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Canberra Hospital and Health ServicesClinical ProceduresPeritoneal Dialysis Contents

Contents....................................................................................................................................1

Introduction..............................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – PD: Catheter Exit Site Management.......................................................................2

Section 2 – Continuous Ambulatory Peritoneal Dialysis............................................................5

Section 3 – Automated Peritoneal Dialysis.............................................................................17

Section 4 – Infection and Peritoneal Dialysis..........................................................................17

Section 5 – Special Procedures...............................................................................................26

Definitions...............................................................................................................................30

Implementation...................................................................................................................... 31

Related Policies, Procedures, Guidelines and Legislation.......................................................31

References.............................................................................................................................. 31

Attachments............................................................................................................................32

Doc Number Version Issued Review Date Area Responsible PageCHHS15/153 2 28/05/2015 30/04/2018 Medicine 1 of 32

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Introduction

Peritoneal Dialysis is a Renal Replacement Therapy which is performed by the patient at home. Patients are trained and monitored by the Renal Home Therapies Team. Patients who are admitted and unable to perform their own Peritoneal Dialysis will be assisted by the Renal Home Therapies Team and the ward 8B nurses.

Back to Table of Contents

Scope

This document applies to adult patients whose care falls under the clinical governance of the Canberra Hospital and Health Service (CHHS) Renal Network.


Section 1 – PD: Catheter Exit Site Management

This procedure covers the three stages of exit site healing, ie post surgery, week one, and thereafter.

A. Post SurgeryWhen patient returns to the ward from surgery inspect dressing to ensure that the whole tube is not underneath the Mepilex dressing as the cap on the end of the catheter can dig into the skin. If the tube is under the dressing proceed as below. Patients must not shower.

Equipment Basic dressing pack. Sterile gloves. Mepilex Border 10cm x 10cm Pkt of Gauze squares. Tegaderm 10 x 12cm Non- sterile gloves

Method1. Perform hand hygiene.2. Clean work surface with disinfectant.3. Open dressing pack and arrange equipment on it. 4. Using unsterile gloves, carefully remove the old dressing, taking note of any ooze or

odour around the site or on the dressing.5. Perform hand hygiene and don sterile gloves.6. Place a new Mepilex dressing over the exit site ensuring Tenckhoff catheter comes out

from under the dressing.



Mepilex

Capped catheter out from under Mepilex

New Mepilex

Tegaderm

Gauze

Capped catheter

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7. Wrap the cap of the Tenckhoff catheter in a piece of gauze to pad it.8. Place Tegaderm dressing over the gauze wrapped Tenckhoff catheter to hold it securely

to the abdomen.

9. The Mepilex dressing absorbs a lot of moisture.10. Remind patients NOT to shower during this period.11. If in Week 2 the site still has moderate ooze, then continue the Mepilex dressing for

another week.

B. First three weeksPatients will attend Renal Home Therapies for weekly dressings. Patients in SNSWLHD will be attended by the Renal Outreach Nurse or community nurse in consultation with the Renal Outreach Nurse.

Mepilex dressing: Post op for one week.

Tegaderm dressing: Replace Mepilex with Tegaderm at end of first week. Patient can now shower. The laparoscopic puncture site dressings are taken down and inspected and no further dressing is required for these sites if clean.

Note: If patient is not commencing PD after three weeks PD Catheter should be flushed and heparin locked monthly.

Equipment Basic dressing pack



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Sterile NaCl Betadine swab sticks Non sterile gloves Sterile Gloves Gauze squares Tegaderm 10 x 12 cm Appropriate PPE

Method1. Close door to room to ensure environment and work area is clean.2. Ask patient to position themselves comfortably and expose dressing.3. Perform hand hygiene.4. Clean trolley and set up equipment.5. Perform hand hygiene.6. Apply non sterile gloves.7. Carefully remove old dressing.8. Observe exit site for any redness, swelling, ooze and take swab if any discharge noted. 9. Perform hand hygiene and don sterile gloves.10. Check the tunnel for tenderness and ooze by gently palpating along the skin where the

catheter passes underneath and in the direction of the exit site. Ensure that care is taken when checking area close to catheter exit site to prevent tissue damage.

11. Check for ooze especially on the underside of the catheter by gently lifting the catheter forward from the exit site.

12. Clean Tenckhoff catheter exit site using NaCl soaked gauze from clean to unclean area in a spiral motion. Repeat twice more and dry with dry piece of gauze.

13. Apply dressing and gauze, ensuring catheter is immobilised by the dressing and is not kinked or twisted. Catheter should come out of the bottom of the dressing so that water from the shower cannot tunnel along the catheter making the dressings wet and thus increasing the risk of infection. If the dressing is wet it must be changed immediately.

14. Discard used equipment and clean trolley.15. Attend hand hygiene.16. Document dressing change and condition of the exit site in the medical record and notify

Advanced Trainee Registrar (ATR) if any concerns. C. Established exit site Once the exit site is healed (usually 3 weeks) the exit site care can be done second daily by the patient after training, which includes signs and symptoms of exit site infection and the procedure for reporting these.

1. Perform hand hygiene.2. Clean area with NaCl soaked gauze x 3 in a circular motion from exit site out.

Dry with gauze.Clean around the exit site with two betadine swab sticks and use the third swab stick in the pack to clean along the catheter.

3. Allow to dry.



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4. Dressing is not necessary. Patients may choose to wear one of a variety of waist bands to secure catheter inside clothing.

Management of infected exit sites: Send swab for M/C/S and following RMO review commence on antibiotics as ordered. Increase frequency of dressings to daily as required.


Section 2 – Continuous Ambulatory Peritoneal Dialysis

2.1- PD - Extension Line change (Fresenius and Baxter) Routine extension line changes are scheduled every 6 months.

Emergency extension line change is done when there is:1. Contamination of the extension line.2. Disconnection of the extension line from the Tenckhoff catheter.3. Damage to, or leaking from, the extension or Tenckhoff catheter.

Patient will need a line change followed by Intra peritoneal Vancomycin cover in the following instances: If the patient has done a bag exchange AFTER contaminating the line. If PD catheter extension line has become disconnected. Damage to the extension line where there is leaking (if no leaking Vancomycin is not

required). The PD catheter has to be cut to remove damaged portion which will involve attaching a

new luer-lock.

