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  • The peritoneum is a large, intricately arranged serous membrane which lines the abdominal wall (parietal peritoneum) and visceral organs of the abdominal cavity (visceral peritoneum). The peritoneal cavity is the space between the parietal and the visceral layers of peritoneum. The primary purpose of the peritoneum is to provide a smooth surface over which the abdominal viscera may easily move. Normally the peritoneal cavity contains less than 100 ml of fluid, but can accommodate a 20-fold increase without patient discomfort. The peritoneal cavity is lined by a layer of living mesothelial cells on a connective tissue base which is perfused with circulatory and lymphatic vessels (1). The peritoneal membrane is semipermeable, i.e. it is highly permeable for water and smaller solutes but permeability decreases with increasing solute size and molecular weight. Transport processes take place in both directions across the peritoneal membrane: from the peritoneal microcirculation into the peritoneal cavity and vice versa, i.e. the peritoneal membrane is bi-directional.
  • The dialysate pulls the waste and extra fluid from the patient's blood into the peritoneal cavity. The dialysate remains in the abdomen for a specified amount of time before it is drained and replaced with fresh dialysate. The time during which the dialysate remains in the patient's abdomen is known as the dwell time. When the dialysate is drained, the wastes and extra fluids are also drained, and fresh dialysate is replaced to clean the blood. This filling and draining process is called an exchange because the dialysate that has been in the abdomen is being exchanged for new, fresh dialysate. Exchanges can be done manually or with a machine called a cycler.
  • The physiological basis of dialysis across the peritoneum entails the processes of diffusion, convection and osmosis.
  • The main factors which affect diffusion in peritoneal dialysis are solute size, concentration gradient, solute electrical charge and capillary blood flow rates. Solute size and electrical charge are also important variables regarding membrane permeability.
  • Osmosis is the movement of a solvent from one solution to another of higher concentration, separated by a semipermeable membrane, in order to extinguish solute concentration gradients across the membrane. The membrane is semipermeable in the sense of being impermeable to solutes in the more concentrated compartment, and being highly permeable to the solvent. Osmotic pressure is the pressure that must be applied to a solution to prevent the inflow of solvent.
  • Transcript

    • 1. The peritoneal membrane • Anatomy • Physiology Solutions Concentrates Dialysers Membranes Machines Peritoneal Dialysis Training Oshakati hospital 2014 College Accesses Tubings MD. JOSE L. RODRIGUEZ NEPHROLOGIST 1
    • 2. Introduction College • DEAR STUDENTS THIS TRAINING ALLOWED YOU TO PROVIDE BETTER CARE TO THE CHRONIC RENAL FAILURE PATIENTS . • WE ARE SURE THAT THE OBJECTIVES OF THIS TRAINING WILL BE ACHIEVED. PROFESSORS…… 2
    • 3. Chronic Kidney Failure College • Chronic kidney failure, also called chronic kidney disease, describes the gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then excreted in your urine. When chronic kidney failure reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can accumulate in your body. 7.2.1 The peritoneal membrane / P. Martin 3
    • 4. The peritoneal anatomy A sagittal section trough the peritoneal cavity College General facts • Living membrane • Reusable • Provides lubrication for internal organs • Normally contains 10 - 100 cc's fluid • Semipermeable • Bi-directional 4
    • 5. Sagittal view of the peritoneal cavity during peritoneal dialysis College 7.2.1 The peritoneal membrane / P. Martin 5
    • 6. The covering layer of peritoneal cells is called mesothelium College Mesothelium is not just a covering layer, it consists of active metabolic cells. Some of the secretory activities are provoked by the dialysis procedure. 7.2.1 The peritoneal membrane / P. Martin 6
