(1) Peritoneal dialysis system Peritoneum is a semi-permeable membrane, which can restrict the passage of cells and protein, but allow the passage of electrolytes and some small and medium molecular solutes. Due to various internal and external factors, its cleaning ability is constantly changing. The peritoneal dialysis system consists of three parts: the vascular network of the peritoneum, the peritoneal membrane through which water and solute can pass, and the dialysate injected into the abdominal cavity.
1. The blood supply of peritoneum comes from 6 pairs of inferior intercostal arteries, superior epigastric artery and inferior epigastric artery, and the blood supply is very rich. Peritoneal vein drains into inferior vena cava and visceral vein drains into portal vein. The blood flow of adult peritoneum is generally 50 ~ 100 ml/min. The effect of blood flow on peritoneal clearance rate is not obvious. When the peritoneal blood flow decreased to 25% of normal, the urea clearance rate only decreased to 75% of normal. It has also been suggested that blood flow is related to the removal of small molecular substances, but not closely related to the removal of medium molecular substances.
2. The area of peritoneum is 2.0~2.2m2, which is larger than that of general hemodialysis membrane (1.0m2). The peritoneal dialysis membrane consists of six layers (Figure 45- 1).
Figure 45- 1 Peritoneal Hierarchy Diagram
3. There is a certain relationship between dialysate flow rate and dialysate flow rate. In intermittent peritoneal dialysis (IPD), the dialysate flow rate is 65ml/min, while in continuous ambulatory peritoneal dialysis (CAPD), the dialysate flow rate is quite low, only 6 ~ 7 ml/min. The removal of small molecular substances is directly proportional to the dialysate flow, while the removal of medium molecular substances has no obvious relationship with the flow, but is related to the total dialysis time and the dialysis membrane area.
(II) Transport Mechanism of Water and Solute in Peritoneal Dialysis The purpose of Peritoneal Dialysis is to eliminate excess water and some toxic substances in the body, correct electrolyte balance disorder and supplement alkaline substances lacking in the body.
1. Removal of water
(1) Permeability: Peritoneum itself has osmosis, and its strength is directly proportional to the exclusion of water.
(2) Ultrafiltration: During peritoneal dialysis, ultrafiltration is related to the following five factors: ① Intraperitoneal capillary pressure; ② colloid osmotic pressure of peritoneal capillaries; ③ colloid osmotic pressure of connective tissue of abdominal wall; ④ Hydrostatic pressure of liquid in abdominal cavity; ⑤ Osmotic pressure of peritoneal dialysate itself. The algebraic sum of the above factors is the membrane filtration pressure. Generally speaking, we can adjust the membrane filtration pressure by adjusting the osmotic pressure of peritoneal dialysate itself.
2. Removal of solution
(1) diffusion: Due to the concentration difference between dialysate and blood during peritoneal dialysis, solutes and some electrolytes can be excreted by diffusion, so as to achieve internal balance.
(2) Convection: The phenomenon that solute is removed with the excretion of solvent is called convection, which is another way to remove solute during peritoneal dialysis. Therefore, when the membrane is permeable, increasing the ultrafiltration rate can not only increase the excretion of water, but also increase the elimination of solute.
(3) Transport of solute in peritoneal dialysis: During peritoneal dialysis, solute moves in complex biological tissue layers. It has many similarities with glomerular basement membrane and is better than hemodialysis. Because the artificial dialysis membrane used in hemodialysis can not truly reflect the transport of complex biofilm. Peritoneal dialysis clearance rate and solute transport capacity are usually used to measure the rate and quantity of solute transport during dialysis.
Second, peritoneal dialysis technology
(1) Peritoneal dialysis tube Since the first clinical application of peritoneal dialysis, people have designed many kinds of peritoneal dialysis tubes (Figure 45-2). Peritoneal dialysis tube should be non-toxic, soft, smooth, X-ray opaque, unaffected by temperature, acid salt and disinfectant, and have good biocompatibility.
