Transcript RayPeritoneal_Dialys.. - ANNA Jersey North Chapter 126
Peritoneal dialysis
Presented by Ray Agnello BSN, RN, CNN Renal Educator St. Joseph’s Medical Center
Objectives
To provide attendees with a summarized review of peritoneal dialysis.
To highlight key points in the clinical care of a PD patient.
Catheter placement Care of catheter Infectious complication Non-infectious complications Adequacy Fluid balance assessment of the patient with PD
Peritoneal Dialysis
Alternative to hemodialysis
Patient is taught to perform dialysis exchanges in the home setting
Focus is on patient autonomy and self care management
Patient must be followed by a licensed Peritoneal Dialysis unit
Peritoneal Membrane
Translucent Vascular membrane Two layers Parietal (inner surface of abdominal wall) Receives blood supply from the arteries of the abdominal wall.
Visceral (covers abdominal viscera) Covers the abdominal organs.
Blood is carried by the mesenteric and celiac arteries.
Most vascular layer where most of the dialysis occurs.
Envelope of space between layers called peritoneal cavity.
Semi-permeable; acts as a filter.
Kelley (2004)
Anatomy and Physiology
Peritoneal Membrane
Semi-permeable
Bi-directional Membrane size – 1-2 m 2 Vascular wall, interstitium, mesothelium , and adjacent fluid films
Closed in males Women – Ovaries and fallopian tubes open into the peritoneal cavity Peritoneal cavity normally contains about 100 ml transudate
Kinetics of Peritoneal Dialysis
Diffusion
Osmosis
Ultrafiltration
Drug Transport
Diffusion
Tea Bag = Peritoneal Membrane Water = PD Fluid Tea Leaves = Waste
Scheme of semi-permeable membrane: red = blood blue = PD fluid yellow = membrane wikipedia.org/
Osmosis
The diffusion of pure solvent across a membrane in response to a concentration gradient, usually from a solution of lesser to one of greater solute concentration.
Miller-Keane 6th Edition
Osmotic Pressure of Dextrose Solution
1.5 % Solution 2.5 % Solution 4.25 % Solution
The Peritoneal Dialysis Process
Definition-intra (within) corporeal dialysis Three phases to the exchange process
Drain Fill Dwell
How Does PD Work?
The semi-permeable peritoneal membrane lines the abdominal cavity and covers the abdominal viscera.
The membrane allows (via diffusion) the passage of toxins and electrolytes into the dialysis solution.
Ultra-filtration (removal of fluid) occurs via osmosis.
A “steady state” of toxin clearance and fluid management is achieved due to daily performance of dialysis.
Kelley (2004).
How Does PD Work?
Dialysis solution is infused and drained via a catheter that is surgically placed in the peritoneal cavity.
The action of draining and infusing dialysis solution is called an exchange.
The frequency of exchanges and volume is determined by the presence of residual renal function and the individual membrane characteristic.
Infusion or Fill
Baxter®
Drain
Baxter®
Peritoneal Dialysis
Dialysis occurs during the dwell phase.
Diffusion: Solutes cross from area of greater concentration to lesser one.
- Depends on concentration gradient.
- Enough peritoneal surface area.
- Size of fill volume.
Ultra-filtration: Water removal due to osmotic gradient between the hyperosmolar PD fluid and the capillary bed.
Kelley (2004).
Historical Perspectives
Acute – 1966 – Predominant use of PD prior to 1960s Automated cycler 1967 – 1975 – 1978 – Tenckhoff catheter CAPD Polyvinyl bags manufactured 1980s – New catheter designs 1987 – 1990s – PET and tidal PD – Twardowski Alternative dialysate solutions, updated system designs
Who Are the PD Patients ?
Choose PD as renal replacement therapy
Hemodialysis patient without access
Failed allograft (transplanted kidney)
Have CHF or CVD which exempts them from hemodialysis
Often people without the benefit of CKD education
PD Patient Selection
Inclusion criteria include patients who:
Choose the modality.
Want “control.”
Prefer home for dialysis.
Have residual renal function.
CVD, CHF.
Geriatric.
Pediatric.
Social support system.
