Transcript Document

Certification Review
Peritoneal Dialysis
Ray Agnello, BSN, RN, CNN
Saint Joseph’s Regional Medical Center
Paterson, New Jersey
To provide attendees with a summarized
review of peritoneal dialysis
To highlight key points in the clinical care of
a PD patient
Catheter Placement
Care of Catheter
Infectious Complication
Non Infectious Complications
Fluid Balance assessment of the PD patient.
Peritoneal Dialysis
 Alternative
to hemodialysis
 Patient is taught to perform dialysis
exchanges in the home setting
 Focus is on patient autonomy and self
care management
 Patient must be followed by a licensed
Peritoneal Dialysis unit & Nephrologist
Peritoneal Membrane
Vascular membrane
Two layers
Parietal (inner surface of abdominal wall)
Receives blood supply from the arteries of the abdominal
Visceral (covers abdominal viscera)
Covers the abdominal organs
Blood is carried by the mesenteric and celiac arteries
Most vascular layer where most of the dialysis occurs
Envelope of space between layers called peritoneal
Semi-permeable-acts as a Filter
Kelley 2004
Anatomy and Physiology
Peritoneal Membrane
 Semi-permeable
 Bi-directional
 Membrane size- 1-2 m2
 Vascular wall, interstitium,
mesothelium , and adjacent fluid
 Closed in males
 Women- ovaries and fallopian tubes
open into the peritoneal cavity
 Peritoneal cavity normally contains
about 100 ml transudate
Kinetics of
Peritoneal Dialysis
 Diffusion
 Osmosis
 Ultrafiltration
 Drug
Tea Bag = Peritoneal Membrane
Water = PD Fluid
Tea Leaves = Waste
Scheme of semi-permeable membrane:
red = blood
blue = PD fluid
yellow = membrane
The diffusion of pure solvent across a
membrane in response to a
concentration gradient, usually from a
solution of lesser to one of greater
solute concentration.
Miller-Keane 6th Edition
Osmotic Pressure of Dextrose Solution
1.5 %
2.5 %
4.25 %
The Peritoneal Dialysis
Definition- intra (within)
corporeal dialysis
Three Phases to the
Exchange process
How Does PD Work?
The semi-permeable peritoneal membrane
lines the abdominal cavity and covers the
abdominal viscera.
 The membrane allows (via diffusion) the
passage of toxins and electrolytes into the
dialysis solution.
 Ultra-filtration (removal of fluid) occurs via
 A “steady state” of toxin clearance and fluid
management is achieved due to daily
performance of dialysis.
K. Kelly , RN
NNJ Sept-Oct 2004
How Does PD Work?
Dialysis solution is infused and drained via
a catheter that is surgically placed in the
peritoneal cavity.
The action of draining and infusing dialysis
solution is called an exchange.
The frequency of exchanges and volume is
determined by the presence of residual
renal function and the individual
membrane characteristic.
Infusion or Fill
Peritoneal Dialysis
occurs during the dwell phase
solutes cross from area of greater
concentration to lesser one
-depends on concentration gradient
-enough peritoneal surface area
-size of fill volume
water removal due to
osmotic gradient between the hyperosmolar
PD fluid and the capillary bed
Kelley 2004
Historical Perspectives
Acute-Predominant use of PD prior to 1960’s
1966- Automated cycler
1967- Tenckhoff catheter
1975- CAPD
1978- Polyvinyl bags and manufactured in the US
(prior PD fluid was available in glass bottles)
1980’s- New catheter designs
1987- PET and tidal PD -Twardowski
1990’s-Alternative dialysate solutions,
updated system designs
ANNA Core Curriculum 5 Ed
Who Are the PD Patients ?
Choose PD as Renal Replacement Therapy
Hemodialysis Patient without Access
Failed allograft (transplanted kidney)
Have CHF or CVD which exempts them
from hemodialysis
Often people with the benefit of CKD
PD Patient Selection
Inclusion Criteria Include
Patients who:
Choose the modality
Want “control”
Prefer home for dialysis
Have residual renal function
Vascular Access Failure
Social support system available
Selection Continued
Exclusion Criteria
Patients who:
Have abdominal aortic aneurysm AAA
(size dependent)
Derm. disease of the abdominal wall
Morbid abdominal obesity
Altered mental status, poor coping styles
Solitary life style
Patient states lack of interest in modality
Multiple abdominal surgeries- adhesions
Ostomies (increase risk of infection)
Recurrent hernias
Steps to PD Catheter Access
Evaluation by Nephrologist for PD
catheter placement and identified as
Educated about catheter placement, pre
and post operative care routines.
