Transcript Document
Certification Review Course
Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph’s Regional Medical Center Paterson, New Jersey
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 PD patient .
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 & Nephrologist
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.
K. Kelly , RN NNJ Sept-Oct 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-Predominant use of PD prior to 1960’s 1966- Automated cycler 1967- Tenckhoff catheter 1975- CAPD 1978- Polyvinyl bags and manufactured in the US (prior PD fluid was available in glass bottles) 1980’s- New catheter designs 1987- PET and tidal PD -Twardowski 1990’s-Alternative dialysate solutions, updated system designs ANNA Core Curriculum 5 th Ed
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 with 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
Vascular Access Failure
Social support system available
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 life style
Patient states lack of interest in modality
Multiple abdominal surgeries- adhesions
Ostomies (increase risk of infection)
Recurrent hernias
Steps to PD Catheter Access
Evaluation by Nephrologist for PD catheter placement and identified as candidate.
Educated about catheter placement, pre and post operative care routines.
Referred to surgeon for evaluation that includes determination of exit site,clinical & anesthesia work-up, contraindications, completion of consent forms and scheduling of surgery.
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
Surgical Evaluation
Abdominal wall weakness or hernia Repair hernia preemptively or when symptomatic Previous abdominal surgeries: multiple surgeries = increased likelihood of adhesions Abdominal wall obesity
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
Question
Evidence-based practice suggests which of the following upon PD catheter implantation?
a.
b.
Large fill volumes immediately post-op No need to wear a mask while performing PD exchanges c.
Incision site to be exposed to air during immediate post-op period d.
Administration of prophylactic IV antibiotics prior to catheter implantation to reduce the risk of peritonitis Core curriculum for Nephrology Nursing, 5 th Nurses’ Association Edition. American Nephrology
Peri Operative Routines Anesthesia
Local infiltration with sedation
Intravenous propofol with Monitored Anesthesia Care
General anesthesia
Insertion Techniques
Bedside-temporary catheters Laparoscopic placement Surgical dissection Buried Catheter technique Percutaneous placement per Interventional Radiology
Insertion Techniques Buried catheter:
Entire catheter placed in subcutaneous pocket for 4-6 weeks or longer, allowing cuff & tunnel to heal
Exit site is externalized in a separate procedure Reduced bacterial colonization(?) Do not have long term outcomes yet Flanigan, Gokal, 2005
Catheter History
•
Early catheters were glass cannulas with straight or with mushroom ends
•
1920-40’s: Various medical devices were used in the beginning of PD: needles, glass cannulas, sump drains, stainless steel coils, Foley catheters
•
1923-Ganter used a needle for the 1st reported use in humans.
•
1950’s-Nylon catheters, polyethylene, plastic with rounded tip & numerous tiny side holes ANNA Core Curriculum 5th Ed
Catheter History
1960’s-
silicon rubber catheters, with coiled intraperitoneal segment (Palmer, Quinton)
Tenckhoff & Schechter published results with silicone elastomer (Silastic ® ) for chronic dialysis with 2 Dacron ® polyester felt cuffs
1968-Tenckhoff cuffed straight catheter 1970’s-single/double cuff coiled catheter; Toronto Western with 3 silicone disc 1980’s-swan neck configuration ( bent or curved SQ segment; Toronto Western with 2 silicone disc 1990’s-t shaped catheter (Ash); Moncrief & Popovich technique for leaving the exterior segment buried SQ for 4 wk The future..?
ANNA Core Curriculum 5 th Ed
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
Question…
What is one advantage of implanting a cuffed PD catheter?
a.
b.
c.
d.
Acts as a barrier to prevent infection Can only be used for CAPD Ensures optimal adequacy Can be implanted at the bedside Core curriculum for Nephrology Nursing, 5 th Nephrology Nurses’ Association Edition. American
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)
Question
The patient’s fill volume is 2000mL. Upon draining, the patient’s volume is 1500mL. The nurse should assess the patient for which of the following?
a.
Peritonitis b.
c.
Catheter removal Constipation d.
Subcutaneous tunnel infection Core curriculum for Nephrology Nursing, 5 th Nurses’ Association Edition. American Nephrology
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 Instructions (written & verbal) to patient, which include emergency contact numbers Follow-up in PD unit within 48 to 72 hours of discharge Pain medication/prescription Reinforce dressing as needed Teach patient to secure catheter Flush catheter during training sessions
Post Operative Discharge Plan
Remove primary dressing in 5 to 7 days by PD nurse
Dressing changed by PD nurse
Replace dressing with DSD, non-occlusive
Establish training schedule
Bowel regimen
No heavy lifting
Allow catheter to heal for 14 days or longer if possible before use Prevent Constipation
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
NEVER MICROWAVE!!
