Peritoneal dialysis catheter

Peritoneal dialysis catheter insertion and its complication
By Yousaf khan
Renal dialysis lecturer
IPMS- KMU

1. Peritoneal Dialysis Catheter Yousaf khan Renal Dialysis Lecturer IPMS- KMU

2. Peritoneal dialysis catheters Several type catheter Made of silastic rubber with two Dacron cuffs which are placed at either end of a subcutaneous tunnel. The tunnel increases the distance that bacteria have to migrate from the skin into the peritoneum. Double-cuffed catheters have a lower infection rate than single cuffed catheters. Exit site infection remains one of the major complications of catheters. Material of catheter is Silicon rubber ( milky white material ) Poly urethane ( clear material ) Catheter design three portion intraperitoneal , extraperitoneal and extarnal Cuff ( single or double)

3. Peritoneal dialysis catheters

4. Types of catheter Straight Tenkhoff catheter Advantage: Simplest catheter to insert and Can be inserted by variety of techniques Disadvantage: Relatively high risk of catheter migration Coiled Tenkhoff catheter Advantage: Slightly reduced risk of catheter migration and Can be inserted by variety of techniques Disadvantage: Migration of coiled end can cause abdominal pain Insertion is more complicated

5. Types of catheter Swan-necked catheter Advantage: Incidence of exit site infections may be reduced Disadvantage: Can only be inserted surgically Less commonly available so can only be inserted by specialized personnel Toronto western catheter: Advantage: Catheter sutured into pelvis so cannot migrate and catheter tip can be placed into ideal portion Disadvantage : Laparotomy required for insertion and longer skin insertion than other technique

6. Insertion of peritoneal catheters Percutaneous Seldinger technique Advantage: Performed under local anaesthetic Minimizes hospital stay Operating theatre not required Can be performed by physician Incision sites small allowing early use of catheter Disadvantage: A “Blind’’ technique so no control of catheter position Not suitable in presence of intra-abdominal adhesions Not suitable for more complex catheters, e.g. Swan-necked or Oreopoulos

7. Insertion of peritoneal catheters Laparoscopic Advantage: Catheter tip can be positioned Incision sites small allowing early use of catheter Suitable for all types of catheter Catheter tip can be sutured into Pelvis Omentectomy can be performed if needed Disadvantage: Equipment expensive Specialized personnel required

8. Insertion of peritoneal catheters Surgical Advantage: Catheter tip can be positioned Suitable for all types of catheter Essential in presence of adhesions Old PD catheter can be removed at same time Disadvantage: Requires surgical and theatre time General anaesthetic needed Larger incisions so increase risk of incisional hernia or fluid leak if catheter used early

9. Preoperative preparation for peritoneal catheter insertion This is identical for all modes of catheter insertion: Ensure that patient requires the catheter and that he/she understands the principles of catheter care. Obtain consent for the procedure. Patient should bath using an antiseptic soap, e.g. Hibiscrub . Discuss with patient where he/she would like the exit site placed. Avoid belt-line of trousers. Should be easily accessible for the patient to care for the exit site. The exit site should not be under an abdominal overhang in obese patients. Mark exit site with indelible ink with patient sitting.

10. Preoperative preparation for peritoneal catheter insertion Powerful aperient, e.g. Picolax , should be taken the night before catheter insertion to decrease risk of bowel perforation and eases placing of catheter intraperitoneally . Give prophylactic antibiotics approx 1 h before catheter insertion. The patient must empty their bladder immediately before catheter insertion (to avoid accidental bladder perforation). If general anaesthetic is to be used, patient should be starved and an ECG and CXR performed

11. Percutaneous Seldinger insertion technique This technique is simple to learn and can be done easily by physicians. Preoperative patient management Ensure the sheets on the bed are clean. The patient should be lying flat with one pillow. Tell the patient what will happen at each stage of the procedure. Give IV sedation SLOWLY, Scrub up and lay out catheter insertion set on trolley. Anaesthetize area 2- 3 cm below umbilicus (usually with lidocaine ) injecting down towards peritoneum. Make 2- 3 cm horizontal incision in midline Insert 16- 18 gauge introducing needle it is safest to use a needle with a plastic outer sheath, which can be advanced over the sharp inner needle; if in the peritoneum, the plastic sheath should be advanced very easily. The inner needle is then removed. This technique minimizes risk of bowel perforation.