Figure 45-2 Various Peritoneal Dialysis Tubes
A. Tenckoff pipe with double polyester rim; B, Toronto-Westpipe;
C. plutelle-disc tube; D. core catheter.
Standard Teckhoff tube is the most commonly used peritoneal dialysis tube in China at present. The pipe is 42cm long, with an inner diameter of 2.6mm and an outer diameter of 4.6mm, and is divided into three parts. ① Intra-abdominal segment: the length is 15cm, and the end 7cm has 60 side holes with a diameter of 0.5mm and 1 end hole, so dialysate can enter and exit freely. ② Subcutaneous segment: 5cm long, with a polyester ring with a length of 1cm at both ends, located between peritoneum and skin. Due to the stimulation of the rough surface of polyester ring, tissue cells and fibroblasts proliferate, and the polyester ring is wrapped and closely adhered to the surrounding tissues, which can fix the catheter and prevent sinus infection and leakage. ③ Extradermal segment: 20cm long. There are several other models of Tenckhoff tubes, mainly with different lengths in the abdomen, which are suitable for children and people with different heights.
(2) Placement method of peritoneal dialysis tube
1. Puncture with a special trocar under local anesthesia (Figure 45-3). Before puncture, 1000 ~ 2000 ml peritoneal dialysis solution should be injected into the abdominal cavity, which can reduce the chance of damaging abdominal organs during puncture. If the original ascites is not injected, the puncture point was selected in the middle of the lower abdomen because there are few blood vessels there. But it is easy to form abdominal wall diseases. At present, it is considered that puncture at the outer edge of rectus abdominis is is better. The operation steps are as follows: local anesthesia is performed at 3cm below the umbilicus, a skin incision of 0.5cm is made with a sharp knife, and then the trocar is vertically inserted into the abdominal cavity, so that the patient bulges the abdomen and enters the abdominal cavity (white fascia for the first time and peritoneum for the second time) after feeling frustrated, and dialysate (or ascites) can be seen to flow out after pulling out the needle core. Immediately insert the peritoneal dialysis tube with guide wire into the trocar (Figure 45-4) and send it into Douglas cavity. When the end of peritoneal dialysis tube enters the cavity, patients often complain about urination or defecation. At this time, pull out the guide wire, make a subcutaneous tunnel on the abdominal wall, release the outer section of the peritoneal dialysis tube from the tunnel, suture the original incision and start dialysis. This method can be done at the bedside.
Figure 45-3 Special trocar
A. the appearance after combination;
B. the parts of each part.
Figure 45-4 Schematic Diagram of Catheter Placement by Puncture Method
A. During puncture, only the thin section at the end of trocar is inserted into abdominal cavity, and the thick section is blocked by fascia.
B. Schematic diagram of abdominal and subcutaneous fall path after puncture;
A. Application of mono-polyester loop catheter in acute renal failure: B. Application of dual-polyester loop catheter in chronic renal failure.
2. After local anesthesia, cut the skin 3 ~ 5 cm below the umbilicus in the midline of the abdomen, cut the fascia 2 ~ 4 cm, separate the muscular layer to the peritoneum, make an incision of 1cm on the peritoneum, insert the peritoneal dialysis tube into Douglas cavity, sew the peritoneum with catgut as a purse, and then sew each layer separately. Note that the first polyester ring is placed above the peritoneum and below the fascia. Make a tunnel in the subcutaneous fat layer to the upper part of the original skin incision (the tunnel length is 5 ~ 7 cm), make a second incision (0.5cm) here, and pull out the outer part of the catheter skin from this opening. The second polyester ring is placed 2 cm away from the skin outlet, and then the skin is stitched. This method is relatively safe and especially suitable for patients with intestinal paralysis. But the operation is more complicated and more harmful to the patient, so it should be carried out in the operating room.
3. Laparoscopy This method only needs to open a 3mm small hole in the abdominal wall, insert the laparoscope with the help of the elasticity of the abdominal wall, select the appropriate catheter placement under the microscope, and then insert the peritoneal dialysis tube from the endoscope. Other steps are the same as puncture. Because this method can see the anatomical structure of the whole abdominal cavity through laparoscopy, it can avoid the adhesion area and intestinal loop and choose the best position when placing the tube. Since this method was applied in clinic on 198 1, compared with the other two intubation methods, laparoscopic method has the highest early dialysis efficiency and the least intubation complications, especially in the obstruction and leakage of outflow tract, which is superior to puncture method and surgical method.
(3) Peritoneal dialysate Peritoneal dialysate is sold in bags or can be made by ourselves. They are isotonic, hypertonic, potassium-containing, potassium-free, lactic acid and acetic acid. Generally speaking, the composition of peritoneal dialysate should be roughly equal to that of normal extracellular fluid.
