血管通路的再循環

《血管通路的再循環》由会员上传分享，免费在线阅读，更多相关内容在教育资源-天天文库。

1、血管通路的建立與維護Thecreationandmaintenanceofhemodialysisvascularaccess國泰綜合醫院腎臟內科彭聖曾醫師98/5/9第二十四梯次血液透析訓練班Patientsonhemodialysis課程大綱計劃一個血管通路血管通路的種類、選擇、放置時機、手術前的準備、及成熟時間血管通路的監測及維護血管通路的併發症及其處理血管通路照顧的品質標準1.計劃一個血管通路每一個透析中心都應有自己的血管通路小組。適合做為血管通路的手臂靜脈應妥善保存，當GFR小於30ml/min/1.73m2(CKDstage4)時，就應計畫妥當。若是

2、病人的腎功能惡化很快，或是糖尿病人，或是有嚴重週邊血管疾病的病人，可能要更早做血管通路的準備。最適合保留用來做自體動靜脈瘻管(nativearteriovenousfistula)的靜脈是頭靜脈(cephalicvein)。所以，如果要抽血打針，應打在手背上。上肢表淺靜脈頭靜脈cephalicvein基底靜脈basilicvein2a.血管通路的種類Nativearteriovenousfistula(AVF):自體動靜脈瘻管Arteriovenousgraft(AVG):人工血管Polytetrafluoroethylene(PTFE,Gortex®):聚四氟

3、乙烯(四氟乙烯的聚合物，用於製造墊片、管道、絕緣材料等)Polyurethane(Vectra®):聚亞安酯Bovinegraft,cadaverichumanveingraftHemodialysiscatheters:血液透析導管Cuffed(袖口/環扣)tunneledcathetersNon-cuffed,non-tunneledcathetersQuinton-Scribnershunt1960AVfistula:動靜脈瘻管AVfistula:動靜脈瘻管AVfistula的種類RadiocephalicfistulanearthewristBrachi

4、ocephalicfistulaneartheantecubitalfossaTransposedbrachiobasilicfistulaneartheantecubitalfossaAVgraft:動靜脈人工血管AVgraft:動靜脈人工血管AVgraft:chestwallAVgraft:necklaceAVgraft:thighCuffedcatheter:有袖口的導管Permanentcatheter(PermCath)Dialock®Dialock®insituLifesiteport:VascA®Temporarynon-cuffedcathete

5、r中央靜脈插管超音波輔助內頸靜脈穿刺2b.長期血管通路的選擇AVfistula(自體動靜脈瘻管)AVgraft(人工血管)Cuffedtunneledcatheter(有袖口的導管)最理想的血管通路是自體動靜脈瘻管(nativeAVfistula)，因為它有最少的併發症及最長的暢通率。其次是人工血管，只有在不得已的情況下，才將導管做為長期血液透析的血管通路。AVF,AVG與catheter的優缺點比較AVFAVGCuffedcatheterPrimaryfailurerate20-50%10-20%<5%Timetouse(wk)6-122-3Immediate

6、PatencyrateBestFairPoorThrombosisrateLowModerateHighInfectionrateVerylowModerateVeryhighAneurysmsLowLowNoStealphenomenonLowLowNoHeartfailureRareLowNoAnesthesiaLocalNblock,GLocal,GNursingissuesDifficultModerateEasyPatientsurvivalBestModerateWorstAVF與AVG的存活率比較Figure3.Fistulaandgraftsur

7、vivalinincidentpatientswhostartedHDwithapermanentvascularaccess(VA)inDOPPSI.Adjustedfordifferencesinage,gender,diabetes,andperipheralvasculardisease.*InJapan,therewereonlyasmallnumber(n=88)ofincidentpatientsforanalysis.CJASN2006;1:246-55.血管通路的累積暢通率UnassistedprimarypatencyCumulativepa

8、tency有袖口及無袖口