Certification Review Certification Review CourseCourse

Peritoneal DialysisPeritoneal Dialysis

Ray Agnello, BSN, RN, CNNRay Agnello, BSN, RN, CNNEducatorEducator

Saint Joseph’s Regional Medical Saint Joseph’s Regional Medical CenterCenter

Paterson, New JerseyPaterson, New Jersey

To provide attendees with a To provide attendees with a summarized review of summarized review of peritoneal dialysis peritoneal dialysis

To highlight key points in the clinical To highlight key points in the clinical care of a PD patientcare of a PD patient

Catheter PlacementCatheter Placement

Care of CatheterCare of Catheter

Infectious ComplicationInfectious Complication

Non Infectious ComplicationsNon Infectious Complications

AdequacyAdequacy

Fluid Balance assessment of the PD Fluid Balance assessment of the PD patientpatient..

ObjectiveObjectivess

Peritoneal DialysisPeritoneal Dialysis Alternative to hemodialysisAlternative to hemodialysis Patient is taught to perform Patient is taught to perform

dialysis exchanges in the home dialysis exchanges in the home settingsetting

Focus is on patient autonomy and Focus is on patient autonomy and self care managementself care management

Patient must be followed by a Patient must be followed by a licensed Peritoneal Dialysis unit licensed Peritoneal Dialysis unit & Nephrologist& Nephrologist

Translucent Translucent

Vascular membraneVascular membrane

Two layersTwo layers ParietalParietal (inner surface of abdominal wall) (inner surface of abdominal wall)

Receives blood supply from the arteries of the Receives blood supply from the arteries of the abdominal abdominal wallwall

VisceralVisceral (covers abdominal viscera) (covers abdominal viscera)

Covers the abdominal organs Covers the abdominal organs

Blood is carried by the mesenteric and celiac Blood is carried by the mesenteric and celiac arteriesarteries

Most vascular layer where most of the dialysis Most vascular layer where most of the dialysis occursoccurs

Envelope of space between layers called Envelope of space between layers called peritoneal peritoneal cavitycavity

Semi-permeable-acts as a FilterSemi-permeable-acts as a Filter

Kelley 2004Kelley 2004

Peritoneal MembranePeritoneal Membrane

Anatomy and Physiology

Peritoneal MembranePeritoneal Membrane Semi-permeableSemi-permeable Bi-directionalBi-directional Membrane size- 1-2 mMembrane size- 1-2 m22

Vascular wall, interstitium, Vascular wall, interstitium, mesothelium , and adjacent fluid mesothelium , and adjacent fluid filmsfilms

Closed in malesClosed in males Women- ovaries and fallopian Women- ovaries and fallopian

tubes open into the peritoneal tubes open into the peritoneal cavity cavity

Peritoneal cavity normally Peritoneal cavity normally contains about 100 ml transudatecontains about 100 ml transudate

Kinetics of Kinetics of Peritoneal DialysisPeritoneal Dialysis

DiffusionDiffusionOsmosisOsmosisUltrafiltrationUltrafiltrationDrug TransportDrug Transport

Tea Bag = Peritoneal Membrane

Tea Leaves = Waste

Water = PD Fluid

DiffusionDiffusion

Scheme of semi-permeable membrane:red = blood

blue = PD fluidyellowyellow = membrane

.wikipedia.org/

OsmosisOsmosis

The diffusion of pure solvent across a membrane in response to a concentration gradient, usually

from a solution of lesser to one of

greater solute concentration.

Miller-Keane 6th EditionMiller-Keane 6th Edition

1.5 % Solution

2.5 % Solution

4.25 % Solution

Osmotic Pressure of Dextrose Osmotic Pressure of Dextrose SolutionSolution

The Peritoneal Dialysis The Peritoneal Dialysis ProcessProcess

Definition- intra (within) Definition- intra (within) corporeal dialysiscorporeal dialysis

Three Phases to the Three Phases to the Exchange processExchange process DrainDrain FillFill DwellDwell

How Does PD How Does PD Work?Work?

The semi-permeable peritoneal The semi-permeable peritoneal membrane lines the abdominal cavity membrane lines the abdominal cavity and covers the abdominal viscera.and covers the abdominal viscera.

The membrane allows (via diffusion) The membrane allows (via diffusion) the passage of toxins and electrolytes the passage of toxins and electrolytes into the dialysis solution.into the dialysis solution.

Ultra-filtration (removal of fluid) occurs Ultra-filtration (removal of fluid) occurs via osmosis.via osmosis.

A “steady state” of toxin clearance and A “steady state” of toxin clearance and fluid management is achieved due to fluid management is achieved due to daily performance of dialysis.daily performance of dialysis.

K. Kelly , RNK. Kelly , RNNNJ Sept-Oct 2004NNJ Sept-Oct 2004

How Does PD Work? Dialysis solution is infused and drained Dialysis solution is infused and drained

via a catheter that is surgically placed in via a catheter that is surgically placed in the peritoneal cavity.the peritoneal cavity.

The action of draining and infusing The action of draining and infusing dialysis solution is called an exchange.dialysis solution is called an exchange.

The frequency of exchanges and volume The frequency of exchanges and volume is determined by the presence of is determined by the presence of residual renal function and the residual renal function and the individual membrane characteristic.individual membrane characteristic.

Infusion or FillInfusion or Fill

Baxter®Baxter®

DrainDrain

Baxter®Baxter®

Dialysis occurs during the dwell phaseDialysis occurs during the dwell phase

Diffusion: solutes cross from area of Diffusion: solutes cross from area of greater greater concentration to lesser oneconcentration to lesser one

-depends on concentration gradient-depends on concentration gradient

-enough peritoneal surface area-enough peritoneal surface area

-size of fill volume-size of fill volume

Ultra-filtration: water removal due to Ultra-filtration: water removal due to osmotic gradient between the osmotic gradient between the hyperosmolar PD fluid and the capillary hyperosmolar PD fluid and the capillary bedbedKelley 2004Kelley 2004

Peritoneal DialysisPeritoneal Dialysis

Historical Historical PerspectivesPerspectives

Acute-Predominant use of PD prior to 1960’sAcute-Predominant use of PD prior to 1960’s 1966- Automated cycler1966- Automated cycler 1967- Tenckhoff catheter1967- Tenckhoff catheter 1975- CAPD1975- CAPD 1978- Polyvinyl bags and manufactured in the 1978- Polyvinyl bags and manufactured in the

US (prior PD fluid was available in glass US (prior PD fluid was available in glass bottles)bottles)

1980’s- New catheter designs1980’s- New catheter designs 1987- PET and tidal PD -Twardowski1987- PET and tidal PD -Twardowski 1990’s-Alternative dialysate solutions, 1990’s-Alternative dialysate solutions, updated system designs updated system designs ANNA Core Curriculum 5ANNA Core Curriculum 5thth Ed Ed

Who Are the PD Patients ?Who Are the PD Patients ? Choose PD as Renal Replacement TherapyChoose PD as Renal Replacement Therapy

Hemodialysis Patient without AccessHemodialysis Patient without Access

Failed allograft (transplanted kidney)Failed allograft (transplanted kidney)

Have CHF or CVD which exempts them Have CHF or CVD which exempts them from hemodialysisfrom hemodialysis

Often people with the benefit of CKD Often people with the benefit of CKD educationeducation

PD Patient SelectionPD Patient Selection Inclusion Criteria IncludeInclusion Criteria Include

Patients who:Patients who:

Choose the modalityChoose the modality

Want “control”Want “control”

Prefer home for dialysisPrefer home for dialysis

Have residual renal functionHave residual renal function

CVD, CHFCVD, CHF

GeriatricGeriatric

PediatricPediatric

Vascular Access FailureVascular Access Failure

Social support system availableSocial support system available

Selection ContinuedSelection Continued Exclusion CriteriaExclusion Criteria Patients who:Patients who:

Have abdominal aortic aneurysm AAA Have abdominal aortic aneurysm AAA (size dependent)(size dependent)

Derm. disease of the abdominal wallDerm. disease of the abdominal wallMorbid abdominal obesityMorbid abdominal obesityAltered mental status, poor coping stylesAltered mental status, poor coping stylesSolitary life styleSolitary life stylePatient states lack of interest in Patient states lack of interest in modalitymodality

Multiple abdominal surgeries- adhesionsMultiple abdominal surgeries- adhesionsOstomies (increase risk of infection)Ostomies (increase risk of infection)Recurrent herniasRecurrent hernias

Steps to PD Catheter Steps to PD Catheter AccessAccess

Evaluation by Nephrologist for PD Evaluation by Nephrologist for PD catheter placement and identified as catheter placement and identified as candidate.candidate.

Educated about catheter placement, Educated about catheter placement, pre and post operative care routines.pre and post operative care routines.

Referred to surgeon for evaluation that Referred to surgeon for evaluation that includes determination of exit includes determination of exit site,clinical & anesthesia work-up, site,clinical & anesthesia work-up, contraindications, completion of contraindications, completion of consent forms and scheduling of consent forms and scheduling of surgery.surgery.

Surgical EvaluationSurgical EvaluationCatheter InsertionCatheter Insertion

Some units advocate insertion 2 Some units advocate insertion 2 to 6 weeks prior to dialysis to to 6 weeks prior to dialysis to optimize healing.optimize healing.

Some units advocate insertion Some units advocate insertion months in advance.(burying the months in advance.(burying the catheter)catheter)

In most situations, PD access is In most situations, PD access is electiveelective

Surgical EvaluationSurgical Evaluation

Abdominal wall weakness or herniaAbdominal wall weakness or hernia Repair hernia preemptively or Repair hernia preemptively or

when symptomaticwhen symptomatic Previous abdominal surgeries: Previous abdominal surgeries:

multiple surgeries = increased multiple surgeries = increased likelihood of adhesionslikelihood of adhesions

Abdominal wall obesityAbdominal wall obesity

Pre Catheter InsertionPre Catheter Insertion

Patient Education and consent signedPatient Education and consent signed Examination of the patient’s abdomen Examination of the patient’s abdomen

• Avoid scars and fat foldsAvoid scars and fat folds• Avoid beltlineAvoid beltline• Mark the abdomenMark the abdomen

Surgical prepSurgical prep• Empty bladderEmpty bladder• Patient showers with disinfectant Patient showers with disinfectant

soapsoap• Bowel prepBowel prep

Question

Evidence-based practice suggests which of the following upon PD catheter implantation?

a. Large fill volumes immediately post-opb. No need to wear a mask while performing

PD exchangesc. Incision site to be exposed to air during

immediate post-op periodd. Administration of prophylactic IV

antibiotics prior to catheter implantation to reduce the risk of peritonitis

Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’ Association

Peri Operative RoutinesPeri Operative RoutinesAnesthesiaAnesthesia

Local infiltration with sedationLocal infiltration with sedation

Intravenous propofol with Intravenous propofol with Monitored Anesthesia CareMonitored Anesthesia Care

General anesthesiaGeneral anesthesia

Insertion TechniquesInsertion Techniques

Bedside-temporary cathetersBedside-temporary catheters Laparoscopic placementLaparoscopic placement Surgical dissectionSurgical dissection Buried Catheter techniqueBuried Catheter technique Percutaneous placement per Percutaneous placement per

Interventional RadiologyInterventional Radiology

Insertion TechniquesInsertion TechniquesBuried catheterBuried catheter:: Entire catheter placed in Entire catheter placed in

subcutaneous pocket for 4-6 weeks subcutaneous pocket for 4-6 weeks or longer, allowing cuff & tunnel to or longer, allowing cuff & tunnel to heal heal

Exit site is externalized in a Exit site is externalized in a separate procedureseparate procedure

Reduced bacterial colonization(?)Reduced bacterial colonization(?) Do not have long term outcomes yetDo not have long term outcomes yet

Flanigan, Gokal, 2005Flanigan, Gokal, 2005

Catheter HistoryCatheter History•Early catheters were glass cannulas with Early catheters were glass cannulas with straight or with mushroom endsstraight or with mushroom ends

•1920-40’s: Various medical devices were used 1920-40’s: Various medical devices were used in the beginning of PD: needles, glass in the beginning of PD: needles, glass cannulas, sump drains, stainless steel coils, cannulas, sump drains, stainless steel coils, Foley cathetersFoley catheters

•1923-Ganter used a needle for the 1st reported use 1923-Ganter used a needle for the 1st reported use in humans.in humans.

•1950’s-Nylon catheters, polyethylene, plastic 1950’s-Nylon catheters, polyethylene, plastic with rounded tip & numerous tiny side holeswith rounded tip & numerous tiny side holes

ANNA Core Curriculum 5th EdANNA Core Curriculum 5th Ed

Catheter HistoryCatheter History

1960’s-1960’s- silicon rubber catheters, with coiled intraperitoneal silicon rubber catheters, with coiled intraperitoneal

Tenckhoff & Schechter published results with Tenckhoff & Schechter published results with silicone elastomer (Silastic silicone elastomer (Silastic ®®) for chronic dialysis ) for chronic dialysis with 2 Dacron with 2 Dacron ®® polyester felt cuffs polyester felt cuffs

1968-Tenckhoff cuffed straight catheter1968-Tenckhoff cuffed straight catheter 1970’s-single/double cuff coiled catheter; Toronto 1970’s-single/double cuff coiled catheter; Toronto

Western with 3 silicone discWestern with 3 silicone disc 1980’s-swan neck configuration (bent or curved SQ 1980’s-swan neck configuration (bent or curved SQ

segment) Toronto Western with 2 silicone discsegment) Toronto Western with 2 silicone disc 1990’s-t shaped catheter (Ash); Moncrief & Popovich 1990’s-t shaped catheter (Ash); Moncrief & Popovich

technique for leaving the exterior segment buried SQ technique for leaving the exterior segment buried SQ for 4 wkfor 4 wk

The future..?The future..? segment (Palmer, Quinton)segment (Palmer, Quinton)

ANNA Core Curriculum 5ANNA Core Curriculum 5thth Ed Ed

CathetersCatheters

Straight (single or double cuff)Straight (single or double cuff)Coiled (single or double cuff )Coiled (single or double cuff )Swan neck (single or double cuff)Swan neck (single or double cuff)Pre sternal swan neckPre sternal swan neckToronto WesternToronto WesternMissouri cathetersMissouri cathetersDisc cathetersDisc catheters

CuffsCuffs

SingleSingleDoubleDoubleElongatedElongatedBead/flange Bead/flange

configurationconfiguration

Question…

What is one advantage of implanting a cuffed PD catheter?

a. Acts as a barrier to prevent infectionb. Can only be used for CAPDc. Ensures optimal adequacyd. Can be implanted at the bedside

Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’ Association

AdaptorsAdaptors

PlasticPlastic TitaniumTitanium

PD PD Catheter Access Catheter Access ComplicationComplication

Immediate/EarlyImmediate/Early

Bloody effluentBloody effluent

Pain with infusionPain with infusion

Leak at exit siteLeak at exit site

Exit site infectionExit site infection

Migration of catheter tipMigration of catheter tip

Poor fill or drain, with or without Poor fill or drain, with or without painpain

Non-infectious cloudy effluentNon-infectious cloudy effluent

(lymphatic leak or eosinophilic (lymphatic leak or eosinophilic peritonitis)peritonitis)

Question

The patient’s fill volume is 2000mL. Upon draining, the patient’s volume is 1500mL. The nurse should assess the patient for which of the following?a. Peritonitisb. Catheter removalc. Constipationd. Subcutaneous tunnel infection

Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’ Association

PD Catheter Access PD Catheter Access ComplicationComplication

Later IssuesLater Issues Exit site leaks or subcutaneous Exit site leaks or subcutaneous

leaksleaks Pleural communicationsPleural communications Excessive granulation tissueExcessive granulation tissue Chronic site or tunnel infectionChronic site or tunnel infection Cuff extrusionCuff extrusion Cracked, brittle catheterCracked, brittle catheter Repetitive episodes of peritonitisRepetitive episodes of peritonitis Bowel perforationsBowel perforations

Post OpPost Op

Follow up appointment with surgeonFollow up appointment with surgeon Instructions (written & verbal) to Instructions (written & verbal) to

patient, which include emergency patient, which include emergency contact numberscontact numbers

Follow-up in PD unit within Follow-up in PD unit within

48 to 72 hours of discharge48 to 72 hours of discharge Pain medication/prescriptionPain medication/prescription Reinforce dressing as neededReinforce dressing as needed Teach patient to secure catheterTeach patient to secure catheter Flush catheter during training sessionsFlush catheter during training sessions

Remove primary dressing in 5 to 7 days by Remove primary dressing in 5 to 7 days by PD nursePD nurseDressing changed by PD nurseDressing changed by PD nurseReplace dressing with DSD, non-occlusiveReplace dressing with DSD, non-occlusiveEstablish training scheduleEstablish training scheduleBowel regimen Bowel regimen No heavy liftingNo heavy liftingAllow catheter to heal for 14 days or Allow catheter to heal for 14 days or longer if possible before uselonger if possible before use

Post Operative Discharge PlanPost Operative Discharge Plan

Prevent Constipation

Peritoneal Dialysis Peritoneal Dialysis TherapiesTherapies

IPD (Intermittent Peritoneal IPD (Intermittent Peritoneal Dialysis)Dialysis)

CAPD (Continuous Ambulatory CAPD (Continuous Ambulatory Peritoneal Dialysis )Peritoneal Dialysis )

CCPD (Continuous Cycling CCPD (Continuous Cycling Peritoneal Dialysis) also known Peritoneal Dialysis) also known as APD (Automated Peritoneal as APD (Automated Peritoneal Dialysis)Dialysis)

Training Sessions for the PD PatientTraining Sessions for the PD Patient Assess readiness to learnAssess readiness to learn Provide a quiet, relaxed atmosphere Provide a quiet, relaxed atmosphere

for learningfor learning Identify patient’s learning styleIdentify patient’s learning style Individualized with respect to Individualized with respect to

patient’s expectations, cultural patient’s expectations, cultural beliefs, and coping abilitiesbeliefs, and coping abilities

Length of training based on Length of training based on patient’s clinical conditionpatient’s clinical condition

ON Call RN

OONN CCaallll

On Call RNOn Call RN

Warming the SolutionWarming the Solution Use warm, dry heatUse warm, dry heat

At home- PD heating padAt home- PD heating pad

NEVER MICROWAVE!!NEVER MICROWAVE!!Uneven heating of dextrose can create aUneven heating of dextrose can create a1st or 2nd degree burn to peritoneum1st or 2nd degree burn to peritoneum

Leaching of plastics into dialysate canLeaching of plastics into dialysate canCreate a chemical peritonitis Create a chemical peritonitis

NEVER MICROWAVE!!NEVER MICROWAVE!!

Patients at risk for inadequate Patients at risk for inadequate dialysisdialysis

No residual renal functionNo residual renal function Low membrane Low membrane

permeabilitypermeability Large patientsLarge patients Patients not doing their Patients not doing their

treatmentstreatments

PD Equilibration TestPD Equilibration TestAKA: PETAKA: PET

First developed by Z. Twardowski at First developed by Z. Twardowski at the University of Missourithe University of Missouri

A four hour study that assesses A four hour study that assesses membrane transport characteristics.membrane transport characteristics.

Assessment of membrane function Assessment of membrane function allows for accurate prescription allows for accurate prescription planning.planning.

Usually completed within the first Usually completed within the first six weeks of initiating PDsix weeks of initiating PD

Repeated per each unit’s protocolRepeated per each unit’s protocol

PD Equilibration Test PD Equilibration Test continuedcontinued

What does this tell us?The results indicate the

following transport states: High High-average Low-average Low

Transporter Waste removal

Water removal

Best type of PD

High or Fast Fast Poor Frequent exchanges, short dwells – APD

Average Okay Okay CAPD or APD

Low Slow Good CAPD, 5 evenly spaced exchanges – 1 exchange at night using a small machine.

http://www.homedialysis.org/files/pdf/resources/tom/200801.pdf

KT/V TestKT/V Test

What is measured?What is measured? 24 hour collection of dialysate 24 hour collection of dialysate

and urineand urine

Serum values of BUN and Serum values of BUN and CreatinineCreatinine

Frequency of test is determined Frequency of test is determined by each unit’s protocols and by each unit’s protocols and interpretation of K/DOQI interpretation of K/DOQI guidelines. guidelines. (Unit specific, usually (Unit specific, usually quarterly or bi-annually)quarterly or bi-annually)

Kt/V Test continuedKt/V Test continued

What does it tell us?What does it tell us? The adequacy of the current The adequacy of the current

prescriptionprescription

Need for adjustments to insure Need for adjustments to insure appropriate dialysis prescriptionappropriate dialysis prescription

Exit Site CareExit Site Care Healthy exit site: surrounding Healthy exit site: surrounding

skin natural, darkened, or light skin natural, darkened, or light Pink; no drainage or crusting; Pink; no drainage or crusting; visible sinus is dryvisible sinus is dry

Goal: prevent exit site infection Goal: prevent exit site infection and identify problems earlyand identify problems early

ES Care: daily or 3-4 times ES Care: daily or 3-4 times weekly; may be in conjunction weekly; may be in conjunction with showering with showering

Infection PreventionInfection Prevention Exit Site Care:Exit Site Care:

No dressing needed for established No dressing needed for established catheter exit site (unit or pt specific)catheter exit site (unit or pt specific)

Keep catheter secured to abdomen with 2 Keep catheter secured to abdomen with 2 inch tapeinch tape

Daily showers with liquid soap Daily showers with liquid soap Mupirocin (Bactroban ®) or Gentamycin Mupirocin (Bactroban ®) or Gentamycin

Cream at exit site of known staph. CarrierCream at exit site of known staph. Carrier Inpatients-dry dressing to protect site, Inpatients-dry dressing to protect site,

cleaned with soap and water, No occlusive cleaned with soap and water, No occlusive membrane dressings (Tegaderm ®)membrane dressings (Tegaderm ®)

A healed and non-infected exit site is A healed and non-infected exit site is crucial to longevity on Peritoneal Dialysiscrucial to longevity on Peritoneal Dialysis

Question…Following peritoneal dialysis catheter

implantation, a patient is instructed that:

a. The exit will always be tenderb. Baggy clothes will have to be wornc. The catheter will need to be changed

monthlyd. Well-healed healthy exit-sites make

swimming possibleCore curriculum for Nephrology Nursing, 5th Edition. American

Nephrology Nurses’ Association

Infectious Infectious ComplicationsComplications

Exit Site InfectionExit Site Infection

Teach patient to identify and report Teach patient to identify and report immediately to the PD Unit:immediately to the PD Unit:

Redness, tenderness, edema, presence of Redness, tenderness, edema, presence of exudate either at exit site or insertion exudate either at exit site or insertion sitesiteTreatment:Treatment: Culture exudate if possibleCulture exudate if possible Specific antibiotic protocolSpecific antibiotic protocol Oral or IV/IP antibiotics depending on extent of Oral or IV/IP antibiotics depending on extent of

infectioninfection Saline soaks/dressing changes for care of local Saline soaks/dressing changes for care of local

cellulitis (unit/Nephrologist specific)cellulitis (unit/Nephrologist specific)

Exit Site InfectionExit Site Infection S & S : redness, swelling, tenderness or S & S : redness, swelling, tenderness or

pain and purulent drainagepain and purulent drainage Risk Factors: poor catheter healing, Risk Factors: poor catheter healing,

sutures at the exit site, trauma to the sutures at the exit site, trauma to the exit site, cuff extrusion and improper exit site, cuff extrusion and improper catheter carecatheter care

Diagnosis: Observation and cultureDiagnosis: Observation and culture Treatment: Antibiotics, IP,PO, or IV;Treatment: Antibiotics, IP,PO, or IV;

vigilant daily exit site carevigilant daily exit site care

Exit Site InfectionExit Site Infection

A chronic exit site infection can produce a A chronic exit site infection can produce a systemic inflammatory response.systemic inflammatory response.

Inflammation can lead to poor nutrition, Inflammation can lead to poor nutrition, inadequate dialysis and possible inadequate dialysis and possible antibiotic resistance. Vital role of antibiotic resistance. Vital role of DietitianDietitian

Chronic exit site infections may result in Chronic exit site infections may result in peritonitis.peritonitis.

Multiple infections can lead to removal Multiple infections can lead to removal and replacement of catheter.and replacement of catheter.

Consistent assessment and Consistent assessment and documentation is needed to appropriately documentation is needed to appropriately track infections.track infections.

Responsible OrganismsResponsible Organisms

Staphylococcus AureusStaphylococcus Aureus Pseudomonas speciesPseudomonas species Other Gram positive speciesOther Gram positive species Serratia speciesSerratia species Other gram-negative Other gram-negative

organismsorganisms FungiFungi

Tunnel InfectionTunnel InfectionS & SS & S erythema over the tunnelerythema over the tunnelpain and tenderness pain and tenderness drainage from exit site –no other signs drainage from exit site –no other signs of an infectionof an infection Risk factorsRisk factors exit-site infection exit-site infection exit site traumaexit site traumaleak leak external cuff extrusionexternal cuff extrusionTreatment- antibiotic therapy to Treatment- antibiotic therapy to prevent need for catheter removalprevent need for catheter removal