Surgical Evaluation
Abdominal wall weakness or hernia Repair hernia preemptively or when symptomatic Previous abdominal surgeries Likelihood of adhesions Abdominal wall obesity
Surgical Evaluation Catheter Insertion
Some units advocate insertion 2 to 6 weeks prior to dialysis to optimize healing.
Some units advocate insertion months in advance (burying the catheter).
In most situations, PD access is elective.
Peri-Operative Routines Anesthesia
Local infiltration with sedation Intravenous propofol with MAC General anesthesia
Insertion Techniques
Bedside-temporary catheters Laparoscopic placement Surgical dissection Buried catheter technique
Insertion Techniques Buried catheter:
Entire catheter placed in subcutaneous pocket for 4 to 6 weeks or longer, allowing cuff to heal.
Exit site is externalized in a separate procedure.
Reduced bacterial colonization (?).
Do not have long-term outcomes yet.
Flanigan & Gokal (2005).
Pre-Catheter Insertion
Patient education and consent signed Examination of the patient’s abdomen
• •
Avoid scars and fat folds Avoid beltline
•
Mark the abdomen Surgical prep
• • •
Empty bladder Patient showers with disinfectant soap Bowel prep
Steps to PD Catheter Access
Evaluation by nephrologist for PD catheter placement and identified as candidate.
Educated about catheter placement, and pre- and post-operative care routines.
Referred to surgeon for evaluation that includes determination of exit site,clinical and anesthesia work-up, contra indications, completion of consent forms, and scheduling of surgery.
Selection Continued
Exclusion Criteria Patients who:
Have abdominal aortic aneurysm AAA (size dependent)
Derm. disease of the abdominal wall
Morbid abdominal obesity
Altered mental status; poor coping styles
Solitary lifestyle
Patient states lack of interest in modality
Multiple abdominal surgeries – adhesions
Ostomies (increase risk of infection)
Recurrent hernias
•
Catheter History
Early catheters were glass cannulas with straight or with mushroom ends.
•
1920s – Stainless steel coil with rubber drain first used in NYC (Rosenak)
•
1940s – Urinary catheters utilized
•
1950s – Nylon catheters at UCLA
•
1960s – Boen) Button catheters (Scribner,
Catheter History
1964 – Quinton) Slicon rubber catheters (Palmer,
1965 – Tenckhoff intermittent catheter
1968 – Tenckhoff cuffed straight catheter
1970s –
1980s – Single/double cuff coiled catheter Swan neck configuration
2000s – T-shaped catheter (Ash)
The future..?
Catheters
Straight (single or double cuff)
Coiled (single or double cuff )
Swan neck (single or double cuff)
Pre-sternal swan neck
Toronto Western
Missouri catheters
Disc catheters
Cuffs
Single
Double
Elongated
Bead/flange configuration
Plastic
Titanium Adaptors
PD Catheter Access Complication
Immediate/Early Bloody effluent Pain with infusion Leak at exit site Exit site infection Migration of catheter tip Poor fill or drain, with or without pain Non-infectious cloudy effluent (lymphatic leak or eosinophilic peritonitis)
PD Catheter Access Complication
Later Issues
Exit site leaks or subcutaneous leaks Pleural communications Excessive granulation tissue Chronic site or tunnel infection Cuff extrusion Cracked, brittle catheter Repetitive episodes of peritonitis Bowel perforations
Post-Op
Follow up appointment with surgeon
Remove primary dressing in 5 to 7 days
Replace dressing with DSD Teach patient to secure catheter Flush catheter during training sessions Allow catheter to heal for 14 days or longer if possible Schedule training sessions
Post Operative Discharge Plan
Pain medication/prescription
Follow-up in PD unit within 48 to 72 hours of discharge
Dressing intact for 5 to 7 days
Reinforce dressing as needed
Dressing changed by PD nurse
Establish training schedule
Bowel regimen
No heavy lifting Prevent Constipation
Written instructions
Emergency phone numbers
Peritoneal Dialysis Therapies
IPD (Intermittent Peritoneal Dialysis) CAPD (Continuous Ambulatory Peritoneal Dialysis ) CCPD (Continuous Cycling Peritoneal Dialysis) also known as APD (Automated Peritoneal Dialysis)
Training Sessions for the PD Patient
Assess readiness to learn Provide a quiet, relaxed atmosphere for learning Identify patient’s learning style Individualized with respect to patient’s expectations, cultural beliefs, and coping abilities Length of training based on patient’s clinical condition
O N C a
Warming the Solution
Use warm, dry heat At home – PD heating pad
NEVER MICROWAVE!!