Referred to surgeon for evaluation that
includes determination of exit site,clinical
& anesthesia work-up, contraindications,
completion of consent forms and
scheduling of surgery.
Surgical Evaluation
Catheter Insertion
Some units advocate insertion 2 to 6
weeks prior to dialysis to optimize
Some units advocate insertion
months in advance.(burying the
In most situations, PD access is
Surgical Evaluation
Abdominal wall weakness or hernia
Repair hernia preemptively or when
Previous abdominal surgeries:
multiple surgeries = increased
likelihood of adhesions
Abdominal wall obesity
Pre Catheter Insertion
Patient Education and consent signed
Examination of the patient’s abdomen
Avoid scars and fat folds
Avoid beltline
Mark the abdomen
Surgical prep
Empty bladder
Patient showers with disinfectant soap
Bowel prep
Evidence-based practice suggests which of the
following upon PD catheter implantation?
Large fill volumes immediately post-op
No need to wear a mask while performing PD
Incision site to be exposed to air during
immediate post-op period
Administration of prophylactic IV antibiotics
prior to catheter implantation to reduce the risk
of peritonitis
Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology
Nurses’ Association
Peri Operative Routines
Local infiltration with sedation
Intravenous propofol with
Monitored Anesthesia Care
General anesthesia
Insertion Techniques
Bedside-temporary catheters
Laparoscopic placement
Surgical dissection
Buried Catheter technique
Percutaneous placement per
Interventional Radiology
Insertion Techniques
Buried catheter:
 Entire catheter placed in
subcutaneous pocket for 4-6 weeks or
longer, allowing cuff & tunnel to heal
 Exit site is externalized in a separate
 Reduced bacterial colonization(?)
 Do not have long term outcomes yet
Flanigan, Gokal, 2005
Catheter History
catheters were glass cannulas with straight
or with mushroom ends
Various medical devices were used in
the beginning of PD: needles, glass cannulas, sump
drains, stainless steel coils, Foley catheters
used a needle for the 1st reported use
in humans.
catheters, polyethylene, plastic with
rounded tip & numerous tiny side holes
ANNA Core Curriculum 5th Ed
Catheter History
silicon rubber catheters, with coiled intraperitoneal
segment (Palmer, Quinton)
Tenckhoff & Schechter published results with silicone
elastomer (Silastic ®) for chronic dialysis with 2 Dacron ®
polyester felt cuffs
1968-Tenckhoff cuffed straight catheter
1970’s-single/double cuff coiled catheter; Toronto Western
with 3 silicone disc
1980’s-swan neck configuration ( bent or curved SQ segment;
Toronto Western with 2 silicone disc
1990’s-t shaped catheter (Ash); Moncrief & Popovich
technique for leaving the exterior segment buried SQ for 4 wk
The future..?
ANNA Core Curriculum 5th Ed
(single or double cuff)
Coiled (single or double cuff )
Swan neck (single or double cuff)
Pre sternal swan neck
Toronto Western
Missouri catheters
Disc catheters
 Single
 Double
 Elongated
 Bead/flange
What is one advantage of implanting a
cuffed PD catheter?
Acts as a barrier to prevent infection
Can only be used for CAPD
Ensures optimal adequacy
Can be implanted at the bedside
Core curriculum for Nephrology Nursing, 5th Edition. American
Nephrology Nurses’ Association
 Plastic
 Titanium
PD Catheter Access Complication
Bloody effluent
Pain with infusion
Leak at exit site
Exit site infection
Migration of catheter tip
Poor fill or drain, with or without pain
Non-infectious cloudy effluent
(lymphatic leak or eosinophilic
The patient’s fill volume is 2000mL. Upon draining,
the patient’s volume is 1500mL. The nurse
should assess the patient for which of the
a. Peritonitis
b. Catheter removal
c. Constipation
d. Subcutaneous tunnel infection
Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology
Nurses’ Association
PD Catheter Access Complication
Later Issues
Exit site leaks or subcutaneous leaks
Pleural communications
Excessive granulation tissue
Chronic site or tunnel infection
Cuff extrusion
Cracked, brittle catheter
Repetitive episodes of peritonitis
Bowel perforations
Post Op
Follow up appointment with surgeon
 Instructions (written & verbal) to patient,
which include emergency contact numbers
Follow-up in PD unit within
48 to 72 hours of discharge
Pain medication/prescription
Reinforce dressing as needed
 Teach patient to secure catheter
 Flush catheter during training sessions
Post Operative Discharge Plan
primary dressing in 5 to 7 days by
PD nurse
Dressing changed by PD nurse
Replace dressing with DSD, non-occlusive
Establish training schedule
Bowel regimen
No heavy lifting
Allow catheter to heal for 14 days or
longer if possible before use
Prevent Constipation
Peritoneal Dialysis Therapies
IPD (Intermittent Peritoneal
CAPD (Continuous Ambulatory
Peritoneal Dialysis )
CCPD (Continuous Cycling
Peritoneal Dialysis) also known as
APD (Automated Peritoneal
Training Sessions for the PD Patient
Assess readiness to learn
 Provide a quiet, relaxed atmosphere for
 Identify patient’s learning style
 Individualized with respect to patient’s
expectations, cultural beliefs, and coping
 Length of training based on patient’s
clinical condition
Warming the Solution
Use warm, dry heat
At home- PD heating pad
Uneven heating of dextrose can create a
1st or 2nd degree burn to peritoneum
Leaching of plastics into dialysate can
Create a chemical peritonitis
Patients at risk for inadequate
No residual renal function
 Low membrane permeability
 Large patients
 Patients not doing their
PD Equilibration Test
First developed by Z. Twardowski at the
University of Missouri
A four hour study that assesses
membrane transport characteristics.