Equipment Chlorhexidine 2%/Alcohol 70% solution Dressing pack White clamp Underpad Gauze x 2 pkts Disinfectant for cleaning work surface Clean gown Sterile gloves x 2 Masks x 2 Antiseptic hand rub 10ml syringe x 1 19G needle x 1 10ml NaClampoule Fresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension Line and disinfection

cap Baxter – Minicap extended life PD transfer set with twist clamp. Extension line and

Minicap



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Method1. Close doors and windows. 2. Perform hand hygiene.3. Instruct patient and anyone present in room to wear mask. 4. Place absorbent pad under the catheter and place the white clamp on the

catheter above the Luer-lock connector.5. Clean work surface with disinfectant.6. Use ABHR.7. Open dressing pack and open other equipment onto sterile field.8. Open 10ml NaCl ampoule and place on the edge of work surface.9. Don mask and gown.10. Perform one minute scrub and don sterile gloves.11. Draw up the NaCl into the 10ml syringe. Take the cap off the end of the new

line and prime with saline. When primed, clamp line and remove syringe. Screw on new disinfection cap / Minicap.

12. Pick up the patient extension line with a piece of gauze, and scrub the connector with 3 Chlorhexidine 2%/Alcohol 70% soaked gauze swabs and allow to dry.

13. Place sterile paper drape underneath and allow catheter to drop onto sterile field.

14. Remove gloves and perform hand hygiene with ABHR and don sterile gloves.15. Hold the Luer-lock connector and the old extension line with gauze and

disconnect (unscrew) the extension line from the Luer lock connector. Hold the Luer-lock connector very carefully, do not let open end of Tenckhoff catheter touch anything.

16. Connect the new extension line to the Luer-lock of the Tenckhoff catheter connector making sure it is not cross threaded.

17. Remove the white clamp from the Tenckhoff catheter. 18. Remove drape and discard equipment appropriately.19. Document date of line change and batch number in patient’s medical record.

2.2- PD- Cutting the PD catheter (Fresenius and Baxter)This may need to be done if there is damage to the catheter

Equipment Set up as for line change Sterile scissors Fresenius ‘Catheter adaptor Luer-lock with closure cap’. This is the blue connector that

is screwed onto the tenckhoff catheter that the Fresenius OR Baxter extension line attaches to.

ProcedureRefer to: Attaching a new PD Luer Lock to a Tenckhoff catheter procedure

1. Add the following to dressing tray:



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i. sterile scissorsii. Fresenius “Catheter adaptor luer lock with closure cap”

2. These items can be found in the PD line change box, or emergency pack for home patients in SNSWLHD.

3. Cut back damaged area of Tenckhoff; connect Catheter adaptor luer lock with closure cap as per PD Attaching a new PD Luer Lock to a Tenckhoff catheter.

4. Line change, then load IP Vancomycin into correct PD bag and do PD exchange. Send patient home. Tell the patient that antibiotic must dwell for 6 hours before another regular PD bag can be done by the patient.

2.3 PD- Tenckhoff Catheter Luer Lock Connector or Extension Line Accidental Damage Plan of Action

Alert: When notified of the disconnection, advise the patient to clamp off the Tenckhoff catheter with the white emergency clamp. Then swab the end of the catheter with Betadine swab stick, wrap in sterile gauze and cover with a tegaderm.

Advise ACT patients:To come to RHT or emergency department ASAP for one of the following treatments including IP Vancomycin PD bag exchange if a bag exchange has been done after contamination of the circuit.

NSW patients:To go to local ED department with their emergency pack. They may contact Outreach nurse in office hours.

1. PD catheter extension line contamination (Cap has come off end of extension line) Refer to: PD extension Line change (Fresenius & Baxter) procedure (2.1)a) Perform a line change.b) Arrange to meet patient at RHT, ROPD or ED after hours. PD line change box can be

found 8B storeroom, RHT and ED store room. For SNSWLHD patients, equipment is in Emergency Pack at Moruya Renal Unit.

c)Choose the correct line and cap from the box (Baxter or Fresenius): Fresenius – Stay safe catheter extension luer lock 32cm Baxter – Minicap Extended life PD transfer set with twist clamp

2. PD catheter extension line disconnection (Extension line has become disconnected from the catheter)Refer to: PD extension Line change (Fresenius & Baxter) procedure (2.1)

Management of Peritoneal Dialysis Peritonitis procedureAdding antibiotics to PD CAPD bags (Fresenius & Baxter)

a) Perform a line change PLUS IP Vancomycin PD bag exchange.b) Vancomycin is a standing order on our PD Peritonitis protocol. c)Use IP Vancomycin 30mg/kg body weight up to a maximum of 2.5g.



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d) Put correct bag on heater: Fresenius 2.3% or Baxter DIANEAL 2.5% before doing line change to give it time to warm. Do not use Physioneal as stability of antibiotics is not known.

e) Perform a line change first, and then load IP Vancomycin into correct PD bag and do a PD exchange. Send patient home. Tell patient that antibiotic must dwell for minimum 6 hours before another regular PD bag can be done to ensure effectiveness of the antibiotic treatment.

3. Damage to the extension line.a) Depending on where the damage is situated (in relation to the patients peritoneum)

change either just the extension line or the connector and extension line. b) If there is leaking patient will also require IP Vancomycin (30mg/kg body weight.)

4. Damage to Tenckhoff catheterRefer to: Attaching Tenckhoff Catheter Luer Lock Connector procedure (2.4)

PD extension Line change procedure (Fresenius & Baxter) procedure (2.1) Management of Peritoneal Dialysis Peritonitis procedure

Adding antibiotics to PD CAPD bags (Fresenius & Baxter) procedure

a. If damage to the tenckhoff is close to the patients exit site a surgical review may be required.

b. Tenckhoff catheter may need cutting back to remove damage. You may have to cut off old Luer lock connector and attach a new one.

c. You will also need to do a line change PLUS Vancomycin PD bag exchange.d. Put correct bag on heater: Fresenius 2.3% or Baxter DIANEAL 2.5% before doing line

change to give it time to warm.e. Set up as for line change.

2.4 – PD- Attaching Tenckhoff Catheter Luer Lock ConnectorEquipment Correct CAPD bag (Fresenius Balance or Baxter Dianeal) Fresenius Catheter Adaptor Luer Lock with Closure Cap. Sterile scissors Chlorhexidine 2%/Alcohol 70% solution Dressing pack White clamp Underpad Gauze x 2 pkts Disinfectant for cleaning work surface Clean gown Sterile gloves x 2 Masks x 2 Antiseptic hand rub Fresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension Line Disinfection cap



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Baxter – Minicap extended life PD transfer set with twist clamp – Extension line MiniCap 10ml syringe x 1 19G needle x 1 10ml NaCl ampoule

Method1. Put correct CAPD bag on PD bag warmer (antibiotics will be required).2. Close doors and windows.3. Perform hand hygiene.4. Instruct patient and anyone present in room to wear mask. 5. Place absorbent pad under the catheter and place the white clamp on the

catheter above the Luer-lock connector.6. Clean work surface with disinfectant.7. Use ABHR.8. Open dressing pack and open other equipment onto sterile field.9. Open 10ml NaCl ampoule and place on the edge of work surface.10. Don mask and gown.11. Perform one minute scrub and don sterile gloves.12. Draw up the NaCl into the 10ml syringe. Take the cap off the end of the new

line and prime with saline. When primed, clamp line and remove syringe. Screw on new disinfection cap / Minicap.