Uneven heating of dextrose can create a 1st or 2nd degree burn to peritoneum Leaching of plastics into dialysate can create a chemical peritonitis
Patients At Risk for Inadequate Dialysis
No residual renal function Low membrane permeability Large patients
PD Equilibration Test
First developed by Z. Twardowski at the University of Missouri.
A 4-hour study that assesses membrane transport characteristics.
Assessment of membrane function allows for accurate prescription planning.
Usually completed within the first six weeks of initiating PD.
Repeated per each unit’s protocol.
PD Equilibration Test continued
What does this tell us?
The results indicate the following transport states: High High-average Low-average Low
KT/V Test
What is measured?
24-hour collection of dialysate and urine
Serum values of BUN and Creatinine
Frequency of test is determined by each unit’s protocols and interpretation of K/DOQI Guidelines
KT/V Test continued
What does it tell us?
The adequacy of the current prescription
Need for adjustments to insure appropriate dialysis prescription
Infectious Complications
Exit Site Care
Healthy exit site: Surrounding skin natural, darkened, or light pink; no drainage or crusting; visible sinus is dry.
Goal: Prevent exit site infection and identify problems early.
Frequency: Daily or 3 to 4 times weekly; may be in conjunction with showering.
Infection Prevention
Exit Site Care: No dressing needed for established catheter exit site.
Keep catheter secured to abdomen with 2 inch tape.
Daily showers with liquid soap.
Mupirocin (Bactroban ® ) at exit site of known staph. carrier.
Inpatients – Dry dressing to protect site, cleaned with soap and water. No occlusive membrane dressings (Tegaderm ® ).
A healed and non-infected exit site is crucial to longevity on Peritoneal Dialysis.
Exit Site Infection
Teach patient to identify and report immediately to the PD Unit:
Redness, tenderness, edema, presence of exudate either at exit site or insertion site.
Treatment:
Culture exudate if possible
Specific antibiotic protocol Oral or IV/IP antibiotics depending on extent of infection Saline soaks/dressing changes for care of local cellulitis
Exit Site Infection
A chronic exit site infection can produce a systemic inflammatory response.
Inflammation can lead to poor nutrition, inadequate dialysis, and possible antibiotic resistance. Vital role of dietitian.
Chronic exit site infections may result in peritonitis.
Multiple infections can lead to removal and replacement of catheter.
Consistent assessment and documentation is needed to appropriately track infections.
Exit Site Infection
Signs and Symptoms: Redness, swelling, tenderness or pain, and purulent drainage.
Risk Factors: Poor catheter healing, sutures at the exit site, trauma to the exit site, cuff extrusion, and improper catheter care.
Diagnosis: Observation and culture.
Treatment: Antibiotics, IP, PO, or IV; vigilant daily exit site care.
Responsible Organisms
Staphylococcus Aureus
Pseudomonas species Other gram-positive species Serratia species Other gram-negative organisms Fungi
Tunnel Infection
Signs and Symptoms Erythema over the tunnel Pain and tenderness Drainage from exit site – No other signs of an infection Risk factors Exit-site infection Exit-site trauma Leak External cuff extrusion Treatment – Antibiotic therapy to prevent need for catheter removal
Prevention of Peritonitis
Basics of Aseptic Technique: 5-min. hand scrub, face masks during exchanges, warming of PD bags using dry heat, aseptic technique for adding medicines.
Aseptic technique when making critical connections to solution containers and the patient’s transfer set.
Masks reduce the risk of contamination with nasopharyngeal organisms.
