acute peritoneal dialysis (pd) in the picu

Acute peritoneal dialysis Acute peritoneal dialysis (PD) in the PICU(PD) in the PICU

Constantinos J. StefanidisConstantinos J. Stefanidis

““P. & A. Kyriakou” Children's Hospital, Athens, GreeceP. & A. Kyriakou” Children's Hospital, Athens, Greece

C J Stefanidis 2002

HDHD

PDPD

Late Late referralreferral

life-threatening life-threatening hyperkalemia or hyperkalemia or severe volume severe volume

overloadoverloadARFARF

Early Early referralreferral

Choice of dialysis in ARFChoice of dialysis in ARF

CRRTCRRToror

Neonates and infantsNeonates and infants

C J Stefanidis 2002

HDHDPDPD


CRRTCRRT

Were used as the primary means of Were used as the primary means of acute renal replacement therapy in a acute renal replacement therapy in a nearly equal percentage of centersnearly equal percentage of centers

Warady BA, Bunchman T. Dialysis therapy for children with Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-32000;15(1-2):11-3

C J Stefanidis 2002

Preferential use of PD and CRRTPreferential use of PD and CRRT

Warady BA, Bunchman T. Dialysis therapy for children with Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-32000;15(1-2):11-3

PDPD CRRTCRRT

C J Stefanidis 2002

When to start PD in ARF ?When to start PD in ARF ?

• SSymptomatic uraemiaymptomatic uraemia

• HHyperkalaemiayperkalaemia

• VVolume overloadolume overload

• SSevere metabolic acidosis evere metabolic acidosis

( refractory to medical treatment)( refractory to medical treatment)

Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-18311817-1831

C J Stefanidis 2002


S. S. creatinine and blood urea are creatinine and blood urea are

not primary indications for dialysis not primary indications for dialysis

unless they relate to mental status unless they relate to mental status

changeschanges

Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-18311817-1831

C J Stefanidis 2002


IIn the absence of data it is advisable n the absence of data it is advisable

to start dialysis at the earliest sign to start dialysis at the earliest sign

that it may be neededthat it may be needed

TThere are essentially no datahere are essentially no data

Flynn JT. Pediatr Nephrol 2002;17(1):61-9Flynn JT. Pediatr Nephrol 2002;17(1):61-9

C J Stefanidis 2002

Benefits of PDBenefits of PD

PD still remains the modality of renal replacement therapy PD still remains the modality of renal replacement therapy

of choice in many pediatric nephrology centers, because:of choice in many pediatric nephrology centers, because:

1. it requires 1. it requires minimal equipmentminimal equipment and infrastructure and infrastructure

Flynn JT. Choice of dialysis modality for management of Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-92002;17(1):61-9

2. it is fairly 2. it is fairly inexpensiveinexpensive compared with other modalities compared with other modalities

3. it is relatively 3. it is relatively easy easy to perform and to perform and

does not require additional nursing does not require additional nursing personnelpersonnel. .

C J Stefanidis 2002

Benefits of PDBenefits of PD

1. Less haemodynamic instability 1. Less haemodynamic instability


3. Avoidance of angioaccess3. Avoidance of angioaccess

2. Avoidance of systemic anticoagulation2. Avoidance of systemic anticoagulation

Children with ARF who are Children with ARF who are hypotensive, hypotensive, requiring requiring vasopressor vasopressor

supportsupport and children with and children with multiple organ failuremultiple organ failure are successfully are successfully

managed with PDmanaged with PD

C J Stefanidis 2002

Disadvantages of PDDisadvantages of PD

1. Slower correction of metabolic parameters1. Slower correction of metabolic parameters

lower urea clearanceslower urea clearances


2. Lower ultrafiltration2. Lower ultrafiltration

3. Risk of peritonitis3. Risk of peritonitis

C J Stefanidis 2002

Thadhani R et al Acute renal failure. N Engl J Med 1996; 334: 1448-Thadhani R et al Acute renal failure. N Engl J Med 1996; 334: 1448-14601460

ComplexityComplexity

PDPD LowLow controlcontrol VolumeVolume

ModerateModerate

Anticoa-Anticoa-

gulationgulation

NoNo

Use in hy-Use in hy-potensionpotension

YesYes

IntermittentIntermittent

Low andLow and

variablevariable

NoNo

NoNo

HDHD ModerateModerate

CAVHCAVH ModerateModerate

CVVHCVVH ModerateModerate

CVVHDCVVHD HighHigh

EfficiencyEfficiency

ModerateModerate

HighHigh

HighHigh

HighHigh

GoodGood

GoodGood

GoodGood

YesYes

YesYes

YesYes

YesYes

YesYes

YesYes


C J Stefanidis 2002

Acute PD in the PICUAcute PD in the PICU

PD catheters for ARFPD catheters for ARF

Choice of dialysis treatmentChoice of dialysis treatment

Prescription of PD in ARFPrescription of PD in ARF

C J Stefanidis 2002

Trocath cathetersTrocath catheters

Their prolonged use (> 3 days) was Their prolonged use (> 3 days) was

associated with a significant risk of:associated with a significant risk of:

