Certification Review Course Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph’s Regional Medical Center Paterson, New Jersey
Objectives 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 Adequacy Fluid Balance assessment of the PD patient.
Peritoneal Dialysis v Alternative to hemodialysis v Patient is taught to perform dialysis exchanges in the home setting v Focus is on patient autonomy and self care management v Patient must be followed by a licensed Peritoneal Dialysis unit & Nephrologist
Peritoneal Membrane Translucent Vascular membrane Two layers Parietal (inner surface of abdominal wall) Receives blood supply from the arteries of the abdominal wall 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 cavity Semi-permeable-acts as a Filter Kelley 2004
Anatomy and Physiology n Peritoneal Membrane n Semi-permeable n Bi-directional n Membrane size- 1 -2 m 2 n Vascular wall, interstitium, mesothelium , and adjacent fluid films n Closed in males n Women- ovaries and fallopian tubes open into the peritoneal cavity n Peritoneal cavity normally contains about 100 ml transudate
Kinetics of Peritoneal Dialysis n Diffusion n Osmosis n Ultrafiltration n Drug Transport
Diffusion Tea Bag = Peritoneal Membrane Water = PD Fluid Tea Leaves = Waste
Scheme of semi-permeable membrane: red = blood blue = PD fluid yellow = membrane . wikipedia. org/
Osmosis 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 6 th Edition
Osmotic Pressure of Dextrose Solution 1. 5 % Solution 2. 5 % Solution 4. 25 % Solution
The Peritoneal Dialysis Process n n Definition- intra (within) corporeal dialysis Three Phases to the Exchange process n n n Drain Fill Dwell
How Does PD Work? The semi-permeable peritoneal membrane lines the abdominal cavity and covers the abdominal viscera. v The membrane allows (via diffusion) the passage of toxins and electrolytes into the dialysis solution. v Ultra-filtration (removal of fluid) occurs via osmosis. v A “steady state” of toxin clearance and fluid management is achieved due to daily performance of dialysis. v K. Kelly , RN NNJ Sept-Oct 2004
How Does PD Work? v Dialysis solution is infused and drained via a catheter that is surgically placed in the peritoneal cavity. v The action of draining and infusing dialysis solution is called an exchange. v The frequency of exchanges and volume is determined by the presence of residual renal function and the individual membrane characteristic.
Infusion or Fill
Drain Baxter®
Peritoneal Dialysis n. Dialysis occurs during the dwell phase n. Diffusion: solutes cross from area of greater concentration to lesser one -depends on concentration gradient -enough peritoneal surface area -size of fill volume n. Ultra-filtration: water removal due to osmotic gradient between the hyperosmolar PD fluid and the capillary bed Kelley 2004
Historical Perspectives n n n n 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 th
Who Are the PD Patients ? v Choose PD as Renal Replacement Therapy v Hemodialysis Patient without Access v Failed allograft (transplanted kidney) v Have CHF or CVD which exempts them from hemodialysis v Often people with the benefit of CKD education
PD Patient Selection Inclusion Criteria Include Patients who: v. Choose the modality v. Want “control” v. Prefer home for dialysis v. Have residual renal function v. CVD, CHF v. Geriatric v. Pediatric v. Vascular Access Failure v. Social support system available
Selection Continued Exclusion Criteria Patients who: v. Have abdominal aortic aneurysm AAA (size dependent) v. Derm. disease of the abdominal wall v. Morbid abdominal obesity v. Altered mental status, poor coping styles v. Solitary life style v. Patient states lack of interest in modality v. Multiple abdominal surgeries- adhesions v. Ostomies (increase risk of infection) v. Recurrent hernias
Steps to PD Catheter Access v Evaluation by Nephrologist for PD catheter placement and identified as candidate. v Educated about catheter placement, pre and post operative care routines. v 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 n Some units advocate insertion 2 to 6 weeks prior to dialysis to optimize healing. Some units advocate insertion months in advance. (burying the catheter) In most situations, PD access is elective
Surgical Evaluation n n Abdominal wall weakness or hernia Repair hernia preemptively or when symptomatic Previous abdominal surgeries: multiple surgeries = increased likelihood of adhesions Abdominal wall obesity
Pre Catheter Insertion n 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
Question Evidence-based practice suggests which of the following upon PD catheter implantation? a. b. c. d. Large fill volumes immediately post-op No need to wear a mask while performing PD exchanges 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, 5 th Edition. American Nephrology Nurses’ Association
Peri Operative Routines Anesthesia n Local infiltration with sedation n Intravenous propofol with Monitored Anesthesia Care n General anesthesia
Insertion Techniques n n n Bedside-temporary catheters Laparoscopic placement Surgical dissection Buried Catheter technique Percutaneous placement per Interventional Radiology
Insertion Techniques Buried catheter: n Entire catheter placed in subcutaneous pocket for 4 -6 weeks or longer, allowing cuff & tunnel to heal n Exit site is externalized in a separate procedure n Reduced bacterial colonization(? ) n Do not have long term outcomes yet Flanigan, Gokal, 2005
