dialisis

1. Taralan Tambunan
Departemen Ilmu Kesehatan Anak
FKUI – RSCM, Jakarta

2. Dialisis Pada Anak
 Dialisis peritoneal akut
 Dialisis peritoneal kronik (CAPD, CCPD)
 Hemodialisis
 CAVH - CVVH

3. Dialisis Peritoneal Akut (1)
Teknik PD:
a. Premedikasi - sedasi
b. Kosongkan kandung kemih
c. Hangatkan botol dialisis 370 – 380
d. Daerah insersi:
- linea alba
- pertengahan simpisis – umbilikus
e. Prosedur a & antiseptik
f. Asites buatan
g. Insersi stylet-guided kateter
- ABBOT
- JMS
- Tenckhoff
h. Hub. dengan botol dialisat: 1.000 iμ heparin/L
Ref. Alfiler CA, dkk. Pediatr Kidney Digest, 1994

4. i. Dialysis solution:
- inpersol
- dianeal
- 40 – 50 ml/kgbb, glukose 1,5% ; 2,5% & 4,25%
- heparin 1.000 iμ/L
- Kcl 3-6 mEq/L
j. Durasi
- inflow: 5-10 menit
- dwell-time: 15-30 menit
- outflow: 10-15 menit
k. Monitor
- tanda vital cairan
- balans cairan
- kekeruhan cairan, pewarnaan Gram
- elektrolit serum, ureum & kreatinin
Ref. Alfiler CA, dkk. Pediatr Kidney Digest, 1994
Dialisis Peritoneal Akut (2)

6. Komplikasi Peritoneal Dialisis Akut
 Peritonitis
 Perdarahan
 Rasa sakit
 Perforasi buli-buli
 Kebocoran dialisat
 Aliran dialisat lambat / macet
 Gangguan elektrolit: - hipo/hipermalremia
- hipo/hiperkalemia
 Hipotensi
 Distres pernapasan
Ref. Avner ED, dkk. Pediatr Nephrol, 2004

7. DIALISIS PERITONEAL KRONIK (DPK)
TIPE: - CAPD (DPMB)
- CCPD
INDIKASI: CCT:9 – 14 ml/menit/1,73m2
a. Bayi/anak kecil
b. Jauh dari senter dialisis
c. Penggunaan jangka lama
d. Kesulitan memasang HD
e. Gangguan kardiovaskular
f. Pilihan pasien
Ref. Alfiler CA, dkk. Pediatr Kidney Digest, 1994

8. Pelaksanaan CAPD Awal
Implantasi:
 Prosedur bedah
 Kateter Tenckhoff (double cuffed)
 Anestesi umum
 Waktu optimal: 2 – 6 minggu sebelum penggunaan kateter
 Exit site – hindari setinggi ikat pinggang, di atas letak diaperline,
mengarah ke bawah
 Laksatif
 Pasang kateter buli-buli
 Antibiotik profilaksis
 Omentektomi
Ref. Yap HK, Chiu MC. Practical Paediatr Nephrol, 2005
Dangirdas JT, dkk. Handbook of Dialysis, 2007

9. Memulai Dialisis: CCT:9 – 14 ml/17,3m2
 Bilas dengan cairan dialisat + heparin 500 iμ/L
sampai dialisat jernih
 Bila perlu dialisis segera:
- mulai dengan: - 10 ml/kgbb/siklus
- dwell-time pendek
- posisi anak: telentang (supine)
- volume dialisis & dwell-time dinaikkan bertahap
 target 1100 ml/m2 (40-50 ml/kgbb)
 dwell-time 4-6 jam
- fiksasi kateter
- tutup dengan kain kasa steril (1x/minggu)
- jangan diolesi dengan Povidan iodine/betadine atau H2O2
Ref. Chiu MC, Yap HK. Practical Paed Nephrol 2005.

10. PEMANTAUAN
 Buku catatan harian: siklus, in/out, dwell-time, dsb
 Berat badan & tinggi badan
 Lab.: - ureum, kreatinin
- elektrolit Na, K, Cl
 Diuresis
 Evaluasi fungsi ginjal I : 2 minggu
II : 2-4 minggu
III : 3 minggu, dst.