1. During glucose and osmotic pressure dialysis, ultrafiltration dehydration can be carried out by increasing the positive pressure on the blood side and the negative pressure on the dialysate side. In the process of peritoneal dialysis, dehydration can only be achieved by increasing the osmotic pressure in peritoneal dialysate, usually by increasing the glucose concentration in dialysate. Adding 1mg glucose per 100ml peritoneal dialysate can increase osmotic pressure by 55.55mmol/L, and the glucose concentration in common dialysate is 1.5%, 2.5% and 4.5%. Therefore, the higher the glucose concentration, the better the dehydration effect. However, high osmotic dialysate also has many shortcomings, which will cause excessive heat and hyperlipidemia, especially for diabetic patients, which will cause hyperosmotic coma. In addition, hypertonic fluid will increase protein loss, stimulate peritoneum and cause discomfort. At present, some people use xylitol instead of glucose to increase the osmotic pressure of peritoneal dialysis fluid in diabetic patients. Others advocate replacing glucose in peritoneal dialysis solution with fructose or amino acids.
2. The pH value of buffer solution and peritoneal dialysis solution is generally about 5.5, and commonly used buffers are lactate and acetate.
3. Potassium Because patients with renal failure are often accompanied by hyperkalemia, potassium-free dialysate is generally used for dialysis. However, about 10% patients will have hypotension, and potassium salt needs to be added to the dialysate. Adding 2ml 10% potassium chloride to 1L dialysate can increase the potassium concentration by 2.6mmol/L. If 3ml is added, the potassium concentration of dialysate will be 4mmol/L. It is not easy to be too high to prevent hyperkalemia or stimulate peritoneal pain.
4. The sodium concentration of sodium dialysate is generally low, ranging from130 ~132 mmol/L. Because high-glucose dialysis makes the amount of water discharged from the body greater than the amount of sodium discharged, it is easy to form hypernatremia, and low-sodium dialysate can correct this symptom. If the patient has hyponatremia or hypotension, dialysate with sodium content of 140mmol/L should be used for dialysis.
5. The concentration of dialysable free calcium in calcium blood is 1.5mmol/L, while that in peritoneal dialysate is 1.75mmol/L, which is beneficial to positive calcium balance to supplement calcium deficiency in vivo. However, it is worth noting that free calcium can be discharged with ultrafiltrate when high osmotic dialysate is used, forming a negative balance of peritoneal calcium. For example, when 1.5% glucose is used for peritoneal dialysis, the body can absorb 9.8mg of calcium from peritoneal dialysis solution every time, while when 4.25% glucose is used, 2 1ml of calcium is released into peritoneal dialysis solution every time. Therefore, when using high osmotic dialysate for peritoneal dialysis, the calcium concentration in peritoneal dialysate should be increased by 0.25 ~ 0.5 mmol/L.
6. Magnesium Normal people's blood magnesium is 1.0mmol/L, and the magnesium content in peritoneal dialysis fluid is mostly 0.5 mmol/L. In case of hypomagnesemia, the magnesium content in peritoneal dialysis fluid can be increased to 0.75mmol/L, and in case of hypermagnesemia, it can be reduced to 0.25 mmol/L. ..
7. The suitable temperature for intraperitoneal injection of dialysate is about 37℃, so peritoneal dialysate should generally be heated before application.
(4) The standard technical operation flow of peritoneal dialysis is that peritoneal dialysis should be started as soon as possible after the peritoneal dialysis tube is inserted, preferably immediately. Continuous peritoneal dialysis was performed in the first four 12h (i.e. 48h). However, if the catheter is inserted under the guidance of puncture or laparoscopy, the bleeding is not much, and the catheter can only be sealed after dialysis12 hours.
1. In each group, the first 1 12h is 500ml, the second 12h is 12000ml, the third 12h is 1500ml, and the fourth.
2. Time: The entry time of peritoneal dialysate in each group is 5 minutes, the retention time in abdominal cavity is 65438 00 minutes, and the liquid clearance time is 65438 05 minutes.
3. Record in and out, and record the total amount of peritoneal dialysis fluid in and out every day. More excluded water can be supplemented orally by patients.
