Peritoneal dialysis Presented by Ray Agnello BSN, RN, CNN Renal Educator St. Joseph’s Medical Center
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 patient with PD
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 selfcare management v Patient must be followed by a licensed Peritoneal Dialysis unit
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 Kelley (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 Baxter®
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 manufactured 1980 s – New catheter designs 1987 – PET and tidal PD – Twardowski 1990 s – Alternative dialysate solutions, updated system designs
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 without 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. Social support system.
Surgical Evaluation n n Abdominal wall weakness or hernia Repair hernia preemptively or when symptomatic Previous abdominal surgeries Likelihood of adhesions Abdominal wall obesity
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.
Peri-Operative Routines Anesthesia n n n Local infiltration with sedation Intravenous propofol with MAC General anesthesia
Insertion Techniques n n Bedside-temporary catheters Laparoscopic placement Surgical dissection Buried catheter technique
Insertion Techniques Buried catheter: n Entire catheter placed in subcutaneous pocket for 4 to 6 weeks or longer, allowing cuff 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).
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
Steps to PD Catheter Access v Evaluation by nephrologist for PD catheter placement and identified as candidate. v Educated about catheter placement, and pre- and post-operative care routines. v Referred to surgeon for evaluation that includes determination of exit site, clinical and anesthesia work-up, contraindications, completion of consent forms, and scheduling of surgery.
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 lifestyle v. Patient states lack of interest in modality v. Multiple abdominal surgeries – adhesions v. Ostomies (increase risk of infection) v. Recurrent hernias
Catheter History • Early catheters were glass cannulas with straight or with mushroom ends. • 1920 s – Stainless steel coil with rubber drain first used in NYC (Rosenak) • 1940 s – Urinary catheters utilized • 1950 s – Nylon catheters at UCLA • 1960 s – Button catheters (Scribner, Boen)
Catheter History n 1964 – Slicon rubber catheters (Palmer, Quinton) n 1965 – Tenckhoff intermittent catheter n 1968 – Tenckhoff cuffed straight catheter n 1970 s – Single/double cuff coiled catheter n 1980 s – Swan neck configuration n 2000 s – T-shaped catheter (Ash) n. The future. . ?
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
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)
PD Catheter Access Complication Later Issues n n n 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
Post-Op v Follow v v up appointment with surgeon v Remove primary dressing in 5 to 7 days v Replace dressing with DSD Teach patient to secure catheter Flush catheter during training sessions Allow catheter to heal for 14 days or longer if possible Schedule training sessions
Post Operative Discharge Plan v. Pain medication/prescription v. Follow-up in PD unit within 48 to 72 hours of discharge v. Dressing intact for 5 to 7 days v. Reinforce dressing as needed v. Dressing changed by PD nurse v. Establish training schedule v. Bowel regimen Prevent Constipation v. No heavy lifting v. Written instructions v. Emergency phone numbers
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
ll RN 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
Patients At Risk for Inadequate Dialysis No residual renal function n Low membrane permeability n Large patients n
PD Equilibration Test n n n First developed by Z. Twardowski at the University of Missouri. A 4 -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
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
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
Infectious Complications
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. Frequency: Daily or 3 to 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. Keep catheter secured to abdomen with 2 inch tape. Daily showers with liquid soap. Mupirocin (Bactroban®) 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.
Exit Site Infection Teach patient to identify and report immediately to the PD Unit: n 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
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.
Exit Site Infection n n Signs and Symptoms: 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.
Responsible Organisms n Staphylococcus Aureus Pseudomonas species n Other gram-positive species n Serratia species n Other gram-negative organisms n Fungi n
Tunnel Infection Signs and Symptoms 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 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 Portals of Entry n Transluminal – Technique failure, contamination n Periluminal – Incomplete healing , leaking n Hematogenous – Bacteremia n Transmurl – Through the bowel wall n ANNA Core Curriculum
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.
Peritonitis n Defined as the presence of WBC in the effluent numbering 100 or greater. 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 Presentation n Signs and Symptoms: Fever, abdominal pain, nausea and vomiting, 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.
Prevention of Peritonitis n Careful individualized patient training n Adequate daily hygiene n Meticulous hand washing n On-going retraining
Peritonitis n Treatment protocols n Patient may be treated in PD Unit or Emergency Room depending on the 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 has had frequent infections requiring antibiotics. n PD Unit should have specific antibiotic protocols for gram-positive and gram-negative coverage.
