā)性骨髓瘤(增加腎功能恢復(fù)機(jī)會，清除一些小的輕鏈蛋白)PDandHDequallypreferred

可以選擇PD或HDPolycystickidneydiseaseScleroderma,otherconectivetissuediseases(e.g.SLE)Patientslivinginnursinghomes多囊腎疾病硬皮病及其他結(jié)締組織疾?。ㄏ到y(tǒng)性紅斑狼瘡等）居住在護(hù)理院的患者

TheoreticallynottochoosePDinitially–

BUTPDmaybefeasiblewithaddedadjustments

理論上不宜首選腹透治療，

但是進(jìn)行某些改進(jìn)后腹透也可以實(shí)行的情況LargebodysizeDiverticulosis/diverticulitisSeverebackache NIPDHernias NIPDMultipleabdominalsurgeryPoormanualdexterityBlindnessNocompliance體形較大(腸)憩室病/憩室炎重度背痛

NIPD疝氣

NIPD腹部多次手術(shù)史操作不便失明依從性差PsychosocialsituationsinwhichPDismoreappropriate

更適合腹透的心理狀態(tài)PDpreferred

IndependentLife

FrequenttravelsTendencytowardsPD

Greatneedofindependencebythepatient

Needtomaintainwork

DistancetotheHDcenter獨(dú)立生活經(jīng)常旅行優(yōu)先選腹透傾向于腹透患者有強(qiáng)烈獨(dú)立生活的愿望需要繼續(xù)工作遠(yuǎn)離血透中心SuggestedReadingandReferenceMaterial

推薦閱讀和參考文獻(xiàn)OxfordHandbookofDialysisbyJ.Levy,J.MorganandE.Brown,2ndedition2004,OxfordUniversityPressK/DOQIGuidelines(allpublishedintheAmericanJournalofKidneyDisease):NutritioninCRF(06/00),Vascularaccessupdate(01/01),Anemiaupdate(01/01),PDadequacyupdate(01/01),HDadequacyupdate(01/01),ClinicalPracticeGuidelinesforChronicKidneyDisease(02/02),DyslipidemiasinCRF(04/03),HypertensioninCKD(05/04),BonediseaseinCKD(10/04)USRDSAnnualDataReport,UnitedStatesRenalDataSystem,2004.Nephrology101CourseMaterials;AnatomyandPhysiologybyDr.SalimMujais,CNNTDivisionoftheNationalKidneyFoundation,SpringClinicalMeetings.2004.

Empiricprescription

經(jīng)驗(yàn)處方3-5exchangesof2LdialysisbagConsideringmainlyfluidbalance2升袋裝透析液交換3-5次注意保持大致液體平衡TheweightsatwhichtheweeklyKt/Vureaequalstheminimumtargetof1.7

每周尿素Kt/V最少達(dá)到1.7的患者體重水平

NolphKdetal.PeritDialInt1994.14:261-264DifferentPDcatheters

不同腹透管路Straight1cuffStraight2cuffsCoiledTenckhoffcatheters卷曲管Coiled1cuffCoiled2cuffsSwanNeckTenckhoffcatheters鵝頸管StraightCoiledDownwardsdirectedexitsitePermanentbendbetween2cuffs(180°)RightorleftSwanNeckMissouri鵝頸Missouri管StraightCoiledBeadplacedIP,FlangeextraPStraightTenckhoffcatheters直管Variations演變O-Z(T-W)TenckhoffCatheterO-Z(T-W)MissouriTenckhoffCatheterMoncrief-popovichCatheterPediatricPresternalT-FlutedDiPoaloSelflocatingPDCatheterimplantation

腹透置管術(shù)PeritonealCatheterimplantationmustbeperformedbyacompetentandexperiencedsurgeonornephrologist.Optimallongtermperitonealcatheterfunctionandexitsitehealingaredirectlyrelatedtotheskillsandthecompetenceofthecatheterinsertionteam.1腹透導(dǎo)管埋置術(shù)必需由熟練有經(jīng)驗(yàn)的外科醫(yī)生或腎病專科醫(yī)師施行。腹透導(dǎo)管長期保持最佳功能及體外段的愈合，直接與手術(shù)醫(yī)生的技術(shù)和能力相關(guān)1 Gokaletal.Peritonealcatheterandexitsitepractices.