    • 7. Peritoneal physiology College Transport across the peritoneum • Osmosis • Diffusion • Convection 7.2.1 The peritoneal membrane / P. Martin 7
    • 8. Peritoneal physiology College Diffusion 7.2.1 The peritoneal membrane / P. Martin 8
    • 9. Peritoneal physiology College Diffusion RANDOM movement of solutes across the peritoneal membrane from an area of high concentration to an area of low concentration (without assistance by any flow of fluid) HIGH 7.2.1 The peritoneal membrane / P. Martin low 9
    • 10. Peritoneal physiology College Factors affecting diffusion • solute size • concentration gradient • electrical charge • blood flow rates 7.2.1 The peritoneal membrane / P. Martin 10
    • 11. Peritoneal physiology College Osmosis Movement of water across the peritoneal membrane from an area of low concentration to an area of high concentration. low 7.2.1 The peritoneal membrane / P. Martin HIGH 11
    • 12. Peritoneal physiology College Osmotic Ultrafiltration Glucose generates a high osmotic pressure which induces ultrafiltration from the capilaries (blood) to the peritoneal cavity 7.2.1 The peritoneal membrane / P. Martin 12
    • 13. Peritoneal physiology College Factors affecting osmosis • dextrose concentration • dwell time • membrane permeability 7.2.1 The peritoneal membrane / P. Martin 13
    • 14. Fluid removal is dependent on: • the dwell time • the peritoneum characteristics College rapid transperitoneal absorption with decline of the osmotic gradient in time: Dextrose 1.5%: maximum UF rate of 9.27 mL/min Dextrose 4.25%: maximum UF rate of 21.0 mL/min Dextrose 1.5% removes 100-300 cc of extra water Dextrose 2.3% removes 300-500 cc of extra water Dextrose 4.25% removes 600-800 cc of extra water 7.2.1 The peritoneal membrane / P. Martin 14
    • 15. Peritoneal physiology Convection College Solutes move across the peritoneal membrane in an'orderly flow' from one area to another by being carried by a flowing fluid. 7.2.1 The peritoneal membrane / P. Martin 15
    • 16. Peritoneal dialysis • Diffusion solute removal • Convection fluid removal • Ultrafiltration (osmotic pressure gradient) College The composition of PD solution is the key factor that governs diffusion, convection as well as the removal of fluid excess from the body · Electrolytes correction · Body fluid balance · Acid-base control · Blood purification 7.2.1 The peritoneal membrane / P. Martin 16
    • 17. Causes of Chronic Renal Failure: • • • • • • • • • • College HIVAN (Namibia) Diabetes Hypertension Renal vascular disease (also vascular disease) Nephritis Pyelonephritis & chronic UT I Polycystic kidney disease Renal Neoplasms Analgesic nephropathy Immunological disorders: Lupus, Goodpasture syndrome, scleroderma • Metabolic disorders: gout 7.2.1 The peritoneal membrane / P. Martin • Nephrotic Syndrome primary or secondary 17
    • 18. College 7.2.1 The peritoneal membrane / P. Martin 18
    • 19. College 7.2.1 The peritoneal membrane / P. Martin 19
    • 20. College 7.2.1 The peritoneal membrane / P. Martin 20
    • 21. Peritoneal Dialysis Catheter • Two double-cuff Tenckhoff peritoneal catheters: standard (A), curled (B). 7.2.1 The peritoneal membrane / P. Martin College 21
    • 22. Dialysis College Dialysis is the diffusion of solute molecules through a semipermiable membrane, passing from higher concentration to that of lower concentration. It is the process of separating colloids and crystalline substances in solution by the difference in their rate of diffusion through a semi permeable membrane. The purpose of dialysis is to remove endogenous and exogenous toxins and to maintain fluid electrolyte and acidbase balance till the renal function recovers. It is a substitute for some excretory functions of kidneys but does not replace the endocrine and metabolic functions. 7.2.1 The peritoneal membrane / P. Martin 22
    • 23. INDICATIONS • • • • • • • • College Uremic symptoms with neurologic abnormalities Persistent hyperkalemia, above 6.5 mEq/L Blood urea level more than 50 mmol/l Serum Creatinine more than 900 µmol/l Severe acidosis, pH less than 7.2, TCO2 less than 10-12 mEq/L Hyperphosphatemia Pulmonary edema and CCF 7.2.1 The peritoneal membrane / P. Martin 23
