Transcript EXIT SITE CARE PREPARATION BEFORE IMPLANTATION

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THE CHOICE OF DIALYSIS ACCES
CONTROVERSY AND EVIDENCE
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PART 3 : Peritoneal Dialysis
Teaching point
EBM ?
What’s new ?
CONTROVERSY ?
EXPERT BASED
GUIDELINES
Guidelines by an ad hoc European
committe on elective chronic peritoneal
dialysis in pediatric patients
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A.
–
Watson, on behalve of the European pediatric dialysis working
group
Comprehensive pediatric nephrology Geary
Schaefer
CONTROVERSY
PRE-DIALYSIS INORMATION
>POST DIALYSIS FOLLOW UP
>PERI- OPERATIVE CARE
> SURGEON
> CATHETER
CHOICE OF CATHETER
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Catheters
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Length
Length between cuff’s
Place left / right fossa
Swan neck / straight
Straight / Currl
CONTROVERSY
PRE-DIALYSIS INORMATION
>POST DIALYS FOLLOW UP
>PERI- OPERATIVE CARE
> SURGEON
> CATHETER
Preparation of the patient and the family
1) It is essential that the child and family are
prepared by a pediatric nurse experienced in
chronic peritoneal dialysis with access to
appropriate written information and other
teaching aids such as dolls or videos.
2) If the child has phobias then a child
psychologist should be consulted
3) Home visit / School visit
4) Contact with other child /parents
Preparation of the patient and the family
A nutritional assessment will be required for all dialysis
patients. If nutritional support is required then the
appropriate route for supplementation (oral. Nasogastric
or gastrostomy) should ho discussed with the pediatric
renal dietitian and team members.
If it is appropriate to consider a gastrostomy then this can
be placed at the time of the PD catheter under the same
anaesthesie with minimal additional morbidity.
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Use of Catheter and Surgical Procedure
The placement of a peritoneal dialysis catheter
requires an experienced surgeon and should
be given appropriate priority,
A dialysis-catheter is a “LIFE”-line..with only
few alternative options during the life-span of
the patient.
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2)
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“early days” nephrologist was in the theatre..
Now???
Use of Catheter and Surgical Procedure
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2)
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Open technique
Laparoscopic technique
Percutaneous technique
Use of Catheter and Surgical Procedure
2) Double cuff curled catheters are preferred in
most children
 pediatric size in patients 3-10 kgs body weight
 and adult catheter >10 kg.
 A single cuff catheter may be needed in infants
<3kg.
 Data from the NAPRTCS registry suggest
 swan neck tunnels,
 two cuff
 and downward pointing exit sites.
Use of Catheter and Surgical Procedure
2) Presumed advantages of curled catheters
 better separation between abdominal wall and
bowel
 More catheter holes
 Less inflow pain
 Less tendency for migration
 Less prone for omental wrapping
 Potentially less trauma to the bowel
Use of Catheter and Surgical Procedure
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Prior to theatre the exit site for the catheter should be
agreed with the child and marked on the abdomen by
either the dialysis nurse or surgeon.
The exit site should avoid the belt line and be above the
nappy or diaper line in infants.
In all but the smallest infants the exit site should he
downward facing.
The exit site should be located as far as possible from
other exits, ie gastrostomies, colostomies, urostomies to
prevent infections.
Use of Catheter and Surgical Procedure
Use of Catheter and Surgical Procedure
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2.
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Laxatives should be given pre-operatively to
children who suffer from constipation
Empty bladder
Partial omentectomy may reduce postoperative
obstruction but there are no prospective
pediatric series addressing this issue.
Consider elective herniotomv if any evidence of
inguinal or other hernia prior to or during
catheter placement.
Use of Catheter and Surgical Procedure
Entry into the peritoneum should be lateral or paramedian
with the deep cuff outside the peritoneum.
The peritoneum is closed tightly around the catheter
Below the level of the deep cuff using a purse string suture.
