1 PERITONEAL DIALYSIS

2 How Does PD Clean the Blood? Diffusion – passage of particles in solution across a semi- permeable membrane from an area of greater concentration to an area of lower concentration – continues until equilibration is achieved

3 How Does PD Clean the Blood?.. cont Osmosis – movement of water from an area of low concentration to an area of high concentration

4 THE PERITONEUM semi-permeable sac lining the abdominal cavity and covering the abdominal organs

5 PD ACCESS Silastic catheter soft plastic tube usually placed 3-4 inches to the side of the navel easily hidden by clothing

6 PD Catheter Placement Surgical Procedure is usually done under local anesthesia or sedation Coiled or a straight catheter

7 EXIT SITE Most catheters have fussy white fixation cuffs that remain in the muscle The place where the catheter comes out

8 Peritoneal Fluid Has glucose that attracts fluid Kinds: – 1.5% - weak solution – 2.5% - medium solution – 4.25% - strong solution

9 The Exchange Procedure: Infusion

10 The Exchange Procedure: Dwell

11 The Exchange Procedure: Drain

12 PD Types Intermittent Peritoneal Dialysis (IPD) – Acute – Chronic Continuous Ambulatory Peritoneal Dialysis (CAPD) Automated Peritoneal Dialysis (APD)

13 IPD

14 Intermittent PD (IPD) Lasts within hours Done manually or with “cycler” machines Requires hospitalization Interrupted sequence of PD Greater risk of infection Makes use of either a permanent catheter or a temporary catheter

15 CAPD

16 Done regularly 3, 4 or 6 times daily No need for hospitalization (home dialysis) Makes use of a permanent catheter Develops a feeling of well being Allows freedom of movement Lesser incidence of infection Continuous Ambulatory PD (CAPD)

17 Automated PD (APD) New treatment method that is performed at home, at night while you sleep, using a cycling machine Primary method is CCPD ( Continuous Cycling Peritoneal Dialysis) Can go about daily activities

18 PD Suitability Strongly indicated in patients with: – Medical co-morbidities Unstable CV disease Difficult to establish vascular access – Psychosocial Strong patient preference Strong need for autonomy and/or independence

19 Contraindications for PD Medical – Severe inflammatory bowel disease Acute Active Diverticulitis Active Ischemic Bowel Disease Abdominal Abscess Psychosocial – Severe Active Psychotic Disorder Manic Depressive – Marked intellectual disability with no helper

20 PD COMPLICATIONS NON-INFECTIOUS Leaks – External – Subcutaneous Obstruction Hernia

21 Leaks Leakage occurring in the first 30 days following catheter implantation – Usually external in nature – Evident at the catheter exit site or incision site Indicators – External fluid at wound or exit site – Abdominal edema / increase girth – Scrotal or penile or labial edema – Unilateral pleural effusion in the absence of volume overload – Decreased exchange drain volume

22 Leaks Patients at risk – Diabetics – Elderly – Malnourish – Previous abdominal surgery – Hernia – Obese

23 Leak Management ProblemCauseNursing MgtMedical Mgt LeaksPoor implantation Technique Anatomical Abnormalities Use of Catheter prior to healing or trauma Initiate PD in supine position Use low volume exchange (500 – 1500 ml) until leak has healed Delay use of PD for 2 days - 3 wks for patient whose dialysis is not urgently required Re-implantation Exploration Prolong rest period Provide hemodialysis access as back up if needed during healing

24 Leak Management ProblemCauseNursing MgtMedical Mgt Leaks Alter dressing change procedure and frequency to accommodate increased drainage Monitor for signs and symptoms of exit site infection and peritonitis

25 Obstruction Occur more commonly as early complication Can also occur at any time especially during or following episodes of peritonitis

26 Obstruction Indicators – Mechanical blockage Clamps or kinks in transfer set, tubing or catheter including segment under dressing – Post implantation blood clot – Fibrin particularly with peritonitis – Constipation – Catheter tip migration out of pelvis – Catheter entrapment Omental wrap Adhesions