4. Heparinization: Add 500u heparin to every liter of peritoneal dialysate. After 48 hours, 50 ml heparin saline was injected into the peritoneal dialysis tube to stop dialysis. If there is a lot of bleeding, in order to prevent the tube from blocking during dialysis, 50 ml heparin saline (containing 500 ~ 1000 u heparin) can be injected into the peritoneal dialysis tube every 4 ~ 6 hours until the next dialysis starts.
5. Peritoneal dialysis mode After the peritoneal dialysis tube is inserted for 5 ~ 7 days, intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis or continuous circulating peritoneal dialysis can be selected according to the situation, and automatic alarm can be given if there is any fault.
(5) The solute clearance rate of different methods is faster than that of small molecular solute and water, and the equilibrium time is shorter, and its clearance rate is greatly influenced by dialysate flow and blood flow per unit time. Because of slow movement and long balance time, dialysis time and dialysis membrane area are important factors affecting its clearance rate. In hemodialysis, it is better to exclude small molecular solutes because of its large dialysate flow and blood flow. Peritoneal dialysis has the advantages of long dialysis time and large dialysis membrane area, so it is better to exclude medium molecular solute than hemodialysis (Table 45-2).
Table 45-2 Solute Clearance Rate and Its Influencing Factors
solute
molecular weight
Human kidney
Hard disk
IPD
CAPD
CCPD
clean
Except for ...
speed
urea
60
750
135
60
70
67
creatinine
1 13
1200
90
28
60
58
vitamin B2
1352
1000
30
16
50
45
insulin
5500
1000
five
12
30
27
shadow
loudly
because
plain
Blood flow (ml/min)
1200
200~250
50~ 100
50~ 100
50~ 100
Dialysate flow (ml/min)
500
65
6~7
6~7
Dialysis time (hours/hour)
15
40
168
168
Filter membrane area (m2)
1.6
1.0
2.2
2.2
2.2
Note: HD hemodialysis; IPD intermittent peritoneal dialysis; CAPD continuous ambulatory peritoneal dialysis; CCPD continuous circulating peritoneal dialysis.
(6) Matters needing attention in peritoneal dialysis
1. The aseptic operation of peritoneal dialysis intubation and peritoneal dialysis fluid exchange should be strictly aseptic to prevent peritonitis as much as possible.
2. Check that dialysate sold in plastic bags will be destroyed during transportation and storage, causing pollution such as bacteria or mold, and should be carefully checked before use. It is generally believed that turbidity can only be seen when bacteria in dialysate grow more than 106 /ml, and granular impurities can only be found through plastic bags when the bacteria grow more than 50 μ m. ..
3. The amount of fluid in each exchange group is about 50/kg body weight.
4. Check the discharged dialysate. If turbid peritoneal dialysate is found during dialysis, routine, biochemical, bacterial culture and drug sensitivity tests should be made on the dialysate. Generally, a group of peritoneal dialysate which has been preserved in abdominal cavity for the longest time should be taken for examination. Antibiotics were added immediately thereafter, and it was also suggested that antibiotics should be added to peritoneal dialysis fluid regardless of abdominal infection or not.
5. Review the peritoneal dialysis patients with acute renal failure, check the blood electrolyte, blood gas, urea nitrogen, creatinine and other renal function indicators every day, and check every 3 days after the condition is stable, and adjust the components of peritoneal dialysis solution according to the review results. Long-term peritoneal dialysis patients should have a blood biochemical examination once a month (when the condition changes, they should be sent for inspection at any time), including blood potassium, sodium, chlorine, calcium, phosphorus, magnesium, aluminum, alkaline phosphatase, creatinine, uric acid, urea nitrogen and blood pH value. Before the first dialysis and every 3 ~ 6 months, recheck SGPT, HBsAg, ECG and X-ray films (chest, hands and pelvis X-ray films), and recheck echocardiography and blood lipid when necessary.
Indications and contraindications of peritoneal dialysis
(1) indications ① acute renal failure caused by various reasons; ② Chronic renal failure caused by various reasons; ③ Acute pulmonary edema and some refractory congestive heart failure; ④ Severe electrolyte and acid-base disorders, especially hyperkalemia, hypercalcemia crisis and lactic acid poisoning; ⑤ Drugs or poisons that can pass through peritoneum (Table 45-3); ⑥ Others include hypothermia, hepatic coma, bilirubinemia, acute hyperuricemia, hyperoxalate, cystine and acute hemorrhagic pancreatitis.
