acute peritonitis in continuous ambulatory peritoneal dialysis .pptx

Nice presentation

1. Nephrology morning meeting Dr Sidra izhar

2. 4.5 years old weighting 12.6 kg resident of tando Adam k/c of esrd se to renal calculi on capd , presented on 29.04.2017 with complains of abdominal pain -------- 1 day fever ------------ 1 day

3. HOPI

4. Past medical : Birth : unremarkable, Vaccination: According to EPI Development: normal Diet: mother feed for 2 years , weaning started at 6 months, currently on fluid restriction . Drugs: Tab qalsan d, tab Dmax , tab calibin , tab sodamint , syp iberet and tab folic acid, gentamycin local application at exit site Family: 3 rd product of consangenous marriage, elder brother died at 6 months due to renal filure . 7 years old sister alive and healthy Socioeconomic: middle class

5. On examination Sick looking child crying due to pain lying in bed capd catheter in place having vital HR 11o/min RR 26/min Temperature 100f BP 90/65 Crt 2 sec Anthropometry: Wt 12.6 kg ( -3 z score) Height 95cm ( -3 z score) BSA 0.57 Weight / height ( -1.5 z score)

6. Anaemia Jaundice Clubbing negative Patichae Bruises Odema : slight periorbital puffiness

7. Abdominal examination: tense tender , having tenchkoff catheter in place , bowel sounds were diminished . Local examination: Massive hydrocele bilaterally more on left side , hot , red , tender to touch CVS : S1 S2 +0 CNS: intact CHEST: nvb b/l with no added sound

8. Provisional diagnosis ESRD sec to b/l renal calculi on capd since 31.10.2016 Acute bacterial peritonitis with infected hydrocele

9. Initial management Kept npo Essetial fluids were given Rapid cycling done with 2 liter bag Sapmle taken for dr , gram staining and culture with non touch technique Intraperitoneal antibiotics started Loading dose: maintenance dose Inj vancomycin 1 g/ 2l bag 50mg / 2 l bag Inj fortum 500 mg /2l bag 500mg/2 l bag Inj heparin 500 iu / l bag 500 units/ bag DWEll for 4 to 6 hours Cycle volume was reduced to decrease the discomfort and due to hydrocele Injection kinz was given for pain management i /v paracetamol Scrotal support was given Surgical opinion taken

10. investigations PD fluid DR: Color: yellow Appearance turbib Specific gravity 1.01 Blood trace Rbc 3-4/ hpf Tlc 22000/3MM N: 85% L:15% Sugar 509 Gram stain : no organaism seen

11. Cbc Hb : 10.4 Tlc 9800 N: 74 % L 18 % Platlet : 248000 Uce Creatinine 6.3 Na 132 K 3.2 Cl 98 Calcium 7.8

12. PD fluid cs No growth Blood culture awaited

13. Clinical course Child’s conditions started improving the next day Pain was resolved, he passed stool , gut sounds were audible, orally allowed Pd fluid became clear Negative balance of pd fluid achieved on 3 rd day Urine output improved , scrotal swelling sarted decreasing Discharged yesterday with a plan of 2 weeks ip antibiotic thereapy

14. discussion acute peritonitis in continuous ambulatory peritoneal dialysis

15. introduction Infectious complications remain the most significant cause for morbidity in pediatric patients receiving chronic peritoneal dialysis (PD). the frequency of peritonitis in children on PD continues to exceed that seen in adults, and peritonitis remains the most common reason for changing dialysis modality in children . Leads to significant morbidity, catheter loss, transfer to hemodialysis, transient loss of ultrafiltration, possible permanent membrane damage, and occasionally death .

16. Clinical presentations Symptoms : Abdominal pain 95 %, Nausea/vomiting 30 %, Feverish sensation 30%, Constipation / diarrhoea 15%. Signs : Cloudy peritoneal fluid 99%, Abdominal tenderness 80%, Rebound tenderness 15-50% (highly variable ), Pyrexia 33%, Leucocytosis 25 %

17. Differential Diagnosis of Cloudy PD effluent fluid Culture-positive infectious peritonitis Infectious peritonitis with sterile cultures (20 %) Chemical peritonitis Eosinophilic peritonitis Haemoperitoneum Malignancy (rare ) Chylous effluent ( rare) Specimen taken from “dry” abdomen

18. An empiric diagnosis of peritonitis should be made if the peritoneal effluent is cloudy, the effluent white blood cell (WBC) count is greater than 100/mm3, and at least 50% of the WBCs are polymorphonuclear leukocytes. The diagnostic workup should be performed using a standardized procedure A repeat effluent DR and cs is recommended 3 to 5 days after to see improvement. Negative culture(20 %) does not rule out peritonitis and empirical therapy should be continued for 2 weeks at least. the effluent be centrifuged, and the resulting sediment be cultured if possible. Blood-culture bottles should be used as an alternative culture technique (1B

19. Empirical therapy

20. Adjunctive therapy . prophylactic antibiotic administration after accidental intraluminal contamination to lower the risk of peritonitis (2B ). . We suggest prophylactic antibiotic administration before invasive dental procedures to lower the risk of peritonitis (2D). . Reduce the peritoneal fill volume during the initial 24 – 48 hours of therapy in patients with significant abdominal discomfort (not graded ). . the intraperitoneal administration of 500 – 1000 IU/L heparin until complete resolution of dialysate cloudiness (2B). . the provision of intravenous immunoglobulin G be considered in selected patients with frequent or refractory peritonitis episodes or in infants with documented hypogammaglobulinemia and peritonitis or sepsis (2D).

21. CONSENSUS GUIDELINES FOR THE PREVENTION AND TREATMENT OF CATHETER-RELATED INFECTIONS AND PERITONITIS IN PEDIATRIC PATIENTS RECEIVING PERITONEAL DIALYSIS: 2012 UPDATE references

22. Thank you