Complications of Dialysis Presented by : Saud Mahmoud RN BScN

Complications of Dialysis Infectious Non Infectious

Patient Assessment Daily weight Blood pressure lying and standing Physical assessment observing for signs fluid overload /dehydration Temperature Blood chemistry Observe for complications

Patient Assessment cont

Patient Assessment Ask patient about bowel habits Check if patient has urine output Check exit site on admission Culture if infection suspected Check clarity of PD fluid

Infectious Complications Peritonitis Exit site infection Tunnel infection

Definition: Peritonitis is a generalized or localized inflammation of the peritoneum. This condition most often results from contamination and may be a complication of one of the following: Diverticulitis Colitis Peritoneal Dialysis Appendicitis

Causes of Peritonitis Organisms enter the peritoneum in various ways namely: Intraluminal - infections travel to the peritoneum via the catheter. Touch contamination or damaged PD systems are examples of this method of entry. Per luminal - – bacteria entering the peritoneum via the peritoneal tract or tunnel, e.g. exit site infection.

Causes of Peritonitis Tran mural - bacteria enter the peritoneum through the bowel wall, e.g. constipation. Hematogenous - infections come from the blood stream. Transvaginal - organisms can travel through the reproductive tract.

Common Organisms Gram Positive: Organism Port of Entry Information Diptheroids Intraluminal Periluminal Normal Skin flora – poor hygiene / break in technique and poor handwashing Enterococcus Transmural Fecal organisms, sometimes hospital acquired – cross contamination Staphylococcus Aureus Nasal Carrier Staphylococcus Epi (Coagulase negative staph) Due to break in technique (touch contamination) Streptococcus Hematogenous Found in soil, water, vegetation and dairy products. Normal GI flora and respiratory tracts

Common Organisms Gram negative: Organism Port of Entry Information Acinetobacter Intraluminal Periluminal Found in soil, water and sewage Enterobacteria Transmural Indication of fecal contamination Escherichia (E.Coli) Found in nature, animal and human intestinal tract Hemophilus Organisms from this species are normal of the upper respiratory tract

Common Organisms Gram negative: Organism Port of Entry Information Klebsiella Intraluminal Periluminal Normal flora of the GI tract, colonization of the upper respiratory tract Proteus Species Transmural Found in soil, water and sewage. Normal fecal flora Pseudomonas Found in soil and water Serratia Hospital acquired

Common Organisms Yeast: Mycobacterium: Organism Port of Entry Information Candida Albicans Intraluminal Periluminal Transvaginal Diabetes, those on antibiotics at high risk. Moist exit sites Organism Port of Entry Information Mycobacterium TB Hematogenous Diagnosis: lymphocytes in PD fluid cell count often elevated.

Peritonitis

Signs and Symptoms Cloudy fluid +/- Fever Abdominal pain Nausea/ vomiting

Classification of Peritonitis Recurrent Peritonitis - an episode that occurs within four weeks of completion of therapy of a prior episode but with a different organism. Relapsing Peritonitis - an episode that occurs within four weeks of completion of therapy of a prior episode with the same organism or one sterile episode.

Classification of Peritonitis Refractory peritonitis - failure to respond to appropriate antibiotics within 5 days. Recommendation – catheter removal to protect the peritoneal membrane for future use. Re-infection - new episode 4 weeks after completion of treatment.

Nursing Intervention Obtain dialysate effluent from the first bag BFH (body fluid hematology) Lavendar tube Gram stain & culture ( send whole bag) Strict aseptic technique with collection Specimens sent to lab STAT

Immediate care Specimens sent to lab STAT Perform 3 quick flushes 4th bag add the loading dose of antibiotics and heparin as prescribed The loading dose must dwell for 6 hrs

Diagnosis BFH - White cell count >100mm3 Polymorph more than 50% Gram stain – positive Culture Cloudy effluent and abdominal pain

Effective Culture Technique Solution must dwell in peritoneum for at least 4 hrs prior to sampling Mix effluent well before sampling Obtain sample aseptically Send a large volume to lab > 50ml (for centrifuging and performing a gram stain on sediment) preferable to send whole bag Inform lab if patient has received any antibiotics within the last week

Management Do not leave patient on extended drain. Empirical antibiotic therapy to start as soon as possible as per standing order for suspected peritonitis ISPD recommendations 2005

Management Antibiotic therapy will be adjusted according to the organism Patient to be taught to add own meds as soon as able to do so Re-evaluation of technique

Exit Site Infection Exit site infection Signs and symptoms Inflammation at the catheter exit site Redness and pain +/- purulent discharge

EXIT SITE INFECTION

Risk Factors Trauma e.g. excessive manipulation of catheter Cuff extrusion Staph Aurous nasal carrier Leak at exit site Skin breakdown

Management Minimum of twice daily dressing Use Normal saline ( no spirit based lotions) Topical antibiotic – Gentamicin cream IP / Oral antibiotics Assess response to antibiotic therapy Keep exit site clean and dry ( no showering) Shave the cuff if exposed

Tunnel Infection Infection in subcutaneous tunnel between exit site and peritoneum. Signs and Symptoms: Redness along tunnel Purulent discharge Pain tenderness along tunnel Abscess over tunnel Exit site infection and or peritonitis present

References www.ispd.org www.pdserve.com