Placing Peritoneal Dialysis Catheters - A Nephrologist's Perspective 11.01.13
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Transcript of Placing Peritoneal Dialysis Catheters - A Nephrologist's Perspective 11.01.13
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Placing PD Catheters - a Placing PD Catheters - a nephrologist's perspectivenephrologist's perspective
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Nephrology Dept – 1971 > 25000 HD sessions annually > 75 transplants annually
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Overview
Introduction
What does it involve?
Challenges
Opportunities
PD catheter insertion procedure
Our learning curve
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Introduction incidence of CKD in developing countries Pts - inadequate access to HD & Tx - CAPD - obvious
preferred modality for renal replacement therapy
Laparotomy / direct visualization - conventional mainstay of access placement
Necessitates availability of surgeon / anaesthetist cost / duration of hospital stay
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IntroductionPD catheter placement techniques
Laparotomy / open surgicalLaparoscopyPeritoneoscopyFluoroscopyBlind
Percutaneous
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Introduction Percutaneous Blind PD catheter placement - 1984
[Nakanishi T et al. Nephron 1984;37:128–132]
popularity in the past decade
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What does we need? Reasonably spacious area –
minor operating room in dialysis area Clean room with enough elbow space
Instruments / implements – most easily obtained
Willing nephrologist – usually the toughest part !!!
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Challenges Obsession with aseptic / universal precautions
Skill of PD catheter placement – very easily acquired!
Knowledge of complications of technique Blind procedure Complications - laceration of viscera, bleeding, perforation Prompt recognition urgent surgical consultation /interventionWhat the mind does not know the eye does not see!
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Challenges Co-operation / support of surgical colleagues –
imperative
Immediate consultation & intervention where needed
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Challenges One of our earliest patients - Jejunal mesenteric artery
laceration – severe bleeding shock Multiple transfusions Urgent laparotomy & ligation of bleeder – save life
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Challenges
Paramedian approach – Inf epigastric A injury reported
2% Bleeding in a case series (6/292)
Messana JM Injury to the Inferior Epigastric Artery Complicating Percutaneous Peritoneal Dialysis Catheter Insertion.Perit Dial Int. 2001;21: 313-15.
Mital S, Bleeding complications associated with peritoneal dialysis catheter insertion.Perit Dial Int 2004;24:478–80.
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Challenges Clues to bleeding
Blood tinged PD effluent fluid Drop in blood pressures ± tachycardia
[BRADYcardia likely to be vagal response to pain]
Check Hematocrit If hematocrit up to 2% Conservative Rx sufficient Heparinization of PD fluid is necessary to prevent cath clotting
Farooq MM Peritoneal dialysis: An increasingly popular option. Semin Vasc Surg 1997;10:144-50.
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Challenges One patient – upper abdominal distension &
obliteration of liver dullness bowel perforation
Laparotomy – self-sealed – no repair needed
Bladder injury pre-procedure bladder emptying or catherization
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Blunt tip
Cutting edge
Challenges Constant attempts to refine / simplify technique
Using the Veress needle to fill peritoneal cavity
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Attempt to decrease time taken for procedure Initially about 2 hours for uncomplicated cases Now less than 45 minutes (fastest 20 minutes)
Smaller incision sizes Initially 2-3 cm now < 1 cm in length – more cosmetic
Training of colleagues all become adept
Challenges
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Opportunities No break-in period needed
51 consecutive pts - straight double-cuffed Tenckhoff cath Only 1 pericatheter leakage (1.9%)
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Opportunities Time taken
Cost of procedure – saving of Rs. 15000 (~$ 300)
Hospital stay – reducing costs further
Non-requirement of surgical suite No Anaesthetist / Surgeon required Use for uremic CKD 5 patients as acute PD
16 patients in our initial cohort
In the Intensive care for renal replacement therapy
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Opportunities Ideal procedure for HIV / HBV / HCV infected pts
Resource-constrained settings Already overstretched OR facilities Lack of personnel for one-to-one therapy 11 patients in our initial cohort
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In those with past abdominal surgeries??? CONTRAINDICATED in those with previous abdominal surgery
Laparoscopy preferred – direct vision / adhesiolysis if needed
One patient with laparoscopic cholecystectomy + tubectomy
Opportunities
Peppelenbosch A Peritoneal dialysis catheter placement technique and complications. NDT Plus 2008;1 [Suppl 4]: iv23–8.
Successful percutaneous CAPD catheter insertion in a patient with past abdominal surgeries. Varughese S et al Saudi J Kidney Dis Transpl. 2012
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Four patients - laparoscopic cholecystectomyOne patient - past intra-abdominal abscess in right lower quadrant of abdomen for which
laparotomy & surgically drainage had been doneOne patient – appendicectomyOne patient - lower segment caesarian sectionOne patient - right femoro-femoral arterio-venous graft was constructed due to
thrombosis in all vessels; very large perigraft collection occupying entire right lower quadrant left CAPD cath
Four patients – tubectomies (including 2 with past laparoscopic cholecystectomies)
Opportunities
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Percutaneous PD catheter placement can be attempted in
patients with previous abdominal surgeries where risk of
peritoneal adhesions is minimal
Opportunities
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Our initial insertion experience
From November 2007 to 2011 Feb Number of patients: 119 Age: 50.5 yrs (range 23–74 yrs) 64 males
Technique: Trocar and cannula or peel-away sheath using Seldinger technique
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PD Catheter Insertion Procedure
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Secret ingredient = Grace of God!
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s
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End result!
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Our learning curve!
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119 patients
Poor flow (14) Surgical repositioning (9)
Cath Removal (2)
Percutaneous repositioning (3)Current number = 295
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Complications encountered Intra-abdominal bleed - 2
Laparotomy required - 1[Varughese S et al. Jejunal Mesenteric Artery Laceration Following Blind Peritoneal Catheter Insertion Using the Trocar Method Perit. Dial. Int. 2010 30: 573-574.]
Conservative Rx - 1
Leak - 1 Suspected perforation - 1
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Conclusions Percutaneous PD catheterization is a simple & safe
procedure – done by nephrologists
Easy training and practice makes one adept at it
Several challenges and opportunities for the nephrologist
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Challengeso Willingness to learn and do
o Surgical team co-operation
o Aseptic / universal precautions
o Skill of PD catheter placement
o Knowledge of complications
o Refine / simplify technique
o Training of colleagues
o Attempt to decrease time
o Smaller incision sizes
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Opportunities No break-in period costs, time taken, hospital stay No surgical suite, anesthestist, surgeon needed Procedure of choice in pts with HIV, HBV, HCV Use for uremic CKD 5 patients as acute PD Use in Intensive care for renal replacement therapy In pts with past abdominal surgeries with minimal risk
of peritoneal injury
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