training for fluoroscopic peritoneal dialysis catheter ... record success of catheter function and...

Training for Fluoroscopic Peritoneal Dialysis Catheter

Placement

Rajeev Narayan MD

San Antonio Kidney Disease Center

San Antonio, TX

Disclosures

 No financial conflicts of interest to disclose.

 My comments apply primarily to Nephrologists

Introduction:

1.Why should we promote percutaneous PD catheter placement, especially amongst Nephrologists?

2.Training requirements and expected outcomes for certification and for a successful program

3.Suggestions for trainees starting PD insertion (Opinion)

4.Suggestions for trainers to improve success and outcomes (Opinion)

USRDS 2013 Annual Data Report.

 Prevalence of ESRD continues to increase

 Costs of the ESRD population continues to rise out of proportion to the rest of the Medicare population

 PD costs about $20 K less per year than HD

 Despite that- the US PD prevalence rate lags behind many other developed nations.

 When Nephrologists are more involved, PD census increases

Why should Nephrologists get more involved in PD catheter insertion

 Meta-analysis of 13 studies with 2,681 subjects.

 No difference in 1year catheter survival in percutaneous vs surgical PD catheter placement, or in incidence of catheter dysfunction.

 Incidence of fluid leaks similar in both surgical and percutaneous methods.

 Incidence of peritonitis rates were significantly lower with percutaneous placement.

Fluoroscopic PD catheter insertion has similar outcomes to standard laparoscopic placement.

Data from our center (San Antonio) Urgent Start Program

1 year unassisted catheter survival 87%

1 year fluoroscopically assisted catheter survival 94%

PD Census increased as a result of starting PDC placement at the access center

Summary

 There is a clinical and economic need for greater PD prevalence

 Non-surgeons can readily learn to and perform percutaneous fluoroscopic PD catheter insertion

 Nephrologists getting more involved in PD catheter insertion can increase PD census

 If my program can do it and be successful, so can yours.

Outcomes/Goals (ISPD):

 Goal to have 1 year catheter survival > or equal to 80%

 Fewer than 20% of catheters removed per year for any complication including hydraulic failure, failure of deep or subcutaneous cuffs, or infection.

 Peritonitis rate should not exceed 1 episode every 18 months (0.67 per year at risk). (Depends on both inserting facility and PD units)

 Fewer than 10% of catheters a year should be removed for infectious complications.

 Bowel puncture rate < 1%

ASDIN Certification Guidelines  Currently certified by ABIM in Nephrology or American Osteopathic Board of Int

Med in Nephrology, American board of Radiology, or American Board of Surgery

 Completed the following:

 Study of written or audio-visual materials related to the procedure, It is recommended but not required that the apprentice should spend 2 hours in practice of the procedure using a standard permanent PD catheters. At least 2 catheters be placed in a Dummy Tummy model or anesthetized dog or pig or human cadaver

 Observe placement of 2 PD catheters performed by physician trainers

 Performance of 6 placements in the presence of a physician (certified, if possible) in training . Should be done in 1 year, within the US healthcare system

 Documentation and outcome measurement:

 Log outcomes at 1 week, one month

 Record success of catheter function and occurrence of any catheter dysfunction

 Agree to the Monitoring of the Next 10 PD catheter placements for 30 days. If there are more than two procedure related complications or more than three catheter failures by one month, an additional three placement procedures should be monitored.

Suggestion for trainees

 Invest in a electrocautery unit (try not to rely on pen thermal cautery devices)

 Invest in good ultrasound equipment- that will allow you to screen patients well, look for vessels and assist in cannulation if needed.

Suggestions for trainees

 Emphasize Good patient preoperative screening/preparation: Ideally see the patient for preoperative consult, ultrasound abdomen. Rule out “surprises”

 Unlike most regular vascular access procedures, Try to avoid seeing patients for the 1st time the day of surgery

 Involve PD nurses, invite them to watch cases, give them your cell phone number and have their number.

 Be interested in what goes on in the PD unit

 Work with the nurses and fellow physicians to establish protocols for referral, PD catheter dysfunction, make the PD nurses and the Access center part of the same team.

Suggestions for trainees

Suggestions for trainers: Troubleshooting Dysfunction:  Just because ASDIN criteria for certification does not mention troubleshooting for

certification, does not mean we should not teach it with the same enthusiasm as catheter placement

Suggestions for trainers: Train to follow best practice guidelines.

Crabtree, Seminars in Dialysis, 2015

Suggestion for trainers: emphasize safety:

 Consider using a blunt needle to enter the peritoneaum.

 Consider doing a pull back peritoneogram and wire-retraction and re-insertion upon entry into the peritoneum.

Suggestion for trainers: Catheter coil/tip positioning

 Emphasize proper placement of catheter coil/tip: To optimize catheter function and limit drain pain.

Suggestion for trainers: Teach what normal and what is not normal look like- and what to do about it..

Normal Peritoneogram Contrast in pre- peritoneal space

Fibrin Plugging

Omental entrapment

Proximalizing exit site and shaving superficial cuff for cuff extrusion or recurrent exit site infection involving the superficial cuff.

Conclusions:

 In many areas there is a clinical and economical need for nephrologists and non-surgeons to start placing PD catheters, and this can be done with similar good outcomes as standard laparoscopic methods.

 Trainees to should be mindful of ISPD goals as they start their programs, and also be closely involved with the PD units/nurses to maximize success

 Trainers should train to emphasize best practice guidelines, and safety

 Trainers should emphasize not just insertion techniques but also troubleshooting and dealing with complications.