Assessment of membrane function allows
for accurate prescription planning.
Usually completed within the first six
weeks of initiating PD
Repeated per each unit’s protocol
PD Equilibration Test continued
What does this tell us?
The results indicate the following
transport states:
Best type of
High or Fast
Frequent exchanges,
short dwells – APD
CAPD, 5 evenly
spaced exchanges – 1
exchange at night
using a small
KT/V Test
What is measured?
 24 hour collection of dialysate and
Serum values of BUN and Creatinine
Frequency of test is determined by
each unit’s protocols and
interpretation of K/DOQI guidelines.
(Unit specific, usually quarterly or biannually)
KT/V Test continued
What does it tell us?
 The adequacy of the current
Need for adjustments to insure
appropriate dialysis prescription
Exit Site Care
Healthy exit site: surrounding skin
natural, darkened, or light Pink; no
drainage or crusting; visible sinus is
Goal: prevent exit site infection and
identify problems early
ES Care: daily or 3-4 times weekly;
may be in conjunction with
Infection Prevention
Exit Site Care:
No dressing needed for established catheter
exit site (unit or pt specific)
Keep catheter secured to abdomen with 2
inch tape
Daily showers with liquid soap
Mupirocin (Bactroban ®) or Gentamycin
Cream at exit site of known staph. Carrier
Inpatients-dry dressing to protect site,
cleaned with soap and water, No occlusive
membrane dressings (Tegaderm ®)
A healed and non-infected exit site is crucial
to longevity on Peritoneal Dialysis
Following peritoneal dialysis catheter implantation,
a patient is instructed that:
The exit will always be tender
Baggy clothes will have to be worn
The catheter will need to be changed monthly
Well-healed healthy exit-sites make swimming
Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology
Nurses’ Association
Infectious Complications
Exit Site Infection
Teach patient to identify and report
immediately to the PD Unit:
Redness, tenderness, edema, presence of
exudate either at exit site or insertion site
 Culture exudate if possible
 Specific antibiotic protocol
 Oral or IV/IP antibiotics depending on extent of
 Saline soaks/dressing changes for care of local
cellulitis (unit/Nephrologist specific)
Exit Site Infection
S & S : redness, swelling, tenderness or pain
and purulent drainage
Risk Factors: poor catheter healing, sutures
at the exit site, trauma to the exit site, cuff
extrusion and improper catheter care
Diagnosis: Observation and culture
Treatment: Antibiotics, IP,PO, or IV;
vigilant daily exit site care
Exit Site Infection
A chronic exit site infection can produce a
systemic inflammatory response.
Inflammation can lead to poor nutrition,
inadequate dialysis and possible antibiotic
resistance. Vital role of Dietitian
Chronic exit site infections may result in
Multiple infections can lead to removal and
replacement of catheter.
Consistent assessment and documentation
is needed to appropriately track infections.
Responsible Organisms
Staphylococcus Aureus
 Pseudomonas species
 Other Gram positive species
 Serratia species
 Other gram-negative organisms
 Fungi
Tunnel Infection
erythema over the tunnel
pain and tenderness
drainage from exit site –no other signs of
an infection
Risk factors
exit-site infection
exit site trauma
external cuff extrusion
Treatment- antibiotic therapy to prevent
need for catheter removal
Prevention of Peritonitis
Careful individualized patient training
Adequate daily hygiene
Meticulous hand washing
On going retraining
Prevention of Peritonitis
Basics of Aseptic Technique: 5 min. hand
scrub, face masks during exchanges,
warming of PD bags using dry heat,
aseptic technique for adding medicines
Aseptic technique when making critical
connections to solution containers and the
patient’s transfer set
Masks reduce the risk of contamination
with nasopharyngeal organisms
Inflammation of the peritoneal cavity
Defined as the presence of WBC in the effluent
numbering 100 or greater & 50 polys (neutrophil) or
Effluent appears cloudy and milky.