Peritonitis
Portals of Entry
Transluminal – Technique failure, contamination
Periluminal – Incomplete healing ,leaking Hematogenous – Bacteremia Transmurl – Through the bowel wall
ANNA Core Curriculum
Diagnosis of Peritonitis
Effective culture techniques:
Minimum sample volume of 50-100 ml. Large samples reduce false negative results.
Dialysate must be mixed well by inverting bag several times before sampling.
Sample port is disinfected before sampling.
Sample is obtained using aseptic technique.
Peritonitis
Defined as the presence of WBC in the effluent numbering 100 or greater.
Effluent appears cloudy and milky.
Patient may have fever, chills, abdominal pain, nausea, vomiting, and diarrhea.
Some present initially with cloudy fluid as the first sign and no symptoms.
Patient must be taught to contact their PD nurse or nephrologist immediately for cloudy effluent.
Peritonitis Presentation
Signs and Symptoms: Fever, abdominal pain, nausea and vomiting, diarrhea, and cloudy effluent.
Incubation: 24-48 hours; if within 6 hours suspect an enteric source.
Kinetic effects: Increased solute removal and protein loss; increased glucose absorption leading to a decreased osmotic gradient and decreased ultrafiltration.
Prevention of Peritonitis
Careful individualized patient training
Adequate daily hygiene
Meticulous hand washing
On-going retraining
Peritonitis
Treatment protocols
Patient may be treated in PD Unit or Emergency Room depending on the severity of symptoms and availability of resources.
Effluent is sent for cell count, C&S, and gram stain.
Fungal cultures should be included if patient is immunosuppressed or has had frequent infections requiring antibiotics.
PD Unit should have specific antibiotic protocols for gram-positive and gram-negative coverage.
Peritonitis
Organisms
Gram-Positive: Staphylococcus epidermidis Staphylococcus aureus Streptococcus species Enterococcus Gram-Negative: Pseudomonas Klebsiella Escherichia coli Enterobacter Fungal Organisms
PD Affects Drug Transport By:
Systemic drug removal via effluent Drugs can be administered IP Dose related to urine output and mechanism for elimination of drug
Membrane changes
Sclerosing, Encapsulating Peritonitis
A thick fibrous layer of tissue encapsulates the bowel
Membrane becomes thick and opaque Onset gradual or rapid
Presentation
Decreased ultrafiltration and solute clearances
Recurrent abdominal pain Intermittent nausea and vomiting
Partial and/or complete bowel obstruction Intervention – Emergency laparotomy
Clinical Management Issues for the PD Patient
Catheter insertion and healing of exit site Prevention of infection Blood pressure control and fluid management Nutrition evaluation and interventions Systems assessment Medication evaluation Anemia/Ca/Phos./PTH management PET and initial Kt/V Coping with stress of chronic illness Transplantation
Current Issues in Peritoneal Dialysis
Revision of K/DOQI Co-morbidities Role of sodium Volume Control Blood pressure control Utilization of Icodextrin Role of inflammation Integrated dialysis care Improving fellow education CKD education for patients and families ADEMEX study-adequacy European APD Outcome Study (2003) Underutilization of Peritoneal Dialysis
Questions ?
References
Ash
[Author: Need full reference]
Flanigan, M. & Gokal,R. (2005). Peritoneal catheters and exit site practices toward optimum peritoneal access: A review of current developments.
132-139.
Peritoneal Dialysis International, 25
, Kelley, K. (2004) How peritoneal dialysis works.
Nursing Journal, 31
(5), 481-491.
Nephrology
Palmer & Quinton
{Author: Need full reference]
Rosenak
[Author: Need full reference]
Scribner & Boen
[Author: Need full reference]
Additional Readings
Abu-Alfa, A. (2003) The Ademex Study: Expanding the Boundaries of peritoneal dialysis adequacy beyond small solute clearances
. Dialysis and Transplantation, 32
(3), 115-124.
American Nephrology Nurses’ Association (ANNA).
(YEAR?)
.
every nurse should know. Partnering for quality care.
Chronic kidney disease – What
Retrieved May 31, 2007, from www.annalink.com
American Nephrology Nurses’ Association (ANNA). (2006). Peritoneal dialysis. (2006) In Molzahn, A.E., & Butera, E. (Eds.).
contemporary nephrology nursing: Principles and practice
(2nd ed.) (pp. 629-687). Pitman, NJ: Author.