13. Pick up the patient extension line with a piece of gauze, and scrub the area to be cut with 3 Chlorhexidine 2%/Alcohol 70% soaked gauze swabs and allow to dry.

14. Place sterile drape underneath and allow catheter to drop onto sterile field.15. Remove gloves and perform hand hygiene with ABHR and don sterile gloves.16. Open the Catheter Adaptor Luer Lock with Closure Cap package. Screw the

white cap onto the appropriate end of the blue threaded insert.17. Hold the Tenckhoff catheter and cut the old Luer lock connector off just

behind it (or behind damaged part of the Tenckhoff catheter) with the sterile scissors. Continue to hold the Tenckhoff catheter tubing.

18. From the Catheter Adaptor Luer Lock with Closure Cap package, place the blue cone on the catheter.

19. Then push the thin end of the blue threaded insert into the tube lumen firmly as far as it will go. Screw the cone on to the threaded insert as tightly as you can, use the blue spanner to completely tighten it.

20. Remove the white closure cap and connect the new extension line to the Luer-lock of the Tenckhoff catheter connector making sure it is not cross threaded.

21. Remove drapes and discard equipment appropriately.22. Document date of Luer lock and line change in patient record and record the

batch numbers of equipment used.23. Load correct warmed PD bag with IP antibiotic (see clinical procedure).24. Attend PD exchange. The antibiotic bag should dwell for a minimum 6 hours

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2.5 – PD -Fresenius Stay Safe Balance exchangeEquipment 1 x Fresenius Stay Safe Balance bag Organiser 1 x new disinfection cap Disinfectant to clean table Antiseptic Hand rub

Method1. Close doors and windows.2. Perform hand hygiene.3. Clean work surface and organiser with disinfectant. 4. Collect new disinfection cap and check expiry date.5. Place cap, organiser and hand rub on cleaned work surface.6. Check warmed Fresenius PD bag for correct volume, glucose concentration, expiry date,

clarity and leaks. Check that the outer pouch is intact.7. Open new bag, leave in its package. Roll bag from side to break middle seam, then roll

bag from top to break the triangle completely. Check for leaks or irregularities.8. Hang the bag and uncoil the lines, place disc into organiser & drain bag down.9. Make patients extension line accessible (remove from under clothes).10. Place catheter into right side of the organiser.11. Perform hand hygiene with ABHR

Do not talk or cough 12. Remove coloured protection cap from disc.13. Unscrew catheter from cap and connect to disc making sure the catheter is not dropped

& does not touch anything else.14. Put the coloured cap from disc onto old cap. PULL out and discard.



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15. Open clamp on extension line and commence drainage

16. When drainage complete, close clamp on extension line.17. Turn dial to flush position and count to five

18. Then turn the dial to the white circle

19. Make sure there is no air in fill line. Now turn the dial to the blue circle.

20. Open clamp on extension line to commence fill.21. When inflow complete, close clamp on extension line. 22. Turn dial to last position to insert pin.

23. Open new disinfectant cap and place it in left side of organiser.24. Perform hand hygiene with ABHR.

Do not talk or cough



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25. Unscrew cover from the new cap.26. Unscrew catheter and screw onto the new cap making sure the catheter is not dropped

& doesn’t touch anything else.27. PULL catheter out of the organiser.28. Put the cover from new cap onto disc to seal it off.29. Check drained out fluid for clarity, dispose of used equipment, clean up and place a new

bag on the heater pad.

2.6 – PD-Fresenius Stay Safe Balance Drain outEquipment required: 1 x Fresenius Drain bag Organiser 1 x new disinfection cap Disinfectant to clean table and Antiseptic Hand rub

Procedure:1. Wash hands as normal in your bathroom, ensuring your hands and nails are visibly clean

Ensure hands are thoroughly dried.2. Go into your PD room and close doors and windows. Use hand rub and allow to dry.3. Clean work surface and organiser with disinfectant.4. Collect new disinfection cap and check expiry date.5. Place cap, organiser and hand rub on cleaned work surface.6. Open drain bag, and uncoil the lines, place disc into organiser, place drain bag down.7. Get your catheter out. Get your body in the right position and place your catheter into

right side of the organiser.8. Use antiseptic hand rub. Ensure that all your fingers, thumbs, all surfaces of the hands

and wrists are thoroughly cleaned. Allow to dry.9. Do not talk or cough

a) Remove white protection cap from discb) Unscrew your catheter from cap and connect to disc making sure the catheter is not

dropped & does not touch anything else.c) Put the white cap from disc onto your old cap. PULL out and discard

10. Open clamp on extension line and commence drainage



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11. When drainage complete, close clamp on extension line.

12. Turn dial to last position to insert pin.

13. Open new disinfectant cap and place it in left side of organiser.14. Use antiseptic hand rub and allow to dry.15. Do not talk or cough

a) Unscrew cover from the new cap.b) Unscrew your catheter and screw onto the new cap making sure the catheter is not

dropped & doesn’t touch anything else.c) PULL your catheter straight out of the organiser

16. Put the cover from new cap onto disc to seal it off.17. Check drained out fluid for clarity, dispose of used equipment and clean up. 18. Wash hands when complete.

2.7- PD- Baxter Physioneal or Dianeal exchangeEquipment 1 x Baxter Physioneal or Dianeal PD bag, of appropriate glucose strength warmed on a

heater pad designed for this (30 minutes to heat, lines on top, writing side face down). 1 x Minicap 2 x Blue port clamp (Physioneal) OR 1 x Blue Port clamp (Dianeal) Disinfectant to clean work surface Antiseptic hand rub PD table with IV pole

Method 1. Close doors and windows.2. Perform hand hygiene with ABHR.3. Clean work surface with disinfectant.4. Before use: Check bag for correct glucose concentration, volume, clarity, expiry date and

leaks. Check that the outer pouch is intact.5. Open outer pouch of PD bag by tearing diagonally down from one of the notches on one

end. 6. Perform hand hygiene with ABHR.7. Remove bag from outer pouch and place PD bag on cleaned work surface. Push firmly on

bag to check for leaks.8. Uncoil and separate lines with the coloured ring cap on it. (Close blue clamp on drain bag

if Dianeal). Coil up lines with end of lines facing out. Position the end of the line to hang Doc Number Version Issued Review Date Area Responsible PageCHHS15/153 2 28/05/2015 30/04/2018 Medicine 13 of 32


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15-20cm over the edge of the work surface making sure it does not touch anything when let go.

