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

2. 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

3. 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)

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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