(2) Relative contraindications ① Those who have recently undergone abdominal surgery, especially colostomy, may have chemical peritonitis at this time. However, it has also been reported that successful peritoneal dialysis was performed two days after laparotomy. ② There are many abdominal scars or abdominal wall infections. ③ For patients with muscular development and high metabolic state, when BUN rises more than 50 mg/(L d), hemodialysis is the best choice. If peritoneal dialysis is performed, the frequency and time of dialysis should be increased. ④ Patients with acute or severe lung diseases may suffer from respiratory failure after peritoneal dialysis. ⑤ Abdominal hernia or inguinal hernia should be repaired first, and peritoneal dialysis can be performed only after it is cured. Small volume exchange method can be used for dialysis of esophageal hiatal hernia. ⑥ There are different opinions on whether peritoneal dialysis can be performed immediately for patients with abdominal infection. For patients with acute bacterial peritonitis, some people think that dialysis should be performed after the infection is controlled, but others think that peritoneal dialysis can be performed immediately, antibiotics can be added to the dialysate, and peritoneal lavage can make peritonitis recover faster. But don't use CAPD and CCPD methods. For patients with fungal and tuberculous peritonitis, most people think that peritoneal dialysis is not suitable.
Table 45-3 Drugs that can be Dialyzed from Peritoneum
1. Antibiotics:
Gentamicin, kanamycin, amikacin, tobramycin, cefotaxime, cefotaxime, polymyxin B, polymyxin E, SMZ (sulfamethoxazole), isoniazid (rifampicin), ethambutol and 5- fluorocytosine (5-FC).
2. Antipyretic and analgesic drugs:
Aspirin (aspirin), salicylate (salicylate)
3. Sedative:
Phenobarbital, sodium cyclic aldehyde, methaqualone, chloral hydrate, Paraledehyde and Miltown.
4. Cardiovascular drugs:
Quinidine, procainamide, methyldopa, sodium nitroprusside and phenytoin.
5. Chemical reagents:
Acetic acid, acetoacetic acid, methanol, ethanol, isopropanol, boric acid, arsenic, ketone, lithium, thallium, etc.
Table 45-4 Commonly Used Filter Membranes
material
product name
Cellulose Enka
Cellulose acetate cellulose membrane
Pan-Planck
Polymethyl methacrylate (PMMA) Asahi Dongli
Polyamide Gambro
Polysulfone amide ketone
Polycarbonate (PC) gambol
Fourth, complications of peritoneal dialysis.
Medical complications
Peritonitis Peritonitis is the most common complication of peritoneal dialysis. With people's attention to peritonitis, the incidence rate is getting lower and lower. According to statistics, in the dialysis process of 12 patient months, about 50% patients have no peritonitis. The incidence of peritonitis in patients using automatic peritoneal dialysis machine is low. 70% of the bacteria causing peritonitis are Gram-positive cocci, of which 2/3 are Staphylococcus epidermidis and 1/3 is Staphylococcus aureus. 20% are gram-negative bacilli, and the most common are Enterobacter and Pseudomonas. 5% is caused by fungi, and the most common is Candida albicans.
2. The incidence of pulmonary complications is 22% ~ 25%. Include pneumonia, atelectasis, acute bronchitis, pleural effusion and respiratory arrest. The main cause of the disease is that peritoneal dialysate raises diaphragm and affects vital capacity, which is related to some patients staying in bed for a long time. Patients should be encouraged to do deep breathing exercise at ordinary times. If there are pulmonary complications, in addition to symptomatic treatment, the dialysate in each group should be reduced to 1000ml. Pleural effusion is more common on the right side, which may be related to the communication of lymph in the right chest and abdomen. It can be treated by intrapleural injection of talcum powder or fibrin adhesive to cause pleural adhesion.
3. The incidence of cardiovascular complications is 15%. Including pulmonary edema and heart failure caused by fluid retention; Hypotension, arrhythmia, cardiac arrest and hypertension caused by rapid elimination of fluid and rapid reduction of blood volume. In the process of dialysis, we should master the fluid balance and carefully monitor the amount, weight, heart rate, blood pressure and venous pressure of peritoneal dialysis fluid. According to the patient's condition, the glucose content in high-speed dialysate should be determined in time. In addition, for patients who take digitalis orally, we should pay attention to the clinical manifestations of digitalis poisoning and the changes of blood biochemistry (especially blood potassium), electrocardiogram and blood digitalis concentration.