Peritonitis Organisms n Gram-Positive: Staphylococcus epidermidis Staphylococcus aureus Streptococcus species Enterococcus Gram-Negative: Pseudomonas Klebsiella Escherichia coli Enterobacter Fungal Organisms
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
Membrane changes n Sclerosing, Encapsulating Peritonitis 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 and 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 fellow education CKD education for patients and families ADEMEX study-adequacy European APD Outcome Study (2003) Underutilization of Peritoneal Dialysis
Questions ?
![References Ash [Author: Need full reference] Flanigan, M. & Gokal, R. (2005). Peritoneal catheters](https://present5.com/presentation/b7a79b96ff043b46f5f79867f434f599/image-75.jpg "References Ash [Author: Need full reference] Flanigan, M. & Gokal, R. (2005). Peritoneal catheters")
References Ash [Author: Need full reference] Flanigan, M. & Gokal, R. (2005). Peritoneal catheters and exit site practices toward optimum peritoneal access: A review of current developments. Peritoneal Dialysis International, 25, 132 -139. Kelley, K. (2004) How peritoneal dialysis works. Nephrology Nursing Journal, 31(5), 481 -491. Palmer & Quinton {Author: Need full reference] Rosenak [Author: Need full reference] Scribner & Boen [Author: Need full reference]
Additional Readings Abu-Alfa, A. (2003) The Ademex Study: Expanding the Boundaries of peritoneal dialysis adequacy beyond small solute clearances. Dialysis and Transplantation, 32(3), 115 -124. American Nephrology Nurses’ Association (ANNA). (YEAR? ). Chronic kidney disease – What every nurse should know. Partnering for quality care. Retrieved May 31, 2007, from www. annalink. com American Nephrology Nurses’ Association (ANNA). (2006). Peritoneal dialysis. (2006) In Molzahn, A. E. , & Butera, E. (Eds. ). contemporary nephrology nursing: Principles and practice (2 nd ed. ) (pp. 629 -687). Pitman, NJ: Author. American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2003). Peritoneal dialysis nurse resource guide. Nephrology Nursing Journal, 30(5), 535. American Nephrology Nurses’ Association (ANNA) Peritoneal Dialysis Special Interest Group. (2004). A monograph on peritoneal dialysis. Nephrology Nursing Journal, 31(5). American Nephrology Nursing Association (ANNA) Peritoneal Dialysis Special Interest Group. (2005) The Peritoneal equilibration test. Nephrology Nursing Journal, 32(4), 452 -453. Bargman, J. (1995). Preventing hernias and leaks in long-term patients on peritoneal dialysis. Seminars in Dialysis. , 8(6), 370 -372.
Additional Readings kidney Babcock, D. E. , & Miller, M. A. (1994). Client education: Theory and practice. St. Louis, MO: Mosby. Bargman, J. (2000). Non-infectious complications of peritoneal dialysis. In R. Gokal, R. Khanna, R. Krediet, & K. Nolph (Eds. ), Textbook of peritonealdialysis (2 nd ed. ) (pp. 609 -646). London: Kluwer Academic Publishers. Bernardini, J. (2004). Peritoneal dialysis: Myths, barriers, and achieving optimum outcomes. Nephrology Nursing Journal, 31(5), 494 -498. Bernardini, J. , Bender, F. , Florio, T. , Sloand, J. , Palmmontalbano, L. , Fried, L. , et al. (2005). Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. Journal of American Society of Nephrologists. 16(2), 539 -545. Burkart, J. (2003). The Ademex Study and its implications for peritoneal dialysis adequacy. Seminars in Dialysis, 16(1), 1 -4. Burrows-Hudson, S. Chronic (2005) Nursing, 105(2), 40 -49. Crawford-Bonadio, T. , & Diaz-Buxo, J. (2004) Comparison of peritoneal dialysis solutions. Nephrology Nursing Journal, 31(5), 500 -513.
Additional Readings Dana, C. (2004). What is missing in making PD a success? Nephrology News and Issues, 18(9), 25 -28. Davies, S. J. , Woodrow, G. , Donovan, K. , Plum, J. , Williams, P. , Johansson, A. C. , et al (2003) Icodextrin improves the fluid status of peritoneal dialysis patients: Results of a double-blind randomized controlled trial. Journal of American Society of Nephrology, 14(9), 2338 -2344. De. Haan, B. (2003) Why peritoneal dialysis should be the first treatment option. Dialysis & Transplantation, 32(3), 160 -164. Diffusion. www 2. merriam-webster. com/mwmednl. Accessed 8/23/2007 Gokal, R. , Khanna, R. , Krediet, R. , & Nolph, K. (2000) Textbook of peritoneal dialysis (2 nd ed. ). London: Kluwer Academic Publishers. Gokal, R. (2002). What is the evidence that PD is underutilized as an ