Peritoneal Dialysis

PD Access

Peritoneal Dialysis

Peritoneal Catheters

PD catheter is patients lifelineSeveral advances have made access

safer and longer lastingSuccessful outcome is dependent on

meticulous care and attention to detailAdherence to principles of catheter

insertion and subsequent management and care remain the cornerstone of successful PD access

Peritoneal Dialysis

The ideal PD Catheter

• Rapid rate of dialysate flow• Minimal or no - leaks - migration - exit and tunnel infections - peritonitis• Ease of insertion by all techniques• Long lasting• Inert material - durability - resistant ot infection/biofilm - antimicrobial properties

Peritoneal Dialysis

Peritoneal Catheters and Exit Site Practices

- Towards Optimum Peritoneal Access - 1998 Update

Gokal R et al Perit Dial Int 1998;18:11-33

Peritoneal Dialysis

Peritoneal Catheters and Exit Site Practices

Areas Covered

Peritoneal CathetersCatheter Choice and Catheter OutcomesCatheter InsertionImmediate post - operative careChronic care of healed exit-site

Peritoneal Dialysis

Peritoneal Catheters

Intraperitoneal Segment

Straight Coiled

Silicone discs T-fluted

Subcutaneous Tract

straight

permanent bend - Swan-neck/Missouri

Swan-neck presternal

Anchorage Dacron cuffs

Bead-and-flange - Swan-neck

Peritoneal Dialysis

P

Currently available

chronic peritoneal

catheters

Gokal et al PDI 1998;18:11-33

Peritoneal Dialysis

Catheter Insertion

• Prevention of complications begins with the decision to place a patient on peritoneal dialysis

Peritoneal Dialysis

Appropriate candidates

• Motivated ESRD patient• Patient support – family, carer, etc• Ability to understand and use sterile technique• Physical capability• Ideal candidate would have no prior abdominal

procedures

Peritoneal Dialysis

Insertion Complications

• EARLY

- Leak- Obstruction to flow- Bleeding- Infection- Intestinal perforation- Inability to insert catheter

• LATE

- Obstruction to flow- Hernia- Hydrothorax- Peritonitis- Exit-site erosion / infection- Other surgical problems

* diverticulitis

* cholecystitis

Peritoneal Dialysis

Catheter Insertion

• Who should place the PD catheter?

The Surgeon!

Peritoneal Dialysis

Communication is Essential

Surgeon

NurseNephrologist

Peritoneal Dialysis

Peritoneal Catheters

Outcome in relation to exit direction Downward directed exit site recommended

Golper T et al AJKD 1996;38:428-36 - 38% decreased risk of peritonitis associated with ESI

USRDS 1996 Report - peritonitis less with permanent bent catheter

Peritoneal Dialysis

Peritoneal Catheters

Outcome in relation to number of cuffs

RECOMMENDATIONS Double cuffed catheters should be used for chronic

peritoneal dialysis USRDS 1992 , Warady 1996, Honda 1996

- single cuff associated with shorter time to first peritonitis Linblad et al PDI 1988;8:129-33 and

Favazza et al PDI 1995;15:357-62 - more frequent exit site complications and shorter survival times for single cuff

Eklund et al NDT 1997;12:2664-6 - no difference between single or double cuffs (RCT)

Peritoneal Dialysis

Catheter Choice and Outcomes

RECOMMENDATIONS

• Catheter survival of >80% at one year desirable

• Double cuffed catheter preferred to single cuff

• Downward directed exit-site decreases the risk of catheter related infections (advantage being its- preformed arcuate bend)

• No catheter appears to be superior to the 2 cuff standard Tenckhoff catheter - experience with swan-neck catheters is promising.

Peritoneal Dialysis

Catheter Insertion

PRE-IMPLANTATION PREPARATION

Fully inform patient of details of procedure Pre-surgical assessment (e.g. hernias) Determination of exit-site Skin preparation Bowel preparation Prophylactic antibiotics

- Evidence suggests that peri-op antibiotics

diminishes wound infection

Peritoneal Dialysis

Catheter Implantation Techniques

RECOMMENDATIONS• Implantation to be performed by competent,

experienced operator, in a planned manner. Care and attention to detail is important

• Peritoneal entry - lateral or paramedian• Deep cuff - placed in musculature of anterior

abdominal wall or within posterior rectus fascia. • Subcutaneous cuff - 2cm from exit site• Catheter patency needs checking• Exit-site facing downward or laterally

Peritoneal Dialysis

A Healthy Exit Site

Peritoneal Dialysis

Immediate Post Operative Care

AIMS Minimise bacterial colonisation Prevent trauma to exit-site and traction on cuffs Minimise intra-abdominal pressure to prevent leakage Several approaches to post operative care No evidence to support superiority of any one

RECOMMENDATIONS Minimise catheter movement Minimise catheter handling until healing of wound and

tract - 3-4 weeks

Peritoneal Dialysis

Post implantation Dialysis

RECOMMENDATIONS• Flush catheter with small volumes (e.g. 500ml)

until effluent is clear• Starting CAPD depends on type of implantation

technique - generally catheter should be capped for 2 weeks before starting PD

• PD in the interim should be

- intermittent

- small volumes - gradual increase in volume

- patient in a supine position