19. NURSING CARE
I. Perawatan Kateter Tenckhoff (1)
1.1 Peri operatif
 Biakan kuman dari lubang hidung (nostril) pasien + caregiver:
Bila  Staph. Aureus: MUPIROCIN 2% 2 x sehari
selama 5 hr, setiap bulan
 Pilih ukuran kateter yang tepat
 Tentukan letak exit - site
 Insersi: 2-6 minggu sebelum pemakaian

20. I. Perawatan Kateter Tenckhoff (2)
1.2 Intra Operatif
Setelah kateter terpasang
 Bilas minimal 5 x
 Periksa kondisi kateter
 Periksa ada tidaknya kebocoran pada exit - site
 Periksa aliran dialisat (in – out)
 Volume awal: 10 ml/kg

21. I. Perawatan Kateter Tenckhoff (3)
1.3 Post operatif
 Perhatikan adanya kebocoran, perdarahan
 Perhatikan fiksasi kateter
 Periksa fungsi kateter (in – out)
 Pastikan posisi kateter (X-ray)
 Penanganan nyeri dan penyembuhan luka

23. PERAWATAN EXIT – SITE
 Mencegah infeksi
 Mencegah trauma
 Mencegah peritonitis
 Perhatikan kulit sekitar, eritema, nyeri tekan
 Bila ada nanah  biakan  beri antibiotik empiris
 Hindari palpasi tunnel
 Periksa & ganti verband 1 x seminggu
 jaga kebersihan,
 kering,
 tertutup rapi
 Cepat ganti verband bila basah, berkeringat
 Pakai masker & sarung tangan
 Bila luka sudah sembuh  olesi dengan Povidone iodine swabstick 1%

24. Tanda Infeksi Exit – Site
 Kemerahan
 Edema sekitar kateter
 Pus
 Nyeri sekitar exit-site/tunnel
Ref. Chiu MC, Yap HK. Practical Paed Nephrol 2005.

25. Complication Number of children Percentage
Peritonitis 8 children
(23 episodes)
53%
Exit site infection 4 children
(12 episodes)
26.6%
Bilateral hernia 1 6.6%
Catheter obstruction 1 6.6%
External Leak 1 6.6%
Table. Complications of PD
Ref. Kari JA. Saudi J Kidney Dis Transplant 2005;16(3):348-353

26. Table Complication risk in relation to the time of peritoneal
Dialysis (PD) catheter use
Complication Early use Delayed use P value
N Rate (%)a N Rate (%)a
Malfunction
Dialysate leak
Peritonitis
Exit-site infection
Tunnel infection
All infections
9
12
66
21
10
97
17.7
23.5
0.07
0.02
0.01
0.10
18
6
66
55
8
129
23.7
7.9
0.05
0.04
0.01
0.09
0.415
0.013
0.504
0.150
0.480
0.952
a Rate/patient-month for the infectious complications
Ref. Rahim AK, et al. Pediatr Nephrol 2004;19:1021-28.

27. PERITONITIS ON CAPD IN CHILDREN
Peritonitis rate in children > Adults
Developing country (India)
Etiology
 E. coli 23% (fecal contaminations)
 Pseudomonas 14,3%
 Staph. Aureus 9,5%
 Staph. Epid. 9.5%
 Citro-bacter 9,5%
 Entero-bacter 9.5%
Risk factor
 Poor hand washing
 Lack of fresh running water
 Very low socioeconomic status*
Ref. - Prasad N, et al. Pediatr Nephrol 2006
* Ariza M, et al. www.advancesinpd.com/adv91/children91/.htm

28. EXIT-SITE/TUNNEL INFECTIONS
Def. - Purulent discharge  INFECTION
- Exit-site appears normal:
 ve culture  colonization
- Twardowski score > 4 points  INFECTION
Initial Treatment
- Once or twice daily dressing changes
- Non-alcoholic desinfectans
- Povidone idodine should not be used
- Start antibiotics according to culture result
Ref. Chiu MC, Yap HK. Practical Paediatr Nephrol, 2005.

29. PERITONITIS IN CAPD PATIENTS
Initial Management
- Antibiotic (IV) after specimen saved for culture
- Antibiotic IP route
For very cloudy effluent
- Start Th/ without waiting of cell count.
- Several fluid exchanges
- Heparin 500 iu/L into dialysate
Choice of antibiotics:
- Without risk factor:
1st gen cephalosporin + 3rd gen cephalosporin
- With risk factor: History of MRSA/carriage
Glycopeptide (e.g. vancomycin) + ceftazidine
Give IP
Ref. Chiu MC, Yap HK. Practical Paediatr Nephrol, 2005.

30. CATHETER REMOVAL & REPLACEMENT
A. Indication for catheter removal
a. Relapsing S.aureus peritonitis with concomitant tunnel infection
b. Relapsing Pseudomonas peritonitis]
c. Fungal peritonitis
d. Refractory peritonitis, defined as failure to resolve after 72-96
hours of appropriate antibiotics
e. Refractory exit-site and/or tunnel infections treated for 1 month
B. Catheter Replacement
a. Recommended to wait 2-3 weeks after catheter removal
b. If effluent can first be cleared (WBC < 100/mm3) in relapsing
S. aureus peritonitis, simultaneous catheter replacement
with removal is possible
Ref. Chiu MC, Yap HK. Practical Paediatr Nephrol, 2005.

31. PREVENTION
Careful attention to personal hygiene is key to avoiding
MRSA infections
 Wash your hands frequently, especially if visiting someone
in a hospital or long-term care facility
 Make sure all doctors, nurses, and other healthcare providers
wash their hands before examining you
 Do not share personal items such as towels or razors
with another person - MRSA can be transmitted through
contaminated items
 Cover all wounds with a clean bandage, and avoid contact
with other people’s soiled bandages
 If you share sporting equipment, clean it first with antiseptic
solution
 Avoid common whirlpools or saunas if another participant
has an open lesion
 Ensure that communal bathing facilities are clean
Ref. Smith DS. cdc.www.edc.gov

32. PREVENTION (Contd.)
 Hygiene practice:
- hand washing
- disposable gloves
 Antiseptic solution and wipes
 Treatment and cover any skin breaks
 Mupirocin cream
Ref. Davis C. MRSA infection. http:/www.emedicinehealth.com/mrsa_
infection/page5_em.htm

33. INFECTION CONTROL
To minimize spread & prevent development
of an endemic strain
 Isolated patient in a private room
 using contact precaution (mask)
 Initiate epidemologic and lab. investigation
 Educate health care professionals
 Strictly enforce compliance about epidemologic implication
 Perform baseline culture of hands and nares of:
- those with recent direct contact with visa
- health care professionals for patient with visa
- roommate of patient with visa
Ref. - Redbook 2003. Report of the committee on infections diseases

34. Tujuan/Target CAPD (home dialysis)
1. Dialisis lancar, kondisi anak stabil
2. Bebas infeksi
3. Program CAPD dapat diterima keluarga
4. Anak/pasien tetap dapat sekolah seperti biasa
5. Mengurangi rawat inap di RS

36. PD training program (1-2 minggu)
 Teknik cuci tangan
 Anatomi/fisiologi ginjal
 Perkenalan D.P / CAPD
 Peralatan CAPD
 Perawatan exit - site
 Pentingnya tindakan aseptik
Ref. Chiu MC, Yap HK. Practical Paed Nephrol 2005.

37. PD training program (2)
 Komplikasi CAPD
 Peritonitis
 Penanganan dialisat
 Pengukuran tekanan darah
 Pengaturan diet
 Penanganan masalah di rumah
 Pencatatan yang cermat
 Emergency call
 Pemesanan alat / bahan
 Pengobatan
 Monitor kepatuhan
Ref. Chiu MC, Yap HK. Practical Paed Nephrol 2005.

38. Pentingnya CAPD Nurse
Dalam Penanganan Burnout
BURNOUT:
Kondisi kelelahan & stress pada pasien / keluarga
Konsep filosofis program CAPD pada anak:
1. Peran orangtua sebagai penentu kebijakan
2. CAPD dapat berhasil dengan baik
3. Dapat timbul komplikasi

39. Konsep Edukasi Keluarga Pasien
1. CAPD/CCPD:
Prosedur sederhana, tapi perlu keterampilan
2. Pasien & Keluarga:
Perlu kerjasama yang baik dan koperatif
3. CAPD/CCPD harus dapat dilakukan di rumah
4. Perlu kerjasama yang baik dengan nursing staf

42. HEMODIALYSIS IN CHILDREN
Vascular acces - Av Fistula
- Av Synthetic graft (Polytetra fluoroethylene: PTFE)
- Cuffed CV catheter (double lumen)
THINK BEFORE YOU STICK!!!
Does this patient have renal disease?
HD Systems
- Blood circuit  Qb: 200 ml/min
- Dialysate circuit  Qd: 500 ml/min
- Dialyzer: FRESENIUS
BAXTER
GAMBRO
Ref. Warady BA et al. Pediatric dialysis (2012)

43. Heparin
• Heparin coating: 5000 iu/L saline flush 100 ml/min
• Std heparin anticoagulant:
- initial (bolus): 300-1000 iu/m2 BSA
- continuous inf: 300-800 iu/m2/hour
• Monitoring: ACT: 1,5 – 2 x baseline
Ref. Warady BA et al. Pediatric dialysis (2012)