9. Flip the bag over so it sits on top of the rest of the coiled lines to secure it in place. 10. Break the frangible in the Physioneal bag to mix the glucose solution.11. Make patients extension line accessible (remove from under clothes)12. Perform hand hygiene with ABHR13. Carefully grasp the bag line and remove the coloured ring-cap, then let the line go. Make

sure nothing touches the exposed endDo not talk or cough

14. Pick up the extension line and carefully remove the minicap. Protect the end of the line from falling or touching other objects.

15. Carefully connect (screw) the extension line to the PD bag connection.16. Hang the bag of PD fluid up and place the drainage bag on the floor with the shiny side

facing upwards.17. Drain out by opening the twist clamp on the extension line (open blue clamp on the drain

bag if Dianeal).18. When drainage is complete, close the twist clamp on the extension line. Place blue port

clamp on Physioneal PD drainage line. Close clamp on Dianeal PD drainage line.19. Flush by breaking the green frangible in the tubing of the new PD fluid bag (either

Physioneal or Dianeal) open the clamp on the drainage line and count to five to flush the line. Clamp the drainage line when complete. Check all air from the line has been expelled. If not, then flush again. Make sure with the Physioneal bag that the glucose solution has drained completely into the lower chamber of the PD bag before you flush or fill.

20. Fill the peritoneum by opening the twist clamp on the extension line to commence inflow.

21. When inflow is complete, close the twist clamp on the extension line and place a blue port clamp on the bag inflow line.

22. Open new minicap packaging. 23. Perform hand hygiene with ABHR.24. Disconnect PD bag line from the patients’ extension line and carefully place the minicap

on patients’ extension line. Secure firmly. Make sure nothing touches the exposed end. Do not talk or cough.

25. Drop empty PD bag on floor (both bags are now on the floor). Remove blue port clamps. Tie a knot in lines to prevent any leakage.

26. Check drainage fluid for clarity. Dispose of PD drainage appropriately.27. Dispose of used equipment. Clean up and wash hands when complete.28. Document drainage amount in medical record.



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2.8 - PD- Icodextrin for Fresenius CAPDNote: Patients with diabetes should be informed about the need to source relevant glucose testing strips when using Icodextrin

Equipment Baxter Icodextrin 7.5% bag warmed appropriately Fresenius stay safe Luer –lock set Disinfectant for cleaning work surface Antiseptic hand rub Organiser Disinfection cap Table with pole

Method1. Close door and perform hand hygiene. 2. Clean the work area surface and organizer.3. Check Baxter Icodextrin 7.5% bag for expiry date, clarity, and leaks. Check outer pouch is

intact.4. Open outer pouch of Baxter Icodextrin 7.5% bag & leave on the open packaging. 5. Open packaging of Fresenius stay safe Luer-lock set.6. Perform hand hygiene with ABHR.7. Carefully pull purple ring-cap off the bag line making sure nothing touches it. Do not talk

or cough.8. Carefully take the blue cap off the Fresenius stay safe Luer-lock set and screw to the

Baxter Icodextrin bag.9. Snap the blue pin and wriggle it to make a gap.10. Hang the bag and Uncoil the Fresenius stay safe Luer-lock set lines. 11. Proceed as for Fresenius Staysafe exchange.

2.9- PD -Tenckhoff catheter heparin locking and capping offPatients who do not commence PD three weeks after insertion should have their catheters flushed and heparin locked monthly until they commence on PD

Note: Patients allergic to Heparin (HITS) will have a 10ml Saline flush only, before capping

Equipment Fresenius Catheter Adaptor Luer Lock with Closure Cap Chlorhexidine 2%/Alcohol 70% solution Sterile dressing pack Baxter PD catheter clamp (white) Underpad Gauze x 2 pkts Disinfectant for cleaning work surface Clean gown Sterile gloves



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Masks x 2 Antiseptic hand rub 10ml syringe x 1 5ml syringe x 1 19G needle x 2 10ml NaClampoule Heparin sodium 25000units/5ml

Method1. Close doors and windows.2. Perform hand hygiene using ABHR.3. Instruct patient and anyone present in room to wear a mask. 4. Place absorbent pad under the catheter and place the white clamp on the

catheter above the Luer-lock connector.5. Clean work surface with disinfectant.6. Open sterile dressing pack and add Catheter Adaptor Luer Lock with Closure

package, sterile gauze, syringe and needle onto the draped work surface. 7. Open 10ml NaCl ampoule and place on the edge of another work surface.8. Don mask and gown.9. Perform hand hygiene using ABHR and don sterile gloves.10. Draw up the NaCl into the 10ml syringe.11. Draw up correct amount of Heparin in 5 ml syringe depending on catheter

length:a) 2.3ml for Swan neck straight catheterb) 3.1ml for Swan neck curled or coiled catheter

12. Pick up the extension line with a piece of gauze, scrub the connector with 3x Chlorhexidine 2%/Alcohol 70% soaked gauze swabs. Place sterile drape across the patient's lap and drop the line onto the drape.

13. Change gloves.14. Hold the Luer-lock connector and the old extension line with gauze and

disconnect (unscrew) the extension line from the Luer lock connector. Hold the Luer-lock connector very carefully, do not let open end of Tenckhoff catheter touch anything. Place the 10ml syringe into the end of the Tenckhoff catheter.

15. Carefully undo the white clamp and insert 10ml of Saline. Reclamp white clamp and remove the 10ml syringe and place the 5ml heparin loaded syringe onto the end of the Tenckhoff catheter and insert the correct volume of Heparin.

16. Reclamp the white clamp. Remove the 5ml syringe and attach the white cap to the end of the Tenckhoff catheter making sure not to cross thread it.

17. Remove the white clamp from the Tenckhoff catheter.18. Remove drape and discard equipment appropriately.

19. Attach medication warning label to catheter (including date and time).20. Document heparin locking and capping off in patient progress notes and on

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Section 3 – Automated Peritoneal Dialysis

This procedure is not currently performed for inpatients. Patients who are on APD at home switch to CAPD when admitted


Section 4 – Infection and Peritoneal Dialysis

4.1 Staphylococcus Aureus (S. Aureus) carriers on Peritoneal DialysisMethodPD staff organise routine swabbing to check for MSSA/MRSA & Mupirocin sensitivity following hospital policy

Treatment for a positive S. Aureus result1. A S. aureus carrier is considered to be any patient in whom the last available nasal swab

grew S. aureus2. Nasal Mupirocin should be administered to all S. aureus carriers as soon as carriage is

detected in patient, either pre-surgery or with an existing PD catheter.3. Nasal Mupirocin for current carriers is a self application twice daily for 5 days every

calendar month for six months, then stop for a month and re swab. If negative, stop the application of nasal Mupirocin. In NSW this drug is not PBS. Ensure patient has a relevant script.

