“pergantian cairan peritoneal dialisis -...
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“Pergantian Cairan Peritoneal Dialisis dan Maintenance Peritoneal Dialisis“
Atma Gunawan
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Indikasi Peritoneal Dialisis
1. Dialisis akut : hiperkalemia, fluid overload, pulmonary edema, asidosis, encephalopathy uremicum, muntah-muntah berat, pericarditis
2. Kronik dialisis : end stage renal disease (ESRD)
3. Pasien yang lebih menguntungkan dengan PD : anak-anak, manula, diabetic nephropathy, AVF gagal, tidak toleransi dengan HD
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CAPD
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CAPD
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Cairan dialisat yang
Sebelumnya ditanam
lalu keluarkan dari
rongga perut. Proses
15-20 menit
Prosedur capd
2. Fill
Mengisi ronggaperitonium dengancairan dialisatbaru.Proses ini 10 menit.
3. Dwell
Mendiamkan cairandi dalam rongga perut selama4-12 jam .Pada saat initerjadi proses difusi danosmosis
O
- Ada 3 tahap1. Drain
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Cairan peritoneal dialysis
• Terdapat 3 jenis konsentrasi cairan peritoneal dialysis :
* 1,5% lemah (4 jam me-
narik air 200 cc)
* 2,5% sedang(6 jam me-
narik air 400 cc)
* 4,25% kuat(8 jam me –
narik air 600 cc)
• Cairan lain :physioneal,nutrineal,icodextrin
1,5%
2,5%
4,25%
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Komposisi cairan PD
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Ultrafiltrasi cairan PD
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Preskripsi PD
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• Dikerjakan 1 bulan setelah operasi insersi kateter PD
• Diulang setiap 2 tahun
• Klasifikasi membran transport peritoneal
• Menentukan rejimen PD
• Diagnosis penyebab gagal ultrafiltrasi
• Diagnosis penyebab inadequate solute clearance
PET (peritoneal equilibrum test)
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Prosedur PET
• Posisi duduk : drain out dialisat 2.5% setelah dwell 8-10 jam (malam)
• Posisi baring drain in dialisat 2.5% 2 liter, sekitar 10 menit.Setiap 400 ml masuk, pasien posisi pasien miring kanan-miring kiri
• Drain out dialisat 200 cc ke dalam kantong dibalik-balik.
• Bersihkan medication port dengan bethadine selama 5 menit, aspirasi 10cc cairan dialisat dengan spuit, taruh kedalam red top tube. Masukkan sisanya 190 cc ke rongga peritoneum
• Setelah dwell 2 jam, ulangi prosedur no 4. konektor transfer set boleh dilepas
• Ambil darah 5cc• Jam ke-4: drain out semua dialisat, lakukan seperti protokol
no 4. Lanjutkan dengan cairan dialisat sehari-harinya.
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Copyright of Baxter Healthcare
Peritoneal Equilibration Test
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Tipe Membran Transpor Peritoneal Pasien CAPD di RSSA Malang
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Tipe Membran Solute Cl UF Peresepan
Rapid ++++ + CCPD
High Average +++ ++ CAPD/CCPD
Low A ++ +++ CAPD/CCPD
Low + ++++ CAPD
Hubungan antara tipe membran transpor
dengan peresepan PD
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Peresepan PD
CCPD
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Adequacy of PD :Clearance Creatinine, Urea clearance (KT/V)
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Apakah itu Clearance?
