Transcript Pediatric Peritoneal Dialysis

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
1. 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:
1. Diverticulitis
2. Colitis
3. Peritoneal Dialysis
4. 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
Intraluminal
Periluminal
Nasal Carrier
Staphylococcus Epi
(Coagulase negative staph)
Intraluminal
Periluminal
Due to break in technique (touch
contamination)
Streptococcus
Intraluminal
Periluminal
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)
Intraluminal
Periluminal
Transmural
Found in nature, animal and
human intestinal tract
Hemophilus
Intraluminal
Periluminal
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
Intraluminal
Periluminal
Transmural
Found in soil, water and sewage.
Normal fecal flora
Pseudomonas
Intraluminal
Periluminal
Found in soil and water
Serratia
Intraluminal
Periluminal
Hospital acquired
Common Organisms
 Yeast:
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.
 Mycobacterium:
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
1. Solution must dwell in peritoneum for at least 4
hrs prior to sampling
2. Mix effluent well before sampling
3. Obtain sample aseptically Send a large volume
to lab > 50ml (for centrifuging and performing a
gram stain on sediment) preferable to send
whole bag
4. 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