4. During dialysis, especially during peritonitis, high fever and high osmotic analysis, malnutrition caused by the loss of protein, amino acids and various water-soluble vitamins can lead to malnutrition in patients. Therefore, for long-term dialysis patients, strict protein restriction should not only be avoided in diet, but also albumin, plasma and amino acids should be supplemented intravenously when necessary. The concentrations of plasma protein and exudate protein should be detected regularly.
5. Pain and vagus reflex Because of the pH, osmotic pressure of peritoneal dialysis tube or dialysate itself, drugs added during peritoneal dialysis and rapid drainage, stimulating nerves in abdominal cavity can cause abdominal pain and shoulder pain. It can be solved by adjusting the position of peritoneal dialysis tube or the composition of peritoneal dialysis solution. If the pain is still not relieved, local anesthetics can be added to the peritoneal dialysis solution. The dosage is 5 ml of 2% lidocaine or 6 ml of 2% procaine in 1L peritoneal dialysis solution. In addition, some patients will have vagal reflex such as bradycardia, decreased blood pressure and dyspnea. And atropine can be injected intramuscularly or the flow of dialysate can be slowed down.
(2) Complications caused by biochemical changes in vivo
1. The incidence of hypernatremia and hyponatremia was 8.2%. Because water is more easily excreted through peritoneum than solute, it can increase the concentration of sodium in blood, and in severe cases, convulsions and coma may occur. Peritoneal dialysis can be performed with dialysate with sodium concentration of1.30 mmol/L.
Hyponatremia is rare, with an incidence of 22.2%. Often associated with long-term low-sodium diet or peritoneal dialysis with low-sodium dialysate.
2. The incidence of hypokalemia and hyperkalemia hypokalemia was 10.3%. It is mostly related to the neglect of monitoring serum potassium level when using potassium-free peritoneal dialysis solution for peritoneal dialysis. In addition, peritoneal dialysate contains a lot of glucose and alkaline drugs, which leads to the transfer of serum potassium to cells. At this time, if patients take digitalis, fatal arrhythmia often occurs.
The incidence of hyperkalemia is 6.0%, which is often caused by improper potassium supplementation in dialysate, and is also related to excessive potassium intake, anuria, acidosis and hypercatabolism.
3. The incidence of hyperglycemia and hyperosmotic coma hyperglycemia is 8.6%, which is related to impaired glucose tolerance in uremic patients besides high concentration glucose dialysis. Therefore, continuous use of high osmotic dialysate should be avoided as far as possible, and the blood sugar level of patients should be determined regularly to prevent hyperosmotic coma and death. In addition, increasing osmotic pressure with sorbitol instead of glucose can also lead to hyperosmotic coma. In addition to stopping hypertonic dialysate, insulin can also be used for treatment. The dosage of insulin in peritoneal dialysis solution is 8g glucose plus 1u insulin.
4. Imbalance syndrome is characterized by headache, vomiting, hypertension, disturbance of consciousness, convulsion and coma. The reason is that nitrogen and acidosis in extracellular fluid are corrected too quickly, and nitrogen is not easy to pass through the blood-brain barrier and cause brain edema. However, this situation is rare during peritoneal dialysis. If it happens, dialysis should be temporarily stopped for a few days and symptomatic treatment should be given.
5. The incidence of metabolic alkalosis is 6.5%. When the peritoneal dialysis solution contains lactate or acetate equivalent to 44.6mmol/L(HCO-3), metabolic alkalosis can occur, and the incidence of lactate is higher than that of acetate.
6. Respiratory alkalosis is caused by increased abdominal pressure, increased respiratory rate and hyperventilation.
7. Lactic acidosis When lactic acid is used as a buffer for peritoneal dialysis, sometimes lactic acid cannot be metabolized into carbonate in the body, causing lactic acidosis. This happens mostly to patients with liver disease, but it can also happen to patients without liver disease.
(3) Complications related to technical operation
1. Injury of bladder, intestine, great vessels, liver, spleen and other organs caused by abdominal viscera puncture has been reported, but it is rare. Pay attention to emptying bladder before puncture and inject liquid into abdominal cavity to avoid puncture in surgical scar area. Injuries are usually avoidable.
