Peritoneal Dialysis PD Access. Peritoneal Dialysis Peritoneal Catheters PD catheter is patients...
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Transcript of Peritoneal Dialysis PD Access. Peritoneal Dialysis Peritoneal Catheters PD catheter is patients...
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
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
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