Patient may have fever, chills, abdominal pain,
nausea, vomiting and diarrhea.
Some present initially with cloudy fluid as the first
sign and no symptoms.
Patient must be taught to contact their PD Nurse or
Nephrologist immediately for cloudy effluent.
Portals of Entry:
Transluminal- technique failure,
Periluminal- incomplete healing ,leaking
Hematogenous- bacteremia
Transmural- through the bowel wall
ANNA Core Curriculum
Peritonitis Presentation
S & S: fever, abdominal pain, N & V, diarrhea,
and cloudy effluent
Incubation: 24-48 hours; if within 6 hours
suspect an enteric source
Kinetic effects: increased solute removal and
protein loss; increased glucose absorption
leading to a decreased osmotic gradient and
decreased ultrafiltration
Diagnosis of Peritonitis
Effective culture techniques:
 Minimum sample volume of 50-100
ml. Large samples reduce false
negative results
 Dialysate must be mixed well by
inverting bag several times before
 Sample port is disinfected before
 Sample is obtained using aseptic
A PD effluent cell count differential can determine if
peritonitis is present when there is an elevation in ?
a. eosinophils
b. neutrophils
c. lymphocytes
d. granulocytes
Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology Nurses’
Treatment protocols
Patient may be treated in PD unit or Emergency
Room depending on severity of symptoms and
availability of resources.
Effluent is sent for cell count, C&S and gram stain
Fungal cultures should be included if patient is
immunosuppressed or had had frequent infections
requiring antibiotics
PD Unit should have specific antibiotic protocols for
gram positive and gram negative coverage.
Gram positiveStaphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Gram NegativePseudomonas
Escherichia coli
Fungal organisms
Catheter removal is recommended when the
patient has peritonitis associated by which of
the following organisms?
Staph aureus
Staph epi
Core curriculum for Nephrology Nursing, 5th Edition. American Nephrology
Nurses’ Association
Non Infectious Complications
Non Infectious Complications
Pericatheter and Subcutaneous Leaks
Peritoneal Catheter Obstruction: most
commonly early, yet can occur at any time.
Hernia: significant abdominal wall hernias
should be surgically repaired prior to initiation
of PD. Enlargement may occur due to
increased abdominal wall pressure.
Non Infectious Complications
Pneumoperitoneum (Shoulder Pain): usually
resulting from air infusion
Hemoperitoneum: blood loss into the peritoneal
cavity. A few drops of blood will produce
grossly bloody effluent. Most common in
women in menses. Any bleeding needs to be
Hydrothorax: secondary to a pleuroperitoneal
PD Affects Drug Transport By:
Systemic drug removal via
 Drugs can be administered IP
 Dose related to Urine output
and mechanism for elimination
of drug
Non Infectious Complications
Catheter Adapter Disconnect or Fracture
of Peritoneal Catheter. Stop Dialysis,
obtain culture, replace or repair,
prophylactic antibiotics pending culture
Membrane changes
Sclerosing, Encapsulating Peritonitis:
serious, yet rare, not exclusive to PD
 A thick fibrous layer of tissue
encapsulates the bowel
 Membrane becomes thick and opaque
 Onset gradual or rapid
 Presentation
 Decreased ultrafiltration and solute
 Recurrent abdominal pain
 Intermittent nausea and vomiting
 Partial and/or complete bowel
 Intervention – emergency laparotomy
Clinical Management Issues
for the PD Patient
Catheter insertion and Healing of exit site
Prevention of infection
Blood pressure control & Fluid
Nutrition evaluation and interventions
Systems assessment
Medication evaluation
Anemia,Ca/Phos./PTH management
PET and initial Kt/V
Coping with stress of chronic illness
Current Issues in Peritoneal Dialysis
Revision of K/DOQI
Role of sodium
Volume Control
Blood pressure control
Utilization of Icodextrin
Role of inflammation
Integrated dialysis care
Improving nephrology fellow education
CKD education for patients and families
ADEMEX study-adequacy
European APD Outcome Study (2003)
Underutilization of Peritoneal Dialysis
Final Note
The success of PD can be attributed to the
combined efforts of researchers, individuals on
PD, and healthcare professionals who, in
collaboration with the industrial community,
have realized the potential benefits of the
treatment. Despite a slow start in comparison
to HD, PD has evolved into a modality that
equals HD in long term outcomes.
Contemporary Nephrology Nursing p 633
Questions ??