peritoneal dialysis catheter medical insertion programme

Peritoneal Dialysis Catheter

Medical Insertion Programme

South West Home Therapies Conference

March 2016

David Lewis

Consultant Nephrologist

A personal physician inserted peritoneal dialysis catheter journey

Conflict of interest: I have received honoraria from Baxter Healthcare

http://www.heardfamilyhistory.org.uk/Photo%20Gallery/Exeter/EX78.html

Killingbeck Hospital, Leeds

Post cardiac surgery/bypass AKI

Presumed recoverable

Ventilated on ICU

Hospital 4 miles from renal inpatient site

Junior renal registrar travel to site

Hard cannula “stab” PD

Royal Devon and Exeter Hospital

Devil’s Slide, Lundy Island

Standard issue Renal Registrar transport, 1990’s

Background

• Large, innovative PD service

• Differential tariff HD lines vs fistula

• Borderline financial viability NHS

haemodialysis

• Maintaining strong home therapy

option for patients

• Mortality associated with

haemodialysis on lines

• Line related infection : MRSA

MSSA

• Failed permanent access

The ageing dialysis population: PD, HD and multi-morbidity

• Giving an alternative to hospital HD

• Time spent in travel and treatment

• Tolerate HD: fluid shifts, BP?

• Clinical and moral dilemma permanent access

PD catheter insertion techniques

• Percutaneous needle-guidewire insertion without imaging

• Percutaneous needle-guidewire insertion with imaging

• Peritoneoscope

• Surgical – mini laparotomy

• Surgical - laparoscopic

• Simple technique, simple organisation, start with thin non-scarred abdomen

• Requires angio lab / IRMER training

• Kit to buy, pain of air

insufflation, ?conscious sedation

• General anaesthetic, simple abdominal wall surgery

• GA, kit, complexity, training, surgical enthusiasm

Medical and Surgical insertion Medical • Choice of avoiding general

anaesthetic (GA) • Patients too sick for GA • Immediate use (supine automated

PD) • Short preparation time – bowel

clearance • Minor surgical scars acceptable

(simple appendix, caesarean, kidney transplant)

• Higher BMI with experience • High potassium, anaemia, AF • Much easier to manipulate and

remove • Avoidance of central lines –

infection, future stenoses • Medical ownership – exit site • Cheaper/more flexible frees up

theatre

Surgical • Previous complex abdominal surgery not

absolute contraindication • Controlled surgical environment • Adhesions and omentum divided/resected • Simultaneous hernia repairs • Easier to direct the catheter into the pelvis

(although not fool proof) • Kidney patients high risk general anaesthesia • Patients with advanced CKD or on HD, high

potassium, fluid overload, anaemia likely to be cancelled

• Surgical time zero sum game – reserve for complex cases or vascular access

Elective AAA repair

Vagotomy and pyloroplasty + R nephrectomy

Small umbilical hernia

Patient says renal stone surgery No history of bowel surgery

Do you think tenckhoff insertion is possible?

What are the important factors?