4. Nasal swabs are routinely attended every 6 month for all PD patients, but no sooner than 3 weeks after last administration of nasal Mupirocin.

5. If there is an allergy to Mupirocin, or presence of known S. aureus resistance to Mupirocin, then discuss with Advanced Trainee Registrar.

4.2 - PD Effluent Collection for MicrobiologyEquipment Cloudy PD drain bag Disinfectant to clean work surface Foam Falcon tube holder 2 x falcon tubes 2 x blood culture bottles 1 x 20ml syringe 1 x 50ml syringe 5 x 19g needles Gauze x 1 Pkt Chlorhexidine 2%/Alcohol 70% solution Pathology form Patient Labels x 5 Dressing pack



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Sterile gloves Antiseptic hand rub

MethodTo collect sample use the cloudy PD drain bag that the patient has brought with them or collect a sample from a wet or dry abdomen as below: Abdomen wet –Use a PD drain bag to fully drain dialysate effluent as normal and

disconnect. You will take samples from this drain bag. Abdomen dry – Instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Use a

PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.

Note:Fresenius: Use Staysafe drainage set (drain bag)Baxter: Use Baxter Physioneal bag for use of drain bag (as the Ultraset CAPD Disposable Disconnect Y-set (drain bag) does NOT have a port.)

1. Close door.2. Perform hand hygiene using ABHR.3. Clean work surface with disinfectant.4. Perform hand hygiene using ABHR.5. Open dressing pack. Add needles, syringes & gauze. Pour Chlorhexidine 2%/Alcohol

70%solution into dressing tray.6. Take lids off culture bottles and falcon tubes (Falcon tubes need to sit in white foam

holder).7. Lay PD bag on cleaned work surface. Identify and expose sample port on PD drain bag8. Perform hand hygiene and don sterile gloves.9. Using forceps swab each culture bottle with Chlorhexidine 2%/Alcohol 70% solution

soaked gauze and allow to dry before it is penetrated.10. Wash PD drain bag sample port with Chlorhexidine 2%/Alcohol 70% solution soaked

gauze and allow to dry before it is penetrated.11. Hold the PD drain bag sample port with sterile gauze and collect 20mls of peritoneal

effluent. Change needles. 12. Use a square of gauze to hold culture bottles and change needles in between each bottle.

Insert 10mls of peritoneal effluent into each bottle starting with blue top- aerobic bottle.13. Hold the PD drain bag sample port with sterile gauze and collect 2 x 50 ml samples of PD

effluent from sample port. Use a new needle to collect each sample. Remove needle to deposit sample into falcon tube.

14. Label all samples and send to pathology for WCC, Gram Stain, M/C/S.15. Discard equipment and clean up. PD bag is emptied into sluice and then put into a clinical

waste bin.16. Perform hand hygiene using ABHR.17. Do a PD exchange with antibiotics loaded bag (Refer to: “Adding Antibiotics to CAPD

bags”).18. Document in medical record



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4.3 - Adding antibiotics to CAPD bags (Fresenius Balance & Baxter Dianeal)Equipment Appropriate CAPD bag (Fresenius Balance 2.3% or Baxter Dianeal 2.5%) Sterile scissors (use for Baxter only) Dressing pack 10ml syringe x 1 2ml syringe x 1 (for Gentamycin) 4 x 19G needles Gauze x 1 packet Required Antibiotic(s) Water for injection 10mls depending on dose Chlorhexidine 2%/Alcohol 70%solution Disinfectant for cleaning work surface Antiseptic hand rub Medication additive label Sterile gloves Patient identification label

Method1. All antibiotics need to be checked with another RN or medication endorsed EN before

instillation and additive labels signed. Check patient antibiotic allergies.2. Close door, perform hand hygiene, and clean work surface with disinfectant.3. Perform hand hygiene using ABHR.4. Open dressing pack; add needles, syringes & gauze. Pour Chlorhexidine 2%/Alcohol 70%

solution into dressing tray.5. Check PD bag for expiry date, volume, strength, clarity, and leakage. If packaging is

damaged do not use. For Baxter bag, make sure you have a Dianeal bag NOT a Physioneal bag. A pre-warmed bag can be loaded with antibiotics if it is going to be used straight after.a. Fresenius: Peel back enough outer wrapper of PD bag to expose left blue injection

port. Tape wrapper back. (Blue Injection port attached to Fluid bag, NOT the blue port on the drain bag)

b. Baxter: Using sterile scissors to cut a slit in back of outer wrapper of Baxter Dianeal bag to identify and expose injection port attached to Dianeal fluid bag. Ensure injection port is attached to Dianeal fluid bag and not the drain bag.

6. Open Water for injection and place on edge of work surface. 7. Flip the lids off antibiotic vials.8. If Gentamycin is required - Open Gentamycin ampoule. 9. Open sterile gloves. 10. Perform hand hygiene using ABHR.11. Don sterile gloves.12. Assemble needles and syringes. 13. Draw up Water for injection in the 10 ml syringe. 14. If Gentamycin is required - Draw up required dose of Gentamycin in 2ml syringe and

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15. Wipe antibiotic vial (ie: Vancomycin) with Chlorhexidine 2%/Alcohol 70% soaked gauze swab. Wait 30 seconds for the surface to dry before it is penetrated.

16. Holding antibiotic vial with sterile gauze, inject water into vial and mix, then draw up the mixture and change needles.

17. Wash injection port on bag with Chlorhexidine2% /Alcohol 70% soaked gauze and wait 30 seconds for the surface to dry before it is penetrated.

18. Hold the injection port with sterile gauze and inject antibiotics into the PD Fluid bag taking care not to puncture the bag. (Make sure you are not injecting Antibiotics into the Drainage bag).

19. Label PD bag with patient label and additive label which includes date and time of administration.

20. Reseal the outer pouch with tape.21. Clean up used equipment and dispose of sharps correctly.22. Place bag on heater pad to warm if for use within the hour or place it in the medication

fridge if it is not being used straight away. Needs to warm for at least an hour when taking bag from the fridge.

4.4- PD- PERITONITIS Peritoneal Dialysis Peritonitis: 100 WBC/ mL effluent of which > 50% are neutrophils

Initial Presentation A cloudy bag always requires treatment with antibiotics Take culture and commence treatment immediately and before microscopy results are

available

Culturing Peritoneal Effluent Abdomen dry: instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Drain out

Abdomen wet: fully drain dialysate effluent as normal and disconnect.