Prevention of Prevention of PeritonitisPeritonitis

Careful individualized patient Careful individualized patient trainingtraining

Adequate daily hygieneAdequate daily hygiene

Meticulous hand washingMeticulous hand washing

On going retrainingOn going retraining

Prevention of Prevention of PeritonitisPeritonitis Basics of Aseptic Technique: 5 min. Basics of Aseptic Technique: 5 min.

hand scrub, face masks during hand scrub, face masks during exchanges, warming of PD bags using exchanges, warming of PD bags using dry heat, aseptic technique for adding dry heat, aseptic technique for adding medicinesmedicines

Aseptic technique when making critical Aseptic technique when making critical connections to solution containers and connections to solution containers and the patient’s transfer setthe patient’s transfer set

Masks reduce the risk of contamination Masks reduce the risk of contamination with nasopharyngeal organismswith nasopharyngeal organisms

PeritonitisPeritonitis Inflammation of the peritoneal cavityInflammation of the peritoneal cavity

Defined as the presence of WBC in the effluent Defined as the presence of WBC in the effluent numbering 100 or greater & 50 polys numbering 100 or greater & 50 polys (neutrophil) or segs(neutrophil) or segs

Effluent appears cloudy and milky.Effluent appears cloudy and milky.

Patient may have fever, chills, abdominal pain, Patient may have fever, chills, abdominal pain, nausea, vomiting and diarrhea.nausea, vomiting and diarrhea.

Some present initially with cloudy fluid as the Some present initially with cloudy fluid as the first sign and no symptoms.first sign and no symptoms.

Patient must be taught to contact their PD Patient must be taught to contact their PD Nurse or Nephrologist immediately for cloudy Nurse or Nephrologist immediately for cloudy effluent.effluent.

PeritonitisPeritonitis

Portals of Entry:Portals of Entry: Transluminal- technique failure, Transluminal- technique failure,

contaminationcontamination Periluminal- incomplete Periluminal- incomplete

healing ,leakinghealing ,leaking Hematogenous- bacteremiaHematogenous- bacteremia Transmural- through the bowel wallTransmural- through the bowel wall

ANNA Core CurriculumANNA Core Curriculum

Peritonitis PresentationPeritonitis Presentation S & S: fever, abdominal pain, N & V, S & S: fever, abdominal pain, N & V,

diarrhea, and cloudy effluentdiarrhea, and cloudy effluent

Incubation: 24-48 hours; if within 6 Incubation: 24-48 hours; if within 6 hours suspect an enteric sourcehours suspect an enteric source

Kinetic effects: increased solute Kinetic effects: increased solute removal and protein loss; increased removal and protein loss; increased glucose absorption leading to a glucose absorption leading to a decreased osmotic gradient and decreased osmotic gradient and decreased ultrafiltrationdecreased ultrafiltration

Diagnosis of PeritonitisDiagnosis of Peritonitis Effective culture techniques:Effective culture techniques:

Minimum sample volume of 50-Minimum sample volume of 50-100 ml. Large samples reduce 100 ml. Large samples reduce false negative resultsfalse negative results

Dialysate must be mixed well by Dialysate must be mixed well by inverting bag several times inverting bag several times before samplingbefore sampling

Sample port is disinfected before Sample port is disinfected before samplingsampling

Sample is obtained using aseptic Sample is obtained using aseptic techniquetechnique

Question…

A PD effluent cell count differential can determine if peritonitis is present when there is an elevation in ?a. eosinophilsb. neutrophilsc. lymphocytesd. granulocytes

Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’ Association

PeritonitisPeritonitis

Treatment protocolsTreatment protocols Patient may be treated in PD unit or Patient may be treated in PD unit or

Emergency Room depending on severity of Emergency Room depending on severity of symptoms and availability of resources.symptoms and availability of resources.

Effluent is sent for cell count, C&S and gram Effluent is sent for cell count, C&S and gram stainstain

Fungal cultures should be included if patient is Fungal cultures should be included if patient is immunosuppressed or had had frequent immunosuppressed or had had frequent infections requiring antibioticsinfections requiring antibiotics

PD Unit should have specific antibiotic PD Unit should have specific antibiotic protocols for gram positive and gram negative protocols for gram positive and gram negative coverage.coverage.

