Transcript Clinical Monitoring Systems

Peritoneal Dialysis
PD Access
Peritoneal Dialysis
Peritoneal Catheters
PD catheter is patients lifeline
Several advances have made access
safer and longer lasting
Successful outcome is dependent on
meticulous care and attention to detail
Adherence 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 Catheters
Catheter Choice and Catheter Outcomes
Catheter Insertion
Immediate post - operative care
Chronic 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
Currently available
chronic peritoneal
catheters
Gokal et al PDI 1998;18:11-33
P
Peritoneal Dialysis
Catheter Insertion
• Prevention of complications begins with
the decision to place a patient on
peritoneal dialysis
Peritoneal Dialysis
Appropriate candidates
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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
• LATE
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Leak
Obstruction to flow
Bleeding
Infection
Intestinal perforation
Inability to insert catheter
Obstruction to flow
Hernia
Hydrothorax
Peritonitis
Exit-site erosion / infection
Other surgical problems
* diverticulitis
* cholecystitis
Peritoneal Dialysis
Catheter Insertion
• Who should place the PD catheter?
The Surgeon!
Peritoneal Dialysis
Communication is Essential
Surgeon
Nephrologist
Nurse
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 itspreformed arcuate bend)
• No catheter appears to be superior to the 2 cuff
standard Tenckhoff catheter - experience with swanneck catheters is promising.
Peritoneal Dialysis
Catheter Insertion
PRE-IMPLANTATION PREPARATION
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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
A Healthy Exit Site
Peritoneal Dialysis
Immediate Post Operative Care
AIMS
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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