A tunneling device with a sharp point is recommended for creating the
catheter tunnel
and strict haemostasis is required.
No incision should be made at the exit site.
The subcutaneous cuff should be at least 2cms from the exit site.
A cephalosporin antibiotic should he given intravenously at the time of
catheter implantation.
Procedure in Theatre
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1) Catheter should be tested in theatre for
patency and leaks with dialysis nurse or
nephrologist present.
2) No suture should be placed at the exit
site which should be downward facing
with the possible exveption of infants.
The catheter will be irrigated in theatre until the dialysate is clear
then capped off.
The PD fluid should contain Heparin 5OOiu/L.
Catheter must be immobilised at all times and no keyhole dressing
applied.
If the catheter has to be used for immediate dialysis then use only low
volumes, 10ml/kg/cycle. In this situation keeping the patient supine
for the first few days and adequate analgesia will also help to avoid
high intraperitoneal pressure and possible leaks.
If possible leave catheter for two weeks until the patient returns
for training. This will allow initial healing to take place.
IMMEDIATE POST OPERATIVE CARE
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Pain controle.
Multiple low volume exchanges until clear
effluent.
Dry abdomen as long as possible
Dressing is remained for 5 days.
Bedrest for 7 days.
FIRST WEEK POST OPERATIVE CARE
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Remove primary dressing at day 5
Exit site care done by an experienced
nurse.
Secure normal position of the catheter.
Avoid lifting.
Allow catheter to heal as long as possible.
GENERAL INSTRUCTIONS
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Forbidden:
- to take a bath
- to swim
- contact sports (football…)
Advice against:
- sand (beach)
- intensive sports (basket ball…)
Tollerance of:
- shower
CONCLUSIONS
Catheter complications are to be expected
 when dressing is not remained intact for 5 to 7
day (difficult healing - tunnelinfection)
 immediate use of the catheter (leakkage)
 poor fixation (difficult healing and outgrow cuff)
Catheter characteristics are to be respected:
 to prevent malpositon
 to prevent outgrow cuff
Exit site care is extremely important:
 to prevent infection
 to assure a long life of the access
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THE CHOICE OF DIALYSIS ACCES
CONTROVERSY AND EVIDENCE
EVIDENCE / CONTROVERSY
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SOME THINGS ARE WRONG
SOME THINGS ARE GOOD
MOST THINGS HAVE GOOD AND BAD
POINTS..where the final decision
balances, depending on “choices” made
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Fistula superior to catheter ?
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Yes
But if you choose for nighttime dialysis… not
possible (A. Raes oral presentation ESPN)
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Fistula superior to catheter ?
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Yes
If you are going
for pre-emptive transplantation,
 and waiting list is rather short..
 And time to start dialysis is not predictable
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Integrated care model (Van Biesen)
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Every patient with CKD.. may need every
method for renal replacement therapy such as
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Peritoneal dialysis
Transplant
Hemodialysis
Retransplant
…
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Integrated care model (Van Biesen)
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Peritoneal dialysis
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Is probably not the best choice in adults
If there is no residual renal function
 If BSA / BMI is very high
 IDDM??
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So PD… and PD catheter is treatment of
choice in children because
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you preserve vascular access for later
Acute dialysis
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Hemodialysis
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Catheter
Single / double Lumen
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Genius… then double lumen
Femoral catheter
Often the choice
 To not interfere with other central catheters
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Acute dialysis
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Peritoneal catheter
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Surgical
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Percutaneous Tenckhoff
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Adults good experience
In children few reports
Seldinger place acute catheter (pigtail) (Buchmann, Vande Walle
adv Perit Dialysis)
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Often time… to surgery is long
Especially in small children
Cardiac surgery
To gain time when there is hyperkaliemia (Start dialysis in 10min)
Two catheter technique
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Continuous flow dialysis (Vande Walle Adv Perit Dial)