    • 24. Peritoneal dialysis College Peritoneal dialysis is a technique that employs the patient’s peritoneal membrane as a dialyzer. Excess body water is removed by an osmotic gradient created by the high dextrose concentration in the dialysate; wastes are removed by diffusion from the peritoneal capillaries into the dialysate. Because peritoneal dialysis is not as efficient as hemodialysis, it must be performed daily rather than 3 times weekly as in hemodialysis. 7.2.1 The peritoneal membrane / P. Martin 24
    • 25. College 7.2.1 The peritoneal membrane / P. Martin 25
    • 26. College 7.2.1 The peritoneal membrane / P. Martin 26
    • 27. 3 steps in peritoneal dialysis College Infusion : A sterile, dialysis solution flows into your peritoneal cavity by gravity via a catheter or tube that has been surgically placed into the abdomen. The filling takes about 10 minutes. Once the filling is complete, the catheter is shut so that it does not leak. Dwell : The lining of the peritoneal cavity called the peritoneum acts as a natural filter. It lets the waste products and excess fluids in the blood filter through into the dialysis solution, while holding back important substances that the body needs. The length of time varies from 3 - 6 hours. While the solution is in the body you can move about. Drain : The dialysis solution containing the wastes is drained again by gravity from your body through the catheter into an empty bag. This takes about 10-20 minutes. A bag containing sterile dialysis solution replaces the bag containing waste products. The whole process is then repeated. Each of these replacements is called a ' Bag Exchange'. 7.2.1 The peritoneal membrane / P. Martin 27
    • 28. INTERMITTEN PERITOENEAL DIALYSIS IPD (USUALLY DONE IN HOSPITAL) College 7.2.1 The peritoneal membrane / P. Martin 28
    • 29. College 7.2.1 The peritoneal membrane / P. Martin 29
    • 30. 1.Continuous ambulatory peritoneal dialysis College It is the most commonly used method of peritoneal dialysis. The filtration process occurs most hours of the day. The exchange usually take about 3 minutes 3-4 times a day and only require a solution bag with tubing attached to it that connects to the child’s blood stream. It gives freedom. 7.2.1 The peritoneal membrane / P. Martin 30
    • 31. 2.Automated Peritoneal Dialysis College a)Continuous Cyclic Peritoneal Dialysis Continuous regimen means that the dialysis solution is present in the peritoneal cavity continuously, with the exception of short significant periods between exchange. It uses duel lumen catheterization, i.e., 2 catheters, one for inflow and other for outflow. 7.2.1 The peritoneal membrane / P. Martin 31
    • 32. Intermittent Peritoneal Dialysis College -USUALLY DONE IN HOSPITAL It means the dialysis sessions are performed several times a week. This technique uses one catheter for inflow and outflow. Flow is interrupted after both inflow and outflow during exchange. 7.2.1 The peritoneal membrane / P. Martin 32
    • 33. PROCEDURE College • • The abdomen is cleaned in preparation for surgery, and a catheter is surgically inserted with one end in the abdomen and the other protruding from the skin. Before each infusion the catheter must be cleaned, and flow into and out of the abdomen tested. The warmed solution is allowed to enter the peritoneal cavity by gravity and remains a variable length of time (usually 10-15 minutes) according to the rate of solute removal and glucose absorption in individual patients. The total volume is referred to as dwell while the fluid itself is referred to as dialysate. 7.2.1 The peritoneal membrane / P. Martin 33
    • 34. College The dwell can be as much as 2.5 litres, and medication can also be added to the fluid immediately before infusion. The dwell remains in the abdomen and waste products diffuse across the peritoneum from the underlying blood vessels. After a variable period of time depending on the treatment (usually 4–6 hours), the fluid is removed and replaced with fresh fluid. 7.2.1 The peritoneal membrane / P. Martin 34
    • 35. College 7.2.1 The peritoneal membrane / P. Martin 35