Clinical Change Forum 28th June, 2016 Ian Currie Consultant Transplant Surgeon Royal Infirmary of Edinburgh

The Patient and the PD Catheter A patient approaching dialysis requires either Arterio-venous fistula Peritoneal Dialysis catheter This patient already had a fistula but had serious problems with haemodialysis The patient wished to have a PD catheter Procedure booked by the Consultant Physician as usual

The Patient and the PD Catheter Previous renal transplant in 1999 Transplanted before dialysis so no experience of Haemodialysis or Peritoneal Dialysis Type 2 diabetes > 10 years Graft failure, commencing dialysis in 2015 Post transplant malignancy (PTLD) 2015 MRSA infection in tumour site (leg)

The Patient and the PD Catheter I met the patient for the first time in early December, in the day surgery unit, pre-op MRSA swabs taken in mid November were +ve for MRSA (probably sent by oncologist)

The Patient and the PD Catheter The plan was to place PD catheter in complex patient Insulin-requiring type 2 diabetes Recent history of treated malignancy Dialysis-dependent renal failure Immunosuppression Insertion of plastic catheter into abdomen Each of which increases risk of infection

The Patient and the PD Catheter Patient centred option Do the operation with counselling about infection and risk of catheter failure and removal My concerns Infection risk was high Risk of fatal outcome Contraindication to insertion of plastic Patient and spouse will be upset Operating list could not start

The Patient and the PD Catheter Patient benefits if we proceed Dialysis can start as soon as possible No need for second admission Expectations of patient and relatives managed

The Patient and the PD Catheter Surgeon/Institutional benefits if we proceed Can start list without further delay Case done – no need to manage during wait No day of surgery cancellation in DSU stats

The Patient and the PD Catheter Patient risks if we proceed MRSA Peritonitis Catheter removal 31% Permanent Haemodialysis 25% Recurrent Peritonitis 24% Death 5% Other MRSA risks Endocarditis, arthritis (consequent interventions)

The Patient and the PD Catheter Surgeon/Institutional Risks if we proceed Need to spend time discussing risks and ensuring understanding immediately pre-op (not good practice) Unable to start operating list (other patients) Loss of peer support Legal pursuit (negligence) Reputation

The Patient and the PD Catheter I explained to the patient High risk of serious outcome (mortality) I had numerous reservations Extremely upset Said she would go home, stop dialysis and die Husband extremely upset

The Patient and the PD Catheter Spoke to Dr Watson and PD Team Three batches of MRSA Swabs sent – all -ve Following week – strongly MRSA positive Family meeting Eradication therapy PD catheter placed 2 months later Multiple negative swabs since then