Towardoptimalperitonealaccess,PeritDialInt,1998;18:11-33ImpactofCatheterinsertionbyNephrologistsonPDutilization

腹膜透析應(yīng)用上腎病醫(yī)師對置管的影響Non-Nephrologists無腎病醫(yī)師Nephrlogists腎病醫(yī)師Non-Nephrologists無腎病醫(yī)師Canter11993-200138-45pts(16%)2001101pts(32%)Center21988-199070-78pts(17%)1991125pts(22%)Center31988-199120-30pts(18%)1991-200097pts(27%)200125pts(6%)SeminarDial200518:157-60Break-inperiod

導(dǎo)管修整期Toallowasufficienttimetohealsurgicalwound(exitsite):2-4weeksAsepticdressingwithminimumopeningisrecommendedImmobilizationisimportantTemporaryHDshouldbeconsideredinthisperiodinpatientswithadvancedkidneyfailureSomecentersstartPDtrainingforpatientsatthisperiod給予足夠的時(shí)間讓手術(shù)傷口愈合（體外段）：2-4周建議使用無菌敷料覆蓋并減少傷口暴露導(dǎo)管固定（體外段）很重要此期，若患者腎衰持續(xù)進(jìn)展，可以考慮暫時(shí)血液透析過渡有些中心在此期開始腹透患者培訓(xùn)PeritonealDialysisTechnique

腹透技術(shù)BasicproceduresInfusionDwelltime(variable)Drainageofdialysissolution(effluent)VolumedescribestheamountofdialysissolutionusedineachexchangeDosedepictstheamountofsolutionusedoveraspecifiedtimeperiodIntermittentPDandcontinuousPDdescribetheregimensorplansofthetherapyoveraperiodoftime基本操作灌注留腹時(shí)間（可變）引流腹透液(流出液)容量＝每次交換所用的腹透液的量劑量＝某一時(shí)間段內(nèi)用的透析液總量間歇性腹透及連續(xù)性腹透＝一段時(shí)期內(nèi)用的腹透方案或用法2-2.5Ldialysissolutions,4-5exchanges/dayEachexchangemaytake30-50min.2-2.5L透析液，每天交換4－5

次，每次交換時(shí)間約30－50分鐘“FlushbeforeFill”DesignUltratransferset.WithrollerclampDisconnectsystemUsingstandardspikeSolution.Prefilled

MinicapDisconnectcap.“灌注前沖洗”的設(shè)計(jì)帶有滾軸夾子的體外導(dǎo)管設(shè)置分離系統(tǒng)使用標(biāo)準(zhǔn)接口溶液.預(yù)備分離小帽Drain–Flush–Fill-Dwell引流－沖洗－灌注－留腹

CommoncomplicationsinPD

腹透并發(fā)癥PeritonitisExitsiteinfectionFluidoverload腹膜炎出口感染容量過多TheimpactofPeritonitisonCAPDResults

腹膜炎對CAPD影響CausesCatheterlossin8.2%ofcasesCatheterinfectionin10.8%ofcasesAccountsfor24.2%ofhospitalizationcases6.7%ofdeath30.0%ofdrop-outViglioetal.Adv.PeritDial1992.8:269-275原因?qū)Ч芄收?.2%導(dǎo)管感染10.8%導(dǎo)致

住院率24.2%

死亡率6.7%

患者退出腹透30.0%30％！管理腹膜炎對于成功腹透的重要性！

374個(gè)病人中腹膜炎的發(fā)生率

（1991年－1998年）

PeritonitisRate–CAPDandAPD

CAPD和

APD的腹膜炎發(fā)生率Early’80:6.3episodes/yrLate‘90Japan–1episodein53.4patientmthsKorea–1episodein25-33.3patientmthsHongKong–1episodein33.5patientmths80年代早期：每年6.3次90年代晚期：日本–53.4病人月韓國–

25-33.3病人月香港–

33.5病人月Y.Kawaguchi.HanDS.LaiKNandLoWK..PDIVol19,Supp3,1999

污染圍手術(shù)期腹瀉/便秘?cái)⊙Y不明原因?qū)Ч芟嚓P(guān)腹膜炎來源腸道損傷41%!提示無菌操作的重要性Peritonitis

腹膜炎IdentificationofperitonitisTurbidPDFPDFWCC>100/mm3Abdominalpain,fever腹膜炎的確診腹透液混濁腹透液中白細(xì)胞數(shù)>100/mm3腹痛，發(fā)熱以上條件中具備兩條即可確診，有一條時(shí)應(yīng)引起高度重視。QualityManagementofperitonitis

控制腹膜炎EnsurepromptdiagnosisEnsureprompttreatmentEnsureappropriatetreatmentEnsuretimelyadjustmentofantibioticsIdentificationofcauseofperitonitisPreventionofrecurrenceofperitonitisMinimizationofperitonitisrate及時(shí)診斷及時(shí)治療恰當(dāng)?shù)闹委熂皶r(shí)調(diào)整抗生素明確腹膜炎的原因預(yù)防腹膜炎的復(fù)發(fā)減少腹膜炎的發(fā)生率Ensurepromptdiagnosis