Method: gently mix contents of bag for at least 30 seconds Using sterile technique, swab port

o aspirate two 50 mls of effluent and place each sample into separate falcon tubeo aspirate 20 mls of effluent and inject 10ml into each of a set of blood culture

bottles (aerobic then anaerobic) o label all bottles and tubes send straight to microbiology . Needs to be analysed

ASAP

Antibiotic TreatmentCommence antibiotic treatment immediately; do not wait for microscopy resultsAll antibiotic dwells are for a 6 hour period. Vancomycin see Medication Standing Order: Intraperitoneal Vancomycin for MRSA

Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD)



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Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A )

Gentamycin: see Medication Standing Order: Intraperitoneal Gentamycin for Empiric Treatment of Peritoneal Dialysis Peritonitis (Attachment B)

If necessary for polymicrobial infections, cephalosporins or vancomycin can be mixed with aminoglycosides in the one dialysate bag. Contact the pharmacy department for stability information.

Day 0: (day antibiotics are commenced) Add Vancomycin and Gentamycin as per the medication standing orders to a new

dialysate bag. Perform a bag exchange using this loaded bag.

Day 1: (first morning after initial antibiotics) Continue IP Gentamycin as per the medication standing order once a day.

Day 2 Obtain Gentamycin and Vancomycin pre-dose blood levels. Adjust if necessary as per the medication standing orders. Discuss treatment course with the Nephrologist.

Treatment Adjustment Based on Gram Stain/ Culture

Note: All changes to be discussed with the Nephrologist

Gram stain available and peritonitis not substantially improved at 48hours.o Gram negative bacilli:

Change IP Vancomycin to IP Cefepime 1g daily; continue IP Gentamycin after discussion with the Nephrologist.

o Fungi: Notify Nephrologist and arrange catheter removal by a General Surgeon.

Culture available.o Pseudomonal Peritonitis:

Treat with 2 antibiotics for a minimum of 3 weeks, Recommended antibiotic combination is either:

IP Cefepime 1g daily and daily Gentamycin until clinical improvement. This is usually followed by IP Cefepime 1g daily and oral ciprofloxacin to

complete three full weeks of treatment.o Gram positive cocci sensitive to cephazolin:

Discuss cessation of Gentamycin and possible change of Vancomycin to Cephazolin with the Nephrologist.

o Other bacterial peritonitis organisms: Antibiotics are based on sensitivity patterns and drug dosing convenience.



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o Enterococci: Treat with IV ampicillin 1g TDS, together with Gentamycin (if not high level

resistance) after discussion with the Nephrologist, Discuss length of Gentamycin therapy with the Nephrologist.

o Fungi: Arrange for urgent catheter removal by general surgeon.

Treatment Adjustments Based on Antibiotic Levels Vancomycin:

o Target (pre-dose blood level) is 12.1 – 20µg/mL.o Take first level on day 2.o Adjust as per the Medication Standing Order: Intraperitoneal Vancomycin for MRSA

Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).

Gentamycin:o Target (pre-dose blood level) is 1.5 – 2.5 mg/L.o Take first level on day 2.o Adjust as per the Medication Standing Order: Intraperitoneal Gentamicin for

Empiric Treatment of Peritoneal Dialysis Peritonitis (Attachment B).

Monitoring of PD Peritonitis Closely monitor clarity of the effluent, document and report to Nephrologist. If the

effluent is not clearing catheter removal may be required. Improvement should be obvious within 48 hours.

Maintain close contact with microbiology to seek culture information. Closely monitor clinical status of patient, attention to MEWS, consider NBM if abdomen

distended. Antibiotic treatment should continue for 2-3 weeks, determined by Nephrologist. Outlying patients at regional hospitals to have follow up dialysate effluent cell count on

day 3 – PD staff to monitor. Outlying patients at regional hospitals that have not improved at 48 hours will require

urgent transfer to The Canberra Hospital. Renal Registrar / Nephrologist to arrange. Failure of dialysate effluent to clear by day 5 is a strong indication for catheter removal. All results and any treatment changes to be discussed with treating Nephrologist VRE status should be monitored according to hospital policy

Stability of Antibiotics in PD It is recommended that all dialysate containing admixed antibiotics are stored in a

refrigerator at 4 degrees Celsius. If made up as the only antibiotic in the bag in pharmacy, and stored at 4 degrees Celsius,

then Vancomycin, Gentamycin, Cephazolin and Cefepime have adequate stability for at least 7 days. Stability for these antibiotics is adequate for 4 days at room temperature. In special cases it may be possible to store admixed fluid for longer or at room



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temperature. (Although Cephalosporins or Vancomycin and Gentamycin can be added to the same bag, they may not be stable for long periods after being mixed.) Contact the pharmacy department for advice.

Icodextran Vancomycin, cephazolin, Ampicillin, Ceftazidime, Gentamycin and Amphotericin are

compatible with Icodextran containing dialysate. There is limited data on long term stability except for Vancomycin.

Catheter RemovalCatheter removal in all CAPD peritonitis is performed by the general surgeons by means of a mini laparotomy with washout.

4.5 - PD peritonitis management planIn ACT: Suspected Peritonitis of non admitted patients is handled by the staff of Renal Home Therapies: during office hours 0700- 1630 1630-0700 (Ring switch and ask for second on call) Information Required.1. Establish whether patient is well or unwell

Send patient to Emergency department if symptomatic PD peritonitis is initially treated by local ED department in SNSWLHD Ask patient to come to Renal Home Therapies or contact Renal Outreach nurse (will

depend on availability)if they are completely symptom free2. PD fluid in situ or abdomen empty?3. Do they have the cloudy bag? They need to bring it with them

Sample is required for culturesIf empty – tell patient to fill before coming in. Ideally fluid should have dwelled for 1-2 hours before draining for a sample.

4. Current weight Required for Vancomycin dosage (see Peritonitis protocol)

5. Allergies If patient is allergic to Vancomycin use Cephazolin (see Peritonitis protocol). If patient is allergic to Gentamycin use Cefepime (see Peritonitis protocol). If patient has known VRE continue current protocol

6. Baxter or Fresenius Choose the correct PD bag to load. For Baxter you must use a DIANEAL bag to load

antibiotics (NOT a Physioneal bag). PD bags can be found at Renal Home Therapies or ward 8B.

7. PD volume 2L/ 2.5L Required for Gentamycin dosage (see Peritonitis protocol).

8. ACT or NSW patient Follow directions below depending on where the patient lives



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ACT PATIENT For the patient with peritonitis in the Emergency Department equipment can be found in ward 8B or emergency dept store room antibiotic Loaded bag drain bag silver PD table with pole hand rub Fresenius – Disinfection cap, white organiser, Fresenius: Staysafe drainage set (drain

bag) Baxter – Mini cap, 2 blue port clamps, Baxter: Ultraset CAPD Disposable Disconnect Y-

set (drain bag)

How to obtain a specimen if the patient does NOT bring their cloudy bag with them.Abdomen wet –Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Then, you can attend to the PD exchange with antibiotics loaded.