• Indications

• Contraindications

• relative

• absolute

• Anatomy

• PD catheter

• Procedure

• who

• where

• when

• Complications

• governance

• Post procedure ward care

• Discharge follow up

• Community team

• assisted APD

Preparation for dialysis clinic outcomes

• Consent: surgical pathway document

• Explanation of procedure and PD catheter/dressing

• PD options: CAPD, APD & assisted APD

• History and examination

• Anaesthetic risk assessment-referral to pre-op/consultant anaesthetist

• Surgical or percutaneous approach

• Pre-operative optimisation medications / BP/ fluid status

• Community team visit: laxatives,body wash

• patient concerns, continuity of care,

• Minimised cancellations

Post procedure

• Eat and drink

• Can start immediate APD 1litre fill

• Dry abdomen while mobilising

• Laxatives

• Avoid codeine

• Don’t touch the dressing, keep dry

Salford Peritoneal Dialysis Pathway

Advanced Kidney Care Service clinic

Late referral from General Nephrology or Transplant clinics

Unplanned start

Preparation for PD clinic MDT

Elective percutaneous PD insertion list fortnightly

AKCS for Transplant clinic

Ad hoc catheter insertion

APD for 4 hours

Remain on ward APD

Discharged home nurse follow up

Home training

AKI

CKD team home visit

Assisted APD

PD nurse home visit

Catheter manipulation

Day case automated PD in Renal Unit Short Stay

Elective Insertion

PD for a multi-morbid & ageing dialysis population

• Giving an alternative to hospital HD

• Time spent in treatment not travel

• Tolerability, diet and fluid balance

• Assisted APD for planned and unplanned start

• aAPD infrastructure

Salford medical and surgical peritoneal dialysis catheter insertion by quarter, 2011-2015

Repositioning of a displaced catheter: guidewire down existing catheter to avoid a new puncture of the

peritoneum, adopted from Elaine Bowes/Hugh Cairns Kings

Central lines – not a victimless crime

Occluded left brachiocephalic vein

12mm balloon angioplasty

Return of patency but likely to recur

Occluded right brachiocephalic unable to recannulate, left IJ line in situ

Setting up a service

• Operators: 2 consultants & ANP

• Assistant: Adele

• Location: ward procedure room

• WHO Surgical checklist

• Protocol:

– bowel prep/antibiotics/sedation/analgesia

– flucloxacillin IV 1G, paracetamol IV 1G, lorazepam sublingual 1-2mg

• Ultrasound: empty bladder/abdominal wall

• Governance: surgical back up

• Teaching/support: Baxter access academy, peer support, Liverpool PD

catheter insertion course

• Ward post procedure care: adjusted APD regime

• PD nursing structure follow up: patient wellbeing, catheter and wound review

• Assisted APD programme

Case 1: unknown

CKD 5

• 51 years old female one year history non-specific symptoms, fatigue

• eGFR 3, Hb 51, small kidneys on USS

• Transfusion, transferred local hospital Friday morning

• Well, few comorbidities, family, works

• Dialysis modality discussed agreed PD

• Accelerated preparation: enema rather than picolax

• Hb 75 urea 70, avoided further transfusion

• Successful procedure Friday afternoon immediate APD

• PD until bowel obstruction from rare tumour

• Fully resected, surgical reinsertion after a period on HD

Case 2: failed HD

access

• 58 year old female, multiple co-morbidities, hysterectomy

• Haemodialysis with multiple failed permanent access

• Progressively difficult central lines

• Unable to dialyse admitted from unit

• Ward inserted percutaneous catheter used immediately

• Discharged home on PD • Trained at home post

discharge

Case 3: bridging or

permanent?

• 73 year old male

• CKD 5 post-infective GN

• Due for AV fistula formation

• Admitted from clinic uraemia

symptoms and fluid overload

• Agreed PD pending permanent

HD access formation

• Catheter inserted, home on PD

• Successful home therapy

Case 4: failed transplant

and surgical risk

• 50 year old female kidney transplant

• Aware slowly failing but acute deterioration

• Chronic hypotension

• Previous peritoneal dialysis wished to restart

• Admitted acutely planned percutaneous PD catheter

• Fast AF at time of insertion

• Clinical decision to continue procedure

• Catheter inserted and used immediately

• Cardiac review, rate control

• Discharged home on PD, retraining by community team

Large PD programme, not at the expense of home HD

• Unit HD 367

• PD 101

• Home HD increasing

• NxStage platform increasingly popular

• 20 patients undertaking home HD beginning March 2016

• Predicted 24/25 by end March 2016

• 13 on NxStage

Medical PD catheter insertion

• Improves choice

• Role in frail/elderly, unplanned

start, AKI

• Stronger home therapy

programme

• Accelerated discharge

• Central line avoidance

• Role for assisted APD

• Connect and disconnect before

training

• Drop in APD?

• Thanks to those helped

establish and improve service

• Thanks MDT maintaining high

quality service

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