1. Peritoneal Dialysis PD Access

2. 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

3. 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

4. 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

5. 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

6. 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

7. Peritoneal Dialysis P Currently available chronic peritoneal catheters Gokal et al PDI 1998;18:11-33

8. Peritoneal Dialysis Catheter Insertion Prevention of complications begins with the decision to place a patient on peritoneal dialysis

9. Peritoneal Dialysis Appropriate candidates 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

10. Peritoneal Dialysis Insertion Complications EARLY -Leak -Obstruction to flow -Bleeding -Infection -Intestinal perforation -Inability to insert catheter LATE -Obstruction to flow -Hernia -Hydrothorax -Peritonitis -Exit-site erosion / infection -Other surgical problems * diverticulitis * cholecystitis

11. Peritoneal Dialysis Catheter Insertion Who should place the PD catheter? The Surgeon!

12. Peritoneal Dialysis Communication is Essential Surgeon NurseNephrologist

13. 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

14. 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)

15. 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 its- preformed arcuate bend) No catheter appears to be superior to the 2 cuff standard Tenckhoff catheter - experience with swan- neck catheters is promising.

16. Peritoneal Dialysis Catheter Insertion PRE-IMPLANTATION PREPARATION  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

17. 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

18. Peritoneal Dialysis A Healthy Exit Site

19. Peritoneal Dialysis Immediate Post Operative Care AIMS  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

20. 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