PeritonitisPeritonitis

Organisms:Organisms: Gram positive-Gram positive-

Staphylococcus epidermidisStaphylococcus epidermidis

Staphylococcus aureusStaphylococcus aureus

Streptococcus speciesStreptococcus species

EnterococcusEnterococcus

Gram Negative-Gram Negative-PseudomonasPseudomonas

KlebsiellaKlebsiella

Escherichia coliEscherichia coli

EnterobacterEnterobacter

Fungal organismsFungal organisms

QuestionCatheter removal is recommended when the

patient has peritonitis associated by which of the following organisms?

a. Staph aureusb. Fungalc. Staph epid. Pseudomonas

Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’ Association

Non Infectious Complications

Non Infectious Complications Pericatheter and Subcutaneous Leaks Peritoneal Catheter Obstruction: most

commonly early, yet can occur at any time.

Hernia: significant abdominal wall hernias should be surgically repaired prior to initiation of PD. Enlargement may occur due to increased abdominal wall pressure.

Non Infectious Complications Pneumoperitoneum (Shoulder Pain):

usually resulting from air infusion Hemoperitoneum: blood loss into the

peritoneal cavity. A few drops of blood will produce grossly bloody effluent. Most common in women in menses. Any bleeding needs to be monitored.

Hydrothorax: secondary to a pleuroperitoneal communication.

PD Affects Drug Transport PD Affects Drug Transport By:By:

Systemic drug removal via Systemic drug removal via effluenteffluent

Drugs can be administered IPDrugs can be administered IP Dose related to Urine output Dose related to Urine output

and mechanism for and mechanism for elimination of drugelimination of drug

Non Infectious Complications Catheter Adapter Disconnect or

Fracture of Peritoneal Catheter. Stop Dialysis, obtain culture, replace or repair, prophylactic antibiotics pending culture results

Membrane changesMembrane changes Sclerosing, Encapsulating Peritonitis: Sclerosing, Encapsulating Peritonitis:

serious, yet rare, not exclusive to PDserious, yet rare, not exclusive to PD A thick fibrous layer of tissue A thick fibrous layer of tissue

encapsulates the bowel encapsulates the bowel Membrane becomes thick and opaqueMembrane becomes thick and opaque Onset gradual or rapidOnset gradual or rapid PresentationPresentation

Decreased ultrafiltration and solute Decreased ultrafiltration and solute clearancesclearances

Recurrent abdominal painRecurrent abdominal pain Intermittent nausea and vomitingIntermittent nausea and vomiting Partial and/or complete bowel Partial and/or complete bowel

obstructionobstruction Intervention – emergency laparotomyIntervention – emergency laparotomy

Clinical Management Issues Clinical Management Issues for the PD Patientfor the PD Patient

Catheter insertion and Healing of exit Catheter insertion and Healing of exit sitesite

Prevention of infectionPrevention of infection Blood pressure control & Fluid Blood pressure control & Fluid

managementmanagement Nutrition evaluation and interventionsNutrition evaluation and interventions Systems assessmentSystems assessment Medication evaluationMedication evaluation Anemia,Ca/Phos./PTH managementAnemia,Ca/Phos./PTH management PET and initial Kt/VPET and initial Kt/V Coping with stress of chronic illnessCoping with stress of chronic illness Transplantation Transplantation

Current Issues in Peritoneal Current Issues in Peritoneal DialysisDialysis

Revision of K/DOQI Revision of K/DOQI Co-morbiditiesCo-morbidities Role of sodiumRole of sodium Volume ControlVolume Control Blood pressure controlBlood pressure control Utilization of IcodextrinUtilization of Icodextrin Role of inflammationRole of inflammation Integrated dialysis careIntegrated dialysis care Improving nephrology fellow educationImproving nephrology fellow education CKD education for patients and familiesCKD education for patients and families ADEMEX study-adequacyADEMEX study-adequacy European APD Outcome Study (2003)European APD Outcome Study (2003) Underutilization of Peritoneal DialysisUnderutilization of Peritoneal Dialysis

Final Note

The success of PD can be attributed to the combined efforts of researchers, individuals on PD, and healthcare professionals who, in collaboration with the industrial community, have realized the potential benefits of the treatment. Despite a slow start in comparison to HD, PD has evolved into a modality that equals HD in long term outcomes.

Contemporary Nephrology Nursing p 633

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