Abdomen dry – Instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Then, you can attend to the PD exchange with antibiotics loaded

Organising AntibioticsVancomycin & Gentamycin administration for peritonitis are covered in a STANDING ORDER. You do not need a registrar to write them up.

Standing order Approval Number for Vancomycin – CHHS 13/597Standing order Approval Number for Gentamycin – CHHS 13/596Standing order approval number for Cephazolin – TCH CHHS13/595 TCH

Loading IP (Intraperitoneal) Antibiotics Load IP antibiotics as per PD RHT Adding Antibiotics to PD CAPD bags NB Consider antifungal prophylaxis

Taking cultures from cloudy bag Take cultures as per PD Effluent collection for Microbiology. You will require a Pathology form with: WCC, Gram Stain, M/C/S. Commence antibiotic treatment immediately; do not wait for Microscopy results. All antibiotic dwells are for a minimum six (6) hour period.

NSW PATIENT Gather information required as per procedure to get all relevant information from PD

patient.



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Tell patient to go their local hospital and find out which hospital they are going to and report to Outreach nurse if available.

Tell PD patient to take the cloudy bag with them. Tell the patient they will need to take ALL their PD supplies with them. It is very likely

the hospital they go to will not have PD supplies. A box of green (2.3% Fresenius or 2.5% Baxter DIANEAL). Extra equipment depending on system used:

o Fresenius – Disinfection caps, white organisero if Baxter – Mini caps, 2 blue port clamps

Bag warmer (Heater pad).

Does the patient have a copy of the peritonitis protocol to take to the local hospital?Yes – Take it with them.

No – Tell the patient to advise the local doctor to phone the Renal Physician on call at the Canberra Hospital.

Outlying PD Patients at Regional hospitals need to have follow-up dialysate effluent white cell count (WCC) on Day 3.

Outlying PD Patients at Regional hospitals that have not improved at 48hrs (bag clearing) will require urgent transfer to TCH. Renal Registrar / Nephrologist to arrange.

4.6- PD exit site and tunnel infectionInfection is determined in the following way:1. Exit site infection

Either purulent discharge or 2 or more of the following: Erythema ˃13 mm at exit site Induration at exit site Tenderness at exit site



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2. Tunnel infection Presence of two or more of the following: Induration of the tunnel Tenderness of the tunnel Radiographic evidence of a collection along the tunnel

Note: It is unusual for there to be a tunnel infection in the absence of an exit site infection

Exit site surface swabsA positive culture in the absence of an abnormal appearance is indicative of colonization rather than infection. The appropriate treatment for this is intensified local cleaning rather than antibiotics. Concomitant catheter related infection and peritonitis is often due to pseudomonas species.

Empiric treatment of mild exit site infections Infections with S. aureus must always be covered. Treatment duration continues 5-7

days after all the infection has resolved Pseudomonas may need to be covered if the patient has a history of pseudomonal

infections Known colonisation in the patient:

o Non MRSA: Dicloxacillin 500 mgs orally tdso Non Multi MRSA: Clindamycin (based on results of sensitivity)o MRSA: IP Vancomycin as per Peritonitis protocol or alternatively oral

fusidic acid + rifampicin


Section 5 – Special Procedures

5.1 - Peritoneal Equilibrium Test procedure (PET)The purpose of the Peritoneal Equilibrium Test (PET) is to establish the transport characteristics of the peritoneal membrane. It defines the membrane clearance and ultrafiltration rates by measuring dialysate to plasma ratios of creatinine and glucose.

Usually done 4 weeks after commencement on PD

Equipment Patient input form (PET form) Pathology form x 2 Labels x 10 Disinfectant Antiseptic hand rub Chlorhexidine 20% & Alcohol 70% solution Sterile gloves x 3 Red top blood tubes x 3 Gauze x 3



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10ml syringe x 3 19G needle x 3

For Fresenius include: Fresenius Balance 2.3% bag for PET, warming on heater pad. Fresenius Balance bag of patient choice for after the test warmed Fresenius Staysafe drainage set. (drain bag) Disinfection Caps x 3

For Baxter include: Baxter Physioneal 2.27% bag for PET, warming on heater pad. Baxter Physioneal bag for mid test (for use of drain bag) Baxter Physioneal bag of patient choice for after the test warmed Minicaps x 3

MethodA PET involves a PD Adequacy which requires the patient to bring in a 24 hour urine collection and three PD effluent bags from the day before. The patient will have been given a date to collect the urine and PD bags pre PET. It is preferred to use a 2.27% or 2.3% or 2.5% (green) PD bag for the overnight bag and for the PET test. The patient is asked to note what time the overnight bag was infused.

Check patient has brought in 24 hour urine and correct PD effluent bags; otherwise there is no point in continuing the test.

1. Measure patient’s sitting and standing blood pressure.2. Close door, wash hands and clean work surface.3. Set up for PD exchange using correct warmed PD bag. (See PD RHT Fresenius Balance bag

change procedure SOP or PD RHT Baxter Physioneal or Dianeal bag change SOP).4. Attach patient to PD exchange and drain out overnight dwell. Work out the time in

minutes that the overnight bag was in for and record it as Dwell time on PET form. Record % glucose and volume infused in Overnight exchange.

5. Note the time in minutes that it takes to drain out the overnight bag completely and record it as Drainage time on PET form. Weigh patient.

6. Flush then Fill. Infuse the PD solution with the patient supine, getting them to roll side to side halfway through filling and again when the infusion is complete. This will mix the solution around the abdomen. Note the time in minutes that it takes to infuse the solution and record it as infusion time on PET form. Record % glucose and volume infused in Four-hour Equilibrium test.

7. PET 1. Sit the patient up. Make sure the DRAIN line is clamped! Now drain approximately 200ml from the abdomen into the PD fluid (FILL) bag (NOT the drain bag that has the overnight PD drainage fluid in it). Close the extension line clamp.

8. Open syringe, needle, gauze and sterile gloves in their packets onto cleaned work surface. Pour Chlorhexidine 20% & Alcohol 70% solution onto gauze.

9. Perform hand hygiene using ABHR and don sterile gloves.



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10. Wash sample port with Chlorhexidine 20% & Alcohol 70% solution soaked gauze. Wait 30 seconds for the surface to dry before it is penetrated.

11. Assemble 10ml syringe and needle. Withdraw 10mls from sample port and inject sample into red top tube. Label sample as PET1 with patient name, ID number, date and time. Dialysate sample 1 (PET1) is recorded as 0 minutes on the PET Form.