2. A small amount of bleeding at the puncture and incision site does not need special treatment. If a hematoma is formed, the blood clot should be removed and sutured to stop bleeding. If blood flows into the abdominal cavity along the peritoneal dialysis tube, the exudate can be bloody. At this time, heparin should be added to the peritoneal dialysis solution to prevent blood clots from blocking the peritoneal dialysis tube.
3. The leakage of dialysate mostly occurs when the peritoneal dialysis tube is cut and placed, and the peritoneal or fascia suture is not tight. At this time, liquid can penetrate into abdominal wall or scrotum, or flow out from skin incision, increasing the chance of infection. In order to avoid leakage of dialysate, it is not advisable to inject too much fluid when dialysis begins immediately after intubation. If there is leakage, pay attention to protect the surrounding skin clean and prevent secondary infection. Abdominal dialysis can still be continued, but a small number of exchanges in the semi-supine position are used. Four weeks later, the two polyester rings on the dialysis tube were wrapped by fibrous tissue, the subcutaneous tunnel was closed and the leakage stopped automatically.
4. Skin and subcutaneous tunnel infection Because the peritoneal dialysis tube directly protrudes from the skin and there are factors such as leakage and necrosis caused by subcutaneous polyester ring extrusion, it is very easy to be infected here. Peritonitis will occur if the infection spreads along the peritoneal dialysis tube. Therefore, if the local skin is red and swollen, antibiotics should be used all over the body. If an abscess is formed, the catheter should be pulled out and cut and drained.
5. Bidirectional obstruction means that dialysate can neither enter the abdominal cavity through peritoneal dialysis tube nor be discharged from the abdominal cavity. The reason is that the peritoneal dialysis tube is twisted (mostly in the subcutaneous tunnel or muscle layer), and the fiber or blood clot blocks the catheter. At this point, a new dialysis tube should be installed after extubation.
6. One-way obstruction Peritoneal dialysate can enter the abdominal cavity through peritoneal dialysis tube, but it cannot be discharged, which is called one-way obstruction and is one of the more common complications. There are many reasons. ① Improper placement or displacement of peritoneal dialysis tube; ② The omentum or intestinal loop wraps the catheter; ③ Constipation, the cause of which is unknown, but the obstruction can be relieved by itself after constipation is relieved; ④ Paralytic ileus; ⑤ The side hole of dialysis tube is blocked by fibrin clot or blood clot, which mostly occurs in peritonitis or the initial stage of peritoneal dialysis tube placement; ⑥ Abdominal adhesion, patients with a history of abdominal trauma or surgery may have difficulty in drainage because peritoneal dialysate is stuck in the small cavity of abdominal adhesion; ⑦ The catheter connection system is faulty, and the gap between the patient's abdomen and the drainage container should be greater than 30cm. Too little will lead to poor drainage. Looseness and air leakage at the joint of the conduit, or bubbles in the conduit will affect the siphon effect.
In the case of a single obstruction in a patient receiving peritoneal dialysis, the following steps can be taken. ① Check whether the catheter connection system leaks and whether the gap between the patient's abdomen and the container is sufficient; (2) It may be effective for patients with catheter displacement, wrapping or abdominal adhesion to instruct patients to constantly change their posture during fluid discharge; ③ Adding heparin, urokinase or streptokinase to peritoneal dialysate may be effective for patients with side hole blockage (the drug dosage is the same as peritonitis); (4) When the side hole is blocked, heparin saline can also be used to pressurize the peritoneal dialysis tube, and the dosage is 2500u heparin and 30ml saline; ⑤ The laxative or enema can be taken orally with rhubarb 3 ~ 5g or enema with rhubarb 10g and 700ml of water. Even patients without constipation can try this treatment; ⑥ In some patients, large flaky clots were formed in peritoneal dialysis tubes. When the fluid is injected, the valve opens at a higher pressure, and when the fluid is discharged, the valve closes at a lower pressure. At this time, a spiral guide wire with a smooth end or a soft non-invasive guide wire can be inserted from the outer end of the peritoneal dialysis tube to discharge the clot from the tube. ⑦ Put a temporary peritoneal dialysis tube for drainage, and then pull it out after the original peritoneal dialysis tube is unobstructed. This method can be used for paralytic intestinal obstruction and peritoneal dialysis tube wrapped by omentum. ⑧ If the above treatments are ineffective, the peritoneal dialysis tube should be pulled out and re-inserted with a new tube.