Patients at risk for inadequate dialysis
No residual renal function Low membrane permeability Large patients Patients not doing their treatments
PD Equilibration Test AKA: PET
First developed by Z. Twardowski at the University of Missouri
A four 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
Transporter High or Fast Average Low Waste removal Fast Okay Slow Water removal Poor Okay Good Best type of PD Frequent exchanges, short dwells – APD CAPD or APD CAPD, 5 evenly spaced exchanges – 1 exchange at night using a small machine.
http://www.homedialysis.org/files/pdf/resources/tom/200801.pdf
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. (Unit specific, usually quarterly or bi annually)
KT/V Test continued
What does it tell us?
The adequacy of the current prescription
Need for adjustments to insure appropriate dialysis prescription
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 ES Care: daily or 3-4 times weekly; may be in conjunction with showering
Infection Prevention
Exit Site Care: No dressing needed for established catheter exit site (unit or pt specific) Keep catheter secured to abdomen with 2 inch tape Daily showers with liquid soap
Mupirocin (Bactroban ®) or Gentamycin Cream 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
Question…
Following peritoneal dialysis catheter implantation, a patient is instructed that: a.
b.
c.
The exit will always be tender Baggy clothes will have to be worn The catheter will need to be changed monthly d.
Well-healed healthy exit-sites make swimming possible Core curriculum for Nephrology Nursing, 5 th Nurses’ Association Edition. American Nephrology
Infectious Complications
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 (unit/Nephrologist specific)
Exit Site Infection
S & S : 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
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.
Responsible Organisms
Staphylococcus Aureus Pseudomonas species Other Gram positive species Serratia species Other gram-negative organisms Fungi
Tunnel Infection
S & S 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
Careful individualized patient training
Adequate daily hygiene
Meticulous hand washing
On going retraining
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
Inflammation of the peritoneal cavity
Defined as the presence of WBC in the effluent numbering 100 or greater & 50 polys (neutrophil) or segs
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
Portals of Entry: Transluminal- technique failure, contamination Periluminal- incomplete healing ,leaking Hematogenous- bacteremia Transmural- through the bowel wall ANNA Core Curriculum
Peritonitis Presentation
S & S: fever, abdominal pain, N & V, 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
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
Question…
A PD effluent cell count differential can determine if peritonitis is present when there is an elevation in ?
a.
eosinophils b.
neutrophils c.
d.
lymphocytes granulocytes Core curriculum for Nephrology Nursing, 5 th Association Edition. American Nephrology Nurses’
Peritonitis
Treatment protocols
Patient may be treated in PD unit or Emergency Room depending on 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 had 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
Question
Catheter removal is recommended when the patient has peritonitis associated by which of the following organisms?
a.
b.
c.
d.
Staph aureus Fungal Staph epi Pseudomonas Core curriculum for Nephrology Nursing, 5 th Nurses’ Association Edition. American Nephrology
Non Infectious Complications
Non Infectious Complications
Pericatheter and Subcutaneous Leaks Peritoneal Catheter Obstruction: most commonly early, yet can occur at any time .
Hernia: significant abdominal wall hernias should be surgically repaired prior to initiation of PD. Enlargement may occur due to increased abdominal wall pressure.
Non Infectious Complications
Pneumoperitoneum (Shoulder Pain): usually resulting from air infusion Hemoperitoneum: blood loss into the peritoneal cavity. A few drops of blood will produce grossly bloody effluent. Most common in women in menses. Any bleeding needs to be monitored .
Hydrothorax: secondary to a pleuroperitoneal communication.
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
Non Infectious Complications
Catheter Adapter Disconnect or Fracture of Peritoneal Catheter. Stop Dialysis, obtain culture, replace or repair, prophylactic antibiotics pending culture results
Membrane changes
Sclerosing, Encapsulating Peritonitis: serious, yet rare, not exclusive to PD
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 & 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 nephrology fellow education CKD education for patients and families ADEMEX study-adequacy European APD Outcome Study (2003) Underutilization of Peritoneal Dialysis
Final Note
The success of PD can be attributed to the combined efforts of researchers, individuals on PD, and healthcare professionals who, in collaboration with the industrial community, have realized the potential benefits of the treatment. Despite a slow start in comparison to HD, PD has evolved into a modality that equals HD in long term outcomes.
Contemporary Nephrology Nursing p 633