27 Obstruction Management ProblemCauseNursing MgtMedical Mgt ObstructionMechanical blockage – Clamps or kinks in transfer set, tubing or catheter including segment under dressing Non-invasive – Eliminate kinks in transfer set, tubing and catheter –Change body position Fluoroscopically guided stiff wires or stylet manipulation Open surgical repositioning of catheter or replacement Partial omentectomy

28 Obstruction Management ProblemCauseNursing MgtMedical Mgt Obstruction Post implantation blood clot Fibrin particularly with peritonitis Constipation Catheter tip migration out of pelvis – Dislodge blockage by infusing dialysis solution or normal saline with a 50cc syringe using moderate pressure, “push and pull” maneuver)

29 Obstruction Management ProblemCauseNursing MgtMedical Mgt Obstruction Catheter entrapment – Omental wrap –Adhesion Correct constipation Obtain flat plate of abdomen to visualize catheter position Add heparin 300 to 1000 U/l to dialysate in fibrin related obstruction

30 Hernia Protrusion at umbilicus, inguinal area or incision Incisional hernia – Occur more commonly when the peritoneal catheter is placed through the midline instead of the paramedial approach through the rectus muscle Increase the risk of further enlargement, pain and bowel entrapment and subsequent discontinuation of peritoneal dialysis

31 Hernia Incisional hernia – Umbilical hernia – Inguinal hernia

32 Hernia Management ProblemCauseNursing MgtMedical Mgt Hernia Weakening of the muscle in the abdomen or the inguinal area Inspect and examine suspected sites Refer to surgeon to determine intervention Surgical repair prior to initiation of dialysis

33 Hernia Management ProblemCauseNursing MgtMedical Mgt Hernia Post repair: - Begin supine, intermittent low volume dialysis to 2 to 4 weeks - Provide back up Hemodialysis access if needed

34 Hernia Management ProblemCauseNursing MgtMedical Mgt Hernia Instruct patient to avoid: - straining - coughing - constipation - stair climbing - lifting

35 PD Complications Infectious Peritonitis – Inflammatory condition of the peritoneum caused by a microbial insult that gain access to the cavity – Abdominal tenderness and rigidity – Cloudy peritoneal fluid (wbc >100/ul,N>50%) – Demonstration of bacteria (by GS or culture) ( 2 out of the 3 criteria)

36 Peritonitis Management ProblemCauseNursing MgtMedical Mgt Peritonitis Break in PD technique causing touch or airborne infection – Tunnel infection –Infectio n migrated from catheter exit site Allow at least 4 hr dwell before submitting specimen for cell count and C/S Check exit site for the presence of infection –Send specimen for ES CS if discharge is present Antibiotic coverage: – 1 st gen. cephalosporin PO (gram +) – Aminogly IP or quinolones PO (gram -)

37 Peritonitis Management ProblemCauseNursing MgtMedical Mgt PeritonitisInfection from the lumen of the catheter For CAPD: – Assess if the patient needs to be admitted Once dialysate fluid cultures result are available adjust the antibiotics as necessary HEPARIN may be added only if there is fibrin and the dialysate fluid remains cloudy (300 – 1000 u/exc

38 Exit Site Infection (ESI) Infection of the skin surrounding the peritoneal dialysis catheter Erythema > 10 mm around the catheter exit site Exudate from the exit site Positive culture from the exudate ( 2 out of the 3 criteria)

39 Exit Site Management ProblemCauseNursing MgtMedical Mgt ESI Tugging of catheter Once diagnosed, send specimen for C/S Frequent exit site care and use non- occlusive dressing Apply mupirocin or fucidin ointment to exit site every change of dressing Start antibiotic therapy –1 st gen. Cephalosporin PO (gram +) – Quinolones PO (gram -)