• leakageleakage

• malfunction malfunction

• peritonitis peritonitis

In our days very few centers use these cathetersIn our days very few centers use these catheters

A major complication was viscus perforation. A major complication was viscus perforation.

C J Stefanidis 2002

Acute PD cathetersAcute PD catheters

Percutaneus guidewire inserted cathetersPercutaneus guidewire inserted catheters

Trocath cathetersTrocath catheters

Tenckhoff catheters implanted Tenckhoff catheters implanted under general anesthesiaunder general anesthesia

C J Stefanidis 2002

Site of introductionSite of introduction: Level of : Level of

umbilicus lateral to the umbilicus lateral to the

rectus sheath (newborns) rectus sheath (newborns)

or any where along a line or any where along a line

parallel to the rectus sheath. parallel to the rectus sheath.

Local anestheticLocal anesthetic


C J Stefanidis 2002


18 G

Angiocath

Insertion of Angiocath 18 GInsertion of Angiocath 18 G

Flushed with 5 ml of N/S Flushed with 5 ml of N/S

and aspirated to ensure and aspirated to ensure

bowel content is not bowel content is not

retrievedretrieved

C J Stefanidis 2002 Seldinger (Acta Radiologica, 38, [1953], 368-376)

The wire is advanced through the The wire is advanced through the

needle needle in the peritoneal cavity (3-4 in the peritoneal cavity (3-4

cm)cm)The Angiocath 18 G is removedThe Angiocath 18 G is removed

Priming of the abdomen is not Priming of the abdomen is not

essentialessential


C J Stefanidis 2002 Seldinger (Acta Radiologica, 38, [1953], 368-376)

3-4 mm incision around the wire. 3-4 mm incision around the wire.

In newborns is not recommended In newborns is not recommended

`̀

The catheter is threaded around The catheter is threaded around

the wire the wire and is forced in the and is forced in the

peritoneal cavity with a peritoneal cavity with a

«screwing action»«screwing action»The wire is removedThe wire is removed

The catheter is taped to the skin The catheter is taped to the skin


C J Stefanidis 2002

Femoral vein catheter for neonatesFemoral vein catheter for neonates

14 G 13.5 cm3 sideports

Kohli HS et al Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol 1999 Apr;13(3):241-4

It was used in 10 neonates.It was used in 10 neonates.

Intraperitoneal bleed : 1 Intraperitoneal bleed : 1

neonateneonate

Dialysate leak: 1 Dialysate leak: 1

Catheter blockade: 4Catheter blockade: 4

Incidence of peritonitis: 1Incidence of peritonitis: 1

Guide wire-inserted femoral vein Guide wire-inserted femoral vein

polyurethane catheter polyurethane catheter

(Medcomp-pediatric)(Medcomp-pediatric)

C J Stefanidis 2002

Cook catheter8.5 French 8 cm44 sideports

Percutaneus guidewire inserted catheterPercutaneus guidewire inserted catheter

http://www.cookgroup.com/cook_incorporated/pdf/CDB11.pdf

C J Stefanidis 2002

5 French Cook PD catheter5 French Cook PD catheter

2929 infants infants

age 4.5 +/- 1.3 months age 4.5 +/- 1.3 months

weight 4.8 +/- 0.5 kgweight 4.8 +/- 0.5 kg

Complications:Complications:

• inadequate inflow in one caseinadequate inflow in one case

• bleeding in one casebleeding in one case

• accidental removal in one caseaccidental removal in one case

Bunchman TE. Acute peritoneal dialysis access in infant renal failure Perit Dial Int 1996;16 Suppl 1:S509-11.