12. Reinfuse any solution left in the fill bag back into the patient, and disconnect as usual.13. Weigh the overnight bag and record it in PET form. Label this bag as overnight bag. 14. Label the other PD bags as PD effluent 1, 2, & 3. Label 24hr urine, date and time. Put all

bags and urine together in PD fluid lab samples box.15. PET 2. At 2 hours, attach a drain bag and drain out 200ml. For FRESENIUS use a Fresenius

Staysafe drainage set. (drain bag). For BAXTER use a Baxter Physioneal bag for (for use of drain bag). Then close extension line clamp.

16. Follow steps 8 through 12 to collect sample PET 2. Label sample 2 as PET 2 with patient name, ID number, date and time and record as 120 min on the PET form

17. After collecting the 2 hour dialysate sample, send patient straight down to Pathology to get bloods done.

18. Pathology Form 1: Urea, Creatinine, Glucose, Albumin.19. PET 3. At 4 hours the patient can prepare their warmed PD bag of choice, and at the

allotted time drain the abdomen of PD effluent completely. This will be their lunchtime bag exchange. Follow steps 8 through 11 to collect sample PET 3. Label sample 3 as PET 3 with patient name, ID number, date and time. Record as 240 min on the PET form

20. Patient then completes PD bag exchange as usual. Patient can go home once bag exchange is complete.

21. Weigh the drain bag and record it on PET form under Four-hour equilibration test: Volume drained. Discard into a yellow infectious waste bin.

22. Make sure ALL tubes and bags are correctly labelled, dated and timed before sending to pathology.

23. Pathology Form 2: PET, 24 hr Urine, 24hr dialysate, Volume, urea, creatinine, glucose, albumin.

5.2 Post Laparoscopic revision of Tenckhoff Catheter PD Exchanges The purpose is to recommence Peritoneal Dialysis slowly and safely after a Laparoscopic review so as to prevent leakage of dialysis fluid into the abdominal tissues

Each surgeon has their own preference for Tenckhoff catheter use post revision: Surgeons request 24 – 48 hours of NOT using the catheter Surgeons request it be used straight away

If catheter is not for use; check on surgical report to see if the surgeon has heparin locked the catheter, otherwise clots and blockages can occurIf the Tenckhoff catheter has not been heparin locked then the Tenckhoff catheter will need to be heparin locked and a new PD extension line attached

MethodRESUMING PD EXCHANGES (may not be day one post op)DAY 1:Doc Number Version Issued Review Date Area Responsible PageCHHS15/153 2 28/05/2015 30/04/2018 Medicine 28 of 32


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BED REST 24 HOURS with toilet privileges (if patient needs to get up for toilet, they need to be drained out first)

1000 ML EXCHANGES X 5 Monitor laparoscopic sites for leaking, moisture. If leaking evident, drain patient out and

for medical review

DAY2: 1000 ML EXCHANGES X 5 Patient should be able to mobilise to shower & toilet with fluid in situ. Monitor laparoscopic sites for leaking, moisture. If leaking evident, drain patient out and

for medical review

DAY 3: 1500 ML EXCHANGES X 4 Patient can mobilise freely with fluid in situ. Monitor laparoscopic sites for leaking, moisture

DAY4: 1500ML EXCHANGES X 4 Patient can mobilise freely. Monitor laparoscopic sites for leaking, moisture.

DAY 5: Review laparoscopy sites: Sites not healing well, to do 1500ML EXCHANGES X4 Sites healed well, to do 2000ML EXCHANGES X4

Please ensure that you do a telephone handover to PD staff on discharge

5.3 Antibiotic Prophylaxis in PD Patients Undergoing Procedures PD catheter extension line disconnection (unintended contamination):

o IP Vancomycin as per Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).

High Risk Procedures:o The abdomen should be drained at the time of the procedure

Colonoscopy:o ISPD guidelines recommend ampicillin 1g IV plus Gentamycin 120mg IV plus

Metronidazole 400mg orally immediately pre-procedure. o This may be impractical in privately performed procedures.o Consult Nephrologist.



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Significant dental work (anything more than scale and polish)o Consider ampicillin alone 2g PO.o Consult Nephrologist.

Prophylaxis before PD tube insertion All patients should have an intranasal swab 5 days to 14 days pre-procedure. Intranasal Staph carriers MRSA or MSSA :

o Mupirocin 2% nasal ointment twice daily for 3 days before, and 2 days post procedure.

Intranasal MRSA carriers: o Admit day before procedure for IV Vancomycin as per the Medication Standing

Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).

Intranasal carriers of sensitive SA MSSA: o DOSA admission with IV cephazolin in theatre


Definitions

Peritoneal Dialysis Peritonitis: 100 WBC/ microlitre effluent of which > 50% are neutrophilsMEWS: Medical Early Warning System NBM: Nil by mouthCAPD: Continuous Ambulatory Peritoneal DialysisISPD: International Society for Peritoneal DialysisMRSA: Methicillin Resistant Staphylococcus aureusMSSA: Methicillin Sensitive Staphylococcus aureus




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Implementation

PD procedures are carried out by Peritoneal Dialysis trained and credentialed nurses in Renal Home Therapies and 8B. SNSWLHD Renal Outreach Nurses are also trained and credentialed in Peritoneal Dialysis. These skills are taught to all new staff members who perform the procedures under the guidance of trained staff until credentialed.


Related Policies, Procedures, Guidelines and Legislation

Hand Hygiene SOP (CED11-50) Antimicrobial prescribing Policy (CHHS13/386) Aseptic non touch technique SOP (CHHS12/347) Medication Standing order SOP (CHHS13/295) Medication Management Policy (DGD12-035) Patient Identification – correct patient, correct site, correct procedure Policy (CED11-26) Management of Peritoneal Dialysis Peritonitis Medication standing order: Intraperitoneal Vancomycin for MRSA, Peritoneal Exit Site

and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion(TCHM11-008)

Medication standing order: Intraperitoneal Gentamycin for Empiric Treatment of Peritoneal Dialysis Peritonitis (TCHM11-07)

Adding Antibiotics to PD CAPD bags PD Effluent collection for Microbiology


References

Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Strippoli GF; Tong A; Johnson D; Schena FP; Craig JC. Am J Kidney Dis 2004 Oct;44(4):591-603.Praino B, et al. ISPD Guidelines/Recommendations. PD Internat. 2010; 30: 393-423



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Attachments

Attachment A: Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis

(PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion.Attachment B: Medication Standing Order: Intraperitoneal Gentamycin for Empiric

Treatment of Peritoneal Dialysis Peritonitis, Gram negative Bacilli Peritonitis, Pseudomonal Peritonitis, Enterococci Peritonitis.

Attachment C: Antibiotic Dosing in PD Fluid

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

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