12. Percutaneous Seldinger insertion technique Attach sterile giving set to the hub on the plastic sheath and run in approx 500 ml warm saline again this minimizes risk of bowel perforation. Advance guidewire through the introducing sheath. The wire should feed in very easily. If there is any resistance to inserting the guidewire , the technique should be abandoned. The most common cause for this is a loop of bowel loaded with faeces , or the existence of adhesions. Remove outer sheath over the wire. Use rigid dilator over guidewire to make a track for the catheter. Insert a larger dilator with a peel-away sheath over the guidewire trying to angle it down into the pelvis. Remove the guidewire and dilator together leaving the large sheath. Insert the catheter through the sheath, which is then peeled off.

13. Percutaneous Seldinger insertion technique Make sure that the first Dacron cuff is buried in the skin incision site. Make the exit site (the spot should be marked). It should be at least 3 cm from the site where the distal cuff will be in the subcutaneous tunnel to avoid subsequent extrusion of the cuff through the exit site. As small an incision as possible should be used to make the exit site to avoid fluid leakage and the need for sutures. Attach a tunnelling device to the catheter to create the subcutaneous tunnel and bring out the catheter. Attach a connector to the catheter, and then a short line to the connection device to enable dialysate bags to be attached. These actual devices will vary depending on the manufacture of the dialysate bags. Suture the original insertion site. Sutures are not needed, and should be avoided, at the exit site, as they increase the risk of early exit site infection.

14. Laparoscopic peritoneal dialysis catheter insertion Many centres are now inserting all PD catheters laparoscopically . Results are much better than with standard surgical insertion at laparotomy; complications are less and catheter survival is longer. A specially designed peritoneoscope or standard laparoscope can be used. The peritoneoscope is a small optical instrument (2.2-mm diameter) used to choose the optimal location within the peritoneum, while the catheter is being inserted percutaneously . Peritonesocopic insertion can be performed under local anaesthetic , can therefore be done by a physician, and does not require operating theatre time.

15. Complications of peritoneal dialysis catheter insertion Bladder perforation Diagnosis : Urine drains from catheter How to Avoid : Ensure that bladder is empty prior to catheter insertion Management : Re-site PD catheter Catheterize bladder for several days. Bowel perforation Diagnosis: Solid particles in PD effluent Abdominal pain with multiple Gram - ve organisms in PD fluid How to Avoid: Bowel evacuation prior to catheter insertion Run in 500 - 1000 ml fluid prior to catheter insertion if using a blind technique Avoid blind percutaneous technique if high risk of adhesions Do not persist with Percutaneous technique if there is resistance to advancing guidewire

16. Complications of peritoneal dialysis catheter insertion Management: Laparotomy to identify and repair perforation. It is often possible to leave the PD catheter in situ Appropriate antibiotics. Intraperitoneal bleed Diagnosis: Blood in PD effluent Change in patient's haemodynamic status depending on amount of blood loss How to avoid: Same as above as Blind percutaneous technique should not be used in patients known to have bleeding disorder. Management: Conservative management if haemodynamically stable Heparanize catheter to avoid its clotting If patient unstable, laparotomy required

17. Complications of peritoneal dialysis catheter insertion Fluid leak Diagnosis: Fluid draining from exit site How to avoid: Make all incisions as small as possible Limit volume of PD exchanges if using catheter early Management: Drain out PD fluid Avoid any further PD until exit site healed Exit site infection Diagnosis : Red exit site with or without pus How to avoid: Prophylactic antibiotics Managemen t: Appropriate antibiotics

18. Care of peritoneal catheter The exit site and related incisions should be cared for in the same manner as other fresh surgical wounds. After placement catheter the exit site should be covered by gauze bandages. The dressing should immobilize the catheter against the skin. Patient should be instructed to avoid catheter movement at the exit site as much as possible. Thrice weekly application of a povidene –iodine solution followed by dry gauze dressing reduce exi.t site infection

19. Catheter removal and replacement Acute catheter: Acute uncuffed catheter should be removed within 3 or 4 days of insertion. After the abdomen has been drained and the sutured removed and pulled out. Best peritoneum rest for a day before new insertion catheter. The replacement catheter should be inserted at least to 2-3 cm from the original site. Chronic catheter: Chronic catheter should be removed by surgical dissection.

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