及時(shí)診斷SendPDFWCCDonotrelyjustonhumaneyesOccasionallyturbidPDFcanbeduetochyle,notWCCSendPDFxGramstainAllowchoiceoftheappropriateantibiotics,identifyingunderlyingcausesWhenwillGramstainresultavailableSendPDFxbacterialcultureInappropriatecollectionordeliverywouldleadtodecreaseyieldofpositivecultureCulturenegativityrateshouldnotbe>20%PDFhastobecollectedbeforeantibioticsadministration送檢腹透液白細(xì)胞不要僅憑肉眼判斷有時(shí)腹透液混濁是乳糜液，非白細(xì)胞造成。送檢腹透液革蘭氏染色病因明確，允許選擇適當(dāng)?shù)目股馗锾m氏染色結(jié)果出來的時(shí)間腹透液細(xì)菌培養(yǎng)標(biāo)本采集、運(yùn)送不當(dāng)會影響結(jié)果的準(zhǔn)確性（保留第一袋透出液送檢至關(guān)重要）。培養(yǎng)的陰性率不應(yīng)該>20%在應(yīng)用抗生素前進(jìn)行細(xì)菌培養(yǎng)Ensureprompttreatment

及時(shí)治療Antibioticsshouldbeadministeredasearlyaspossible,butafterPDFsamplesforbacterialculturecollectedChoiceofantibioticsdependsonthepatternofbacterialandsensitivityinthatcenter/areaChoicebetweencontinuousandintermittentregimeForintermittentregime,dwelltimemustbe>6hoursLoadingdoseneeded應(yīng)盡早使用抗生素，但應(yīng)在標(biāo)本送檢細(xì)菌培養(yǎng)后根據(jù)細(xì)菌類型和藥敏情況選擇合適的抗生素連續(xù)應(yīng)用或間隔應(yīng)用抗生素間歇使用時(shí),腹透液留腹時(shí)間必須>6小時(shí)負(fù)荷量一般病菌治療2周金葡菌、綠膿桿菌、腸球菌治療3周InitialEmpiricTreatment

初始經(jīng)驗(yàn)治療

DrainAbdomenandobtaincellcountandgramstain,culture,changethetransferset引流腹透液，檢測白細(xì)胞數(shù)，進(jìn)行革蘭氏染色

、細(xì)菌培養(yǎng)、更換短管Signsandsymptomsofperitonitis腹膜炎癥狀和體征Loadingdose(dwellfor3h):1,000mgceftazidime1,000mgcefazolin1,000units/LheparinIVloadingpreferredforsepticpatientsthanIPMaintenancedose:accordingtoregularCAP，Schedulewithantibiotics+/-heparin維持劑量:根據(jù)臨床操作規(guī)范，按時(shí)給予抗生素，

透析液添加或不加肝素負(fù)荷劑量(留腹3小時(shí)):1,000mg頭孢他定1,000mg頭孢唑啉1,000u/L肝素

敗血癥病人：靜脈注射（

IV）優(yōu)于腹腔注射（

IP）殘余腎功能↓Afteradministeringantibiotics

應(yīng)用抗生素后IndicationofresponsePDFclearingupMostclearupwithin3days,orWCCdrop>50%BewarefibrintrapmayproduceawrongWCCSubsidenceoffeverandabdominalpainMonitoringofresponseCollectPDFatD0,D1,D3,andatareasonableintervalifgoodresponse有效的反應(yīng)：腹透液變清多數(shù)在3天內(nèi)變清，或白細(xì)胞數(shù)下降>50%纖維蛋白可能使白細(xì)胞數(shù)產(chǎn)生誤差腹痛和發(fā)熱緩解療效的監(jiān)測如果療效好，在當(dāng)天，第一天，第三天和適當(dāng)間隔時(shí)間收集腹透液Whatifpoorresponse

療效欠佳時(shí)Ifculturenegative,stepupthepotencyandspectrumcoverageofantibioticsIfcultureavailable,adjustantibioticsaccordinglyStepupantibiotictherapyatD3isappropriateRe-culturePDF,lookforTB,fungusRemovalofTenckhoffcatheterifpoorresponsebyD5-7如果培養(yǎng)陰性,抗生素升級，應(yīng)用廣譜抗生素如果培養(yǎng)陽性,根據(jù)藥敏調(diào)整抗生素在第3天抗生素?fù)Q用更敏感的抗菌素再次進(jìn)行細(xì)菌培養(yǎng),尋找結(jié)核和真菌如果5－7天后還無療效，需考慮拔除腹透管Ifperitonitissubsided,isitOK?

腹膜炎好轉(zhuǎn)后,是否治療結(jié)束NotsosimpleQualitymanagementincludesIdentificationofunderlyingcausePreventrecurrence不是這么簡單質(zhì)量管理包括找出明確病因防止復(fù)發(fā)Identifyingunderlyingcause

明確根本原因ESIandtunnelinfectionInspectESandtunnel,takecultureifneededCheckpatient’sexchangetechniqueK