• Total jumlah cairan tubuh yang dibersihkan dari kreatinin dalam waktu tertentu• ml/min
• L/week
• Contoh : Creatinine clearance = 50 l/minggu artinya :
50 L yang bersih dari kreatinin selama satu minggu
• Indikator yang serupa adalah Urea Clearance : KT/V
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Penghitungan Peritoneal Creat Clearance
7
)( x
creatinineplasma
creatininedialysatexvolumedraintotallclearancecreatinineweekly
= 10.7 x 0.788 x 7
= 59 l/wk
Normalise to BSA = CCl x 1.73/ patients BSA
Normalised weekly CCl = 59 l/wk/1.73 m2
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7 )
(/ x
aplasma ure
readiaysate ux
ondistributiofvolume
volumedrainvKtweekly
714.1
12.7
31595
10125/ xxvKtweekly
= 0.288 x 7
= 2.02
Penghitungan peritoneal urea clearance (KT/V)
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Peritoneal Dialysis
Recommended Total Solute
Clearance Targets
CAPD Kt/V CCr/1.73m2
NKF-DOQI 1997 2.0 60 L
NKF-DOQI 2000
L&LA 2.0 50 L
HA&H 2.0 60 L
Canadian guidelines
L & LA 2.0 50 L
HA & H 2.0 60 L
Renal Assoc - UK 1.7 50 L
EDTA-ERA 1.7 (Peritoneal)
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Adekuasi pasien CAPD RSSA Malang (n=68)th 2015
Klirens urea (wKT/V) : 1,84 ± 0,56 liter/minggu
Klirens kreatinin (wCCr) : 61,51 ± 23,69 liter/minggu/m2
Standar NKF/K- DOQI : wKT/V ≥ 1.7 liter/minggu
wCCr ≥ 60 liter/minggu/m2
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• Ujung kateter berada di cavum peritoneal menuju cavum Douglas
Penempatan kateter di cavum peritoneal
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Posisi kateter
External cuff
Internal cuff
Intra-Peritoneal segment
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Perawatan pasca insersi kateter PD
• Antibiotik profilaksis diberikan sebelum insersi kateter PD
• Masa tenggang paska insersi kateter : 1 sd 2 minggu
• Dressing exite site dilakukan setiap minggu, sampai luka kering.
• Dressing tambahan dilakukan bila kasa basah atau berdarah.
• Belum boleh kena air selama luka belum kering.
• Mandi/shower boleh setelah luka kering (2-3 minggu post-op).
ISPD Guideline.Perit Dial Int 2012; 32:S29–S86 ; Oxford Univ. Hospital , NHS Found Trust
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Perawatan pasca insersi kateter PD
Lakukan teknik aseptik, masker dan handschoen steril:
• Bersihkan luka sekitar exite site dengan kasa steril yang dibasahi cairan antiseptik.
• Kerak luka dibersihkan dengan kasa dibasahi NS.
• Gunakan kasa lain untuk membersihkan tubing kateter, dari arah tubuh keluar
• Gunakan kasa kering steril beberapa lapis untuk menutup luka. Lalu difiksasi
• Selang kateter difiksasi, sesuai posisinya, untuk mencegah pergerakan.
ISPD Guideline.Perit Dial Int 2012; 32:S29–S86
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Perawatan kateter lanjutan untuk pencegahan infeksi
• Setiap hari dioleskan antibiotik cream/zalf pada exite site.
• Exite site dibersihkan minimal 2x seminggu atau setiap selesai mandi/shower
• Bila terjadi exite site infection : bersihkan exite site setiap hari.
ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE
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Antibakteri Topical , Antiseptik, dan cairan antiseptik untuk pencegahan infeksi terkait kateter
• Povidone-iodine • Chlorhexidine solution • Amuchina solution/hypochlorite solution • Mupirocin cream • Gentamicin cream or ointment • Ciprofloxacin otologic solution • Antibacterial honey • Polysporin triple ointment • Polyhexanide
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Gagal Ultrafiltration
• Ultrafiltrasi (UF) kurang 400 mL setelah dwell 4-jam menggunakan cairan PD 4.25% dextrose.
• Atau UF volume < 750 mL pada pasien anuria, setelah dikesampingkan penyebab lainnya.
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Pencegahan gagal UF
• Hindari peritonitis
• Restriksi cairan dan garam
• Cairan PD non glukosa (icodextrin), purely bicarbonate-buffered low-GDP fluids (physioneal)
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Ruang GantiCairan
Ruang TungguPasien
Ruang PeriksaDokter
Kamar Operasi
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PLB
CAPD Data per Des 2016
6
1717
45
16
9
18
60
76
55
13
16
25
CAPD Px
Mapping
58
35
51
429
95
94
135
324
COE
RSSARS SANGLAH
RSHS
RS CIKINI
RSPAD
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Wassalam