Duration of the placed catheters was Duration of the placed catheters was 9.9 +/- 2.7 days9.9 +/- 2.7 days, ,

without the problems associated with the use of a stiff without the problems associated with the use of a stiff

cathetercatheter

5 French 5.5 cm

C J Stefanidis 2002

8.5 French 15 cm 6 sideports

http://www.cookgroup.com/cook_incorporated/pdf/CADB14.pdf

Cook (pleuropericardial) pig tail catheterCook (pleuropericardial) pig tail catheter

C J Stefanidis 2002

Cook (pleuropericardial) pig tail catheterCook (pleuropericardial) pig tail catheter

Retrospective study (1992-1995) in 46 patientsRetrospective study (1992-1995) in 46 patients

Complications of the Seldinger-placed Cook Complications of the Seldinger-placed Cook

(pleuropericard) catheter were limited: (pleuropericard) catheter were limited:

leakage (1/44) leakage (1/44)

bleeding: n = 0 bleeding: n = 0

obstruction or dislocation: n = 4obstruction or dislocation: n = 4

peritonitis: n = 1 (Candida)peritonitis: n = 1 (Candida)

Vande Walle J et al New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Perit Dial 1997;13:190-4

C J Stefanidis 2002

Tenckhoff cathetersTenckhoff catheters

9.5 French9.5 French

Introducer Introducer 11 French11 French

Lewis MA, Nycyk JA.Practical peritoneal dialysis--the Tenckhoff

catheter in acute renal failure. Pediatr Nephrol 1992 Sep;6(5):470-5

C J Stefanidis 2002

Tenckhoff catheters implanted under general Tenckhoff catheters implanted under general anesthesiaanesthesia

16 French

C J Stefanidis 2002

Tenckhoff catheters (TC) implanted under general Tenckhoff catheters (TC) implanted under general anesthesia compaired with Cook catheters (CC)anesthesia compaired with Cook catheters (CC)

Chadha V et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis. 2000;35(6):1111-6.

TC in 22 patients and a CC in TC in 22 patients and a CC in 37 37 patientspatients

The The duration of useduration of use of TCs ( of TCs (1616 days) was significantly days) was significantly

greater than the duration of CC use (greater than the duration of CC use (55 days; P < 0.001). days; P < 0.001).

By By day 6day 6 of dialysis, of dialysis, 90%90% of TCs were functioning without of TCs were functioning without

complications compared with complications compared with 46%46% of CCs of CCs

Only 2 patients with a TC (Only 2 patients with a TC (99%) developed %) developed complicationscomplications, ,

whereas 18 patients with a CC (whereas 18 patients with a CC (4949%). %).

C J Stefanidis 2002

Laparoscopic Tenckhoff catheter implantationLaparoscopic Tenckhoff catheter implantation

Daschner M et al Perit Dial Int 2002 Jan-Feb;22(1):22-6

In 25 children laparoscopic TCIs and in 23 In 25 children laparoscopic TCIs and in 23 conventionalconventional TCIs TCIs

The inner cuff was placed adjacent to the peritoneum, without The inner cuff was placed adjacent to the peritoneum, without

suturessutures

leakage: n =1, bleeding: n = 0 ,obstruction : n = 2leakage: n =1, bleeding: n = 0 ,obstruction : n = 2

Laparoscopic TCI is feasible in children of all age Laparoscopic TCI is feasible in children of all age

groups, with equivalent functional results compared to groups, with equivalent functional results compared to

conventional TCIconventional TCI

An additional advantage is the option to identify and eliminate An additional advantage is the option to identify and eliminate

anatomical risk factors, such as intra-abdominal adhesions or anatomical risk factors, such as intra-abdominal adhesions or

preformed inguinal hernias in male infantspreformed inguinal hernias in male infants

C J Stefanidis 2002

Acute PD cathetersAcute PD catheters

A Tenckhoff catheter implanted under A Tenckhoff catheter implanted under

general anesthesiageneral anesthesia is recommended is recommended

If the patient can not undergo surgery, a If the patient can not undergo surgery, a

percutaneus guidewire inserted PD percutaneus guidewire inserted PD

catheter should be placedcatheter should be placed

C J Stefanidis 2002

Acute PD in the PICUAcute PD in the PICU

PD catheters for ARFPD catheters for ARF

Choice of dialysis treatmentChoice of dialysis treatment

Prescription of PD in ARFPrescription of PD in ARF

C J Stefanidis 2002

The patient should be connected and The patient should be connected and start start automatedautomated PD PD immediatelyimmediately after surgical catheter implantation. after surgical catheter implantation.

Prescription of acute PDPrescription of acute PD

If APD is not available a If APD is not available a closed-drainage system PD closed-drainage system PD system with disconnectionsystem with disconnection should be used. should be used.