American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2003). Peritoneal dialysis nurse resource guide.
Nephrology Nursing Journal, 30
(5), 535.
American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2004). A monograph on peritoneal dialysis.
Nephrology Nursing Journal, 31
(5).
American Nephrology Nursing Association (ANNA) Peritoneal Dialysis Special Interest Group.
(2005) The Peritoneal equilibration test.
Nephrology Nursing Journal, 32
(4), 452-453.
Bargman, J. (1995). Preventing hernias and leaks in long-term patients on peritoneal dialysis.
Seminars in Dialysis., 8
(6), 370-372.
Additional Readings
Babcock, D.E., & Miller, M.A. (1994).
Mosby.
Client education: Theory and practice
. St. Louis, MO: Bargman, J. (2000). Non-infectious complications of peritoneal dialysis. In R.Gokal, R.Khanna, R.Krediet, & K. Nolph (Eds.),
Textbook of peritonealdialysis
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London: Kluwer Academic Publishers.
Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and achieving optimum outcomes
.
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(5), 494-498.
Bernardini, J., Bender, F., Florio,T., Sloand, J., Palmmontalbano, L., Fried, L., et al. (2005).
Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients.
Journal of American Society of Nephrologists.
16
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Burkart, J. (2003). The Ademex Study and its implications for peritoneal dialysis adequacy.
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Burrows-Hudson, S.
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American Journal of
Crawford-Bonadio, T., & Diaz-Buxo, J. (2004) Comparison of peritoneal dialysis solutions
.
Nephrology Nursing Journal, 31
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Additional Readings
Dana, C. (2004). What is missing in making PD a success?
Issues, 18
(9), 25-28.
Nephrology News and
Davies, S.J., Woodrow, G., Donovan, K., Plum, J., Williams, P., Johansson, A.C., et al (2003) Icodextrin improves the fluid status of peritoneal dialysis patients: Results of a double-blind randomized controlled trial.
Journal of American Society of Nephrology, 14
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DeHaan, B. (2003) Why peritoneal dialysis should be the first treatment option.
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Additional Readings
Luongo, M., & Kennedy, S. (2004) Interviewing prospective patients for peritoneal dialysis: A five-step approach
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(5), 513-520.
Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues.
Journal, 31
(5), 521-532.
Nephrology Nursing
Miller, D., MacDonald, D., Kolnack, K., & Simek, T. (2004). Challenges for nephrology nurses in the management of children with chronic kidney disease.
Nephrology Nursing Journal, 31
(3), 287-294.
Mujais, S., Nolph, K., Gokal, R., Blake, P, Burkart, J., Coles, G., et al. (2000). Evaluation and management of ultrafiltration problems in peritoneal dialysis.
Peritoneal Dialysis International, 20
(Suppl 4), S5-S21.
Oreopoulos, D.G., Lobbedez, T., & Gupta, S. (2004) Peritoneal dialysis: Where is it now and where is it going?
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Paniagua, R., Amato, D., Vonesh, E., Correa-Rotter, R., Ramos, A., Moran, J., et al. (2002).
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.
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Pritchard, S. (2005). Will peritoneal dialysis be left behind?
Seminars in Dialysis, 18
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Prowant, B. (2001) Peritoneal dialysis. In L.E. Lancaster (Ed.),
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Rubin, H.R., Fink, N.E., Plantinga, L.C., Sadler, J.H., Kliger, A.S., & Powe, N.R. (2004) Patient ratings of dialysis care with peritoneal dialysis vs.hemodialysis.
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Additional Readings
Van Dijk, C., Ledesma, S., & Teitelbaum, I. (2005). Patient characteristics associated with defects of the peritoneal cavity boundary.
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Von Biesen, W. (2002). Peritoneal dialysis in anuric patients: Concerns and cautions.
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Zorzanello, M. Fleming,W., & Prowant, B. (2004). Use of tissue plasminogen activator in peritoneal dialysis catheters:a literature review and one center’s experience.
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