Catheter History • Early catheters were glass cannulas with straight or with mushroom ends • 1920 -40’s: Various medical devices were used in the beginning of PD: needles, glass cannulas, sump drains, stainless steel coils, Foley catheters • 1923 -Ganter used a needle for the 1 st reported use in humans. • 1950’s-Nylon catheters, polyethylene, plastic with rounded tip & numerous tiny side holes ANNA Core Curriculum 5 th Ed
Catheter History n n n 1960’sq silicon rubber catheters, with coiled intraperitoneal segment (Palmer, Quinton) q Tenckhoff & Schechter published results with silicone elastomer (Silastic ®) for chronic dialysis with 2 Dacron ® polyester felt cuffs q 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 5 th Ed
Catheters n. Straight (single or double cuff) n. Coiled (single or double cuff ) n. Swan neck (single or double cuff) n. Pre sternal swan neck n. Toronto Western n. Missouri catheters n. Disc catheters
Cuffs n Single n Double n Elongated n Bead/flange configuration
Question… What is one advantage of implanting a cuffed PD catheter? a. b. c. d. 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, 5 th Edition. American Nephrology Nurses’ Association
Adaptors n Plastic n Titanium
PD Catheter Access Complication n Immediate/Early 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 peritonitis)
Question The patient’s fill volume is 2000 m. L. Upon draining, the patient’s volume is 1500 m. L. The nurse should assess the patient for which of the following? a. Peritonitis b. Catheter removal c. Constipation d. Subcutaneous tunnel infection Core curriculum for Nephrology Nursing, 5 th Edition. American Nephrology Nurses’ Association
PD Catheter Access Complication n Later Issues n 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 n n n n
Post Op v Follow up appointment with surgeon v Instructions (written & verbal) to patient, which include emergency contact numbers v Follow-up in PD unit within 48 to 72 hours of discharge v Pain medication/prescription v Reinforce v v dressing as needed Teach patient to secure catheter Flush catheter during training sessions
Post Operative Discharge Plan v. Remove primary dressing in 5 to 7 days by PD nurse v. Dressing changed by PD nurse v. Replace dressing with DSD, non-occlusive v. Establish training schedule v. Bowel regimen v. No heavy lifting v. Allow catheter to heal for 14 days or longer if possible before use Prevent Constipation
Peritoneal Dialysis Therapies n n n IPD (Intermittent Peritoneal Dialysis) CAPD (Continuous Ambulatory Peritoneal Dialysis ) CCPD (Continuous Cycling Peritoneal Dialysis) also known as APD (Automated Peritoneal Dialysis)
Training Sessions for the PD Patient Assess readiness to learn v Provide a quiet, relaxed atmosphere for learning v Identify patient’s learning style v Individualized with respect to patient’s expectations, cultural beliefs, and coping abilities v Length of training based on patient’s clinical condition v
N ll R a n. C O RN all C ON O N C
Warming the Solution n Use warm, dry heat At home- PD heating pad n NEVER MICROWAVE!! Uneven heating of dextrose can create a 1 st or 2 nd degree burn to peritoneum Leaching of plastics into dialysate can Create a chemical peritonitis n NEVER MICROWAVE!!
Patients at risk for inadequate dialysis No residual renal function n Low membrane permeability n Large patients n Patients not doing their treatments n
PD Equilibration Test AKA: PET n n n 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: High-average Low
Transporter Waste removal Water removal Best type of PD High or Fast Poor Frequent exchanges, short dwells – APD Average Okay CAPD or APD Low Slow Good CAPD, 5 evenly spaced exchanges – 1 exchange at night using a small machine. http: //www. homedialysis. org/files/pdf/resources/tom/200801. pdf
KT/V Test What is measured? n 24 hour collection of dialysate and urine n Serum values of BUN and Creatinine n 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? n The adequacy of the current prescription n Need for adjustments to insure appropriate dialysis prescription
Exit Site Care n n n Healthy exit site: surrounding skin natural, darkened, or light Pink; no drainage or crusting; visible sinus is dry Goal: prevent exit site infection and identify problems early ES Care: daily or 3 -4 times weekly; may be in conjunction with showering
Infection Prevention Exit Site Care: n n n 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
Question… Following peritoneal dialysis catheter implantation, a patient is instructed that: a. b. c. d. 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 possible Core curriculum for Nephrology Nursing, 5 th Edition. American Nephrology Nurses’ Association
Infectious Complications
Exit Site Infection n n Teach patient to identify and report immediately to the PD Unit: Redness, tenderness, edema, presence of exudate either at exit site or insertion site Treatment: n Culture exudate if possible n Specific antibiotic protocol n Oral or IV/IP antibiotics depending on extent of infection n Saline soaks/dressing changes for care of local cellulitis (unit/Nephrologist specific)
Exit Site Infection n n 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 n A chronic exit site infection can produce a systemic inflammatory response. n Inflammation can lead to poor nutrition, inadequate dialysis and possible antibiotic resistance. Vital role of Dietitian n Chronic exit site infections may result in peritonitis. n Multiple infections can lead to removal and replacement of catheter. n Consistent assessment and documentation is needed to appropriately track infections.