The use of a closed-drainage system The use of a closed-drainage system

reduced the incidence of system-related reduced the incidence of system-related peritonitisperitonitisValeri A et al Am J Kidney Dis 1993Valeri A et al Am J Kidney Dis 1993

Complications (peritonitis and hypothermia) are Complications (peritonitis and hypothermia) are significantly reduced with the use of a significantly reduced with the use of a cyclercycler compared compared with the manual method. with the manual method. Kohli HS et al Ren Fail 1995Kohli HS et al Ren Fail 1995

C J Stefanidis 2002

Cefazoline (250 mg/liter) Cefazoline (250 mg/liter) and and Heparin 500 U/literHeparin 500 U/liter should be added to the dialysis solution for first two should be added to the dialysis solution for first two days days

Initial prescription of acute PDInitial prescription of acute PD

Dialysate with a glucose concentration of Dialysate with a glucose concentration of 1.36%1.36% for for

volume of volume of urine > 1.5 ml/kg/hrurine > 1.5 ml/kg/hr and UF is not required and UF is not required

Otherwise a dialysate with a higher glucose Otherwise a dialysate with a higher glucose concentration concentration 2.27%2.27% (or even higher) should be (or even higher) should be prescribed prescribed For children with severe lactic acidosis or hepatic For children with severe lactic acidosis or hepatic failure a failure a bicarbonate-based dialysatebicarbonate-based dialysate can be prepared can be prepared in the hospital pharmacyin the hospital pharmacy

C J Stefanidis 2002

Initially the exchange volume is kept low (Initially the exchange volume is kept low (20 ml/kg,20 ml/kg,

100-200 ml/m²100-200 ml/m²) to reduce the risk of dialysate leakage) to reduce the risk of dialysate leakage

Initial prescription of acute PDInitial prescription of acute PD

After 24 hours the volume is increased by 100-200 After 24 hours the volume is increased by 100-200 ml/m²/day up to ml/m²/day up to 800-1000 ml/m²800-1000 ml/m² as tolerated by the as tolerated by the patient patient

The first day The first day one-hour dwellsone-hour dwells are prescribed and are prescribed and usually usually two-hour dwellstwo-hour dwells are recommended on the are recommended on the second daysecond day

C J Stefanidis 2002

Prescription of PD should be Prescription of PD should be individually adjustedindividually adjusted in in

the next days according to the needs of ultrafiltration the next days according to the needs of ultrafiltration

and the parameters of adequacy (bl. urea and s. and the parameters of adequacy (bl. urea and s.

creatinine levels)creatinine levels)

Adapted prescription of acute PDAdapted prescription of acute PD

Usually after the stabilization period Usually after the stabilization period 5 to 8 exchanges 5 to 8 exchanges

dailydaily are effective in most children with ARF. The aim are effective in most children with ARF. The aim

is to deliver a maximum clearance to compensate the is to deliver a maximum clearance to compensate the

catabolic stresscatabolic stress

C J Stefanidis 2002

Messages to take homeMessages to take home

1. Early referral and early initiation of PD is 1. Early referral and early initiation of PD is

very important for the outcome of children very important for the outcome of children

with ARFwith ARF

2. 2. PD should not be used in children with PD should not be used in children with

severe life-threatening hyperkalemia or with severe life-threatening hyperkalemia or with

severe volume overloadsevere volume overload

C J Stefanidis 2002

3. Access to the peritoneal cavity using a 3. Access to the peritoneal cavity using a

Tenckhoff catheter implanted under general Tenckhoff catheter implanted under general

anesthesiaanesthesia is at present one of the key factors is at present one of the key factors

determining long-term success of acute PDdetermining long-term success of acute PD

4. If the patient is not fit for surgery, a 4. If the patient is not fit for surgery, a

percutaneus guidewire inserted PD catheter can percutaneus guidewire inserted PD catheter can

be placed at the bedside in a short period of be placed at the bedside in a short period of

timetime


C J Stefanidis 2002

3. Access to the peritoneal cavity using a 3. Access to the peritoneal cavity using a

Tenckhoff catheter implanted under Tenckhoff catheter implanted under

general anesthesiageneral anesthesia is at present one of is at present one of

the key factors determining long-term the key factors determining long-term

success of acute PDsuccess of acute PD4. If the patient is not fit for surgery, a 4. If the patient is not fit for surgery, a

percutaneus guidewire inserted PD catheter percutaneus guidewire inserted PD catheter

can be placed at the bedside in a short can be placed at the bedside in a short

period of timeperiod of time


C J Stefanidis 2002

5. The perscription of PD treatment should be 5. The perscription of PD treatment should be

optimized in critically ill children with ARF in optimized in critically ill children with ARF in

order to achieve the goal of controlling uremia order to achieve the goal of controlling uremia

and fluid overload, and giving appropriate and fluid overload, and giving appropriate

nutritional supportnutritional support


acute peritoneal dialysis (pd) in the picu

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