Responsible Organisms Staphylococcus Aureus n Pseudomonas species n Other Gram positive species n Serratia species n Other gram-negative organisms n Fungi n
Tunnel Infection S&S 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 leak external cuff extrusion Treatment- antibiotic therapy to prevent need for catheter removal
Prevention of Peritonitis n Careful individualized patient training n Adequate daily hygiene n Meticulous hand washing n On going retraining
Prevention of Peritonitis n Basics of Aseptic Technique: 5 min. hand scrub, face masks during exchanges, warming of PD bags using dry heat, aseptic technique for adding medicines n Aseptic technique when making critical connections to solution containers and the patient’s transfer set n Masks reduce the risk of contamination with nasopharyngeal organisms
Peritonitis n Inflammation of the peritoneal cavity n Defined as the presence of WBC in the effluent numbering 100 or greater & 50 polys (neutrophil) or segs n Effluent appears cloudy and milky. n Patient may have fever, chills, abdominal pain, nausea, vomiting and diarrhea. n Some present initially with cloudy fluid as the first sign and no symptoms. n Patient must be taught to contact their PD Nurse or Nephrologist immediately for cloudy effluent.
Peritonitis n n n Portals of Entry: Transluminal- technique failure, contamination Periluminal- incomplete healing , leaking Hematogenous- bacteremia Transmural- through the bowel wall ANNA Core Curriculum
Peritonitis Presentation n S & S: fever, abdominal pain, N & V, diarrhea, and cloudy effluent n Incubation: 24 -48 hours; if within 6 hours suspect an enteric source n Kinetic effects: increased solute removal and protein loss; increased glucose absorption leading to a decreased osmotic gradient and decreased ultrafiltration
Diagnosis of Peritonitis n Effective culture techniques: n Minimum sample volume of 50 -100 ml. Large samples reduce false negative results n Dialysate must be mixed well by inverting bag several times before sampling n Sample port is disinfected before sampling n Sample is obtained using aseptic technique
Question… 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, 5 th Edition. American Nephrology Nurses’ Association
Peritonitis n Treatment protocols n Patient may be treated in PD unit or Emergency Room depending on severity of symptoms and availability of resources. n Effluent is sent for cell count, C&S and gram stain n Fungal cultures should be included if patient is immunosuppressed or had frequent infections requiring antibiotics n PD Unit should have specific antibiotic protocols for gram positive and gram negative coverage.
Peritonitis n n Organisms: Gram positive. Staphylococcus epidermidis Staphylococcus aureus Streptococcus species Enterococcus Gram Negative. Pseudomonas Klebsiella Escherichia coli Enterobacter Fungal organisms
Question Catheter removal is recommended when the patient has peritonitis associated by which of the following organisms? a. b. c. d. Staph aureus Fungal Staph epi Pseudomonas Core curriculum for Nephrology Nursing, 5 th Edition. American Nephrology Nurses’ Association
Non Infectious Complications
Non Infectious Complications n n n 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 n n n 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 monitored. Hydrothorax: secondary to a pleuroperitoneal communication.
PD Affects Drug Transport By: Systemic drug removal via effluent n Drugs can be administered IP n Dose related to Urine output and mechanism for elimination of drug n
Non Infectious Complications n Catheter Adapter Disconnect or Fracture of Peritoneal Catheter. Stop Dialysis, obtain culture, replace or repair, prophylactic antibiotics pending culture results
Membrane changes n Sclerosing, Encapsulating Peritonitis: serious, yet rare, not exclusive to PD n A thick fibrous layer of tissue encapsulates the bowel n Membrane becomes thick and opaque n Onset gradual or rapid n Presentation n Decreased ultrafiltration and solute clearances n Recurrent abdominal pain n Intermittent nausea and vomiting n Partial and/or complete bowel obstruction n Intervention – emergency laparotomy
Clinical Management Issues for the PD Patient n n n n n Catheter insertion and Healing of exit site Prevention of infection Blood pressure control & Fluid management Nutrition evaluation and interventions Systems assessment Medication evaluation Anemia, Ca/Phos. /PTH management PET and initial Kt/V Coping with stress of chronic illness Transplantation
Current Issues in Peritoneal Dialysis n n n n Revision of K/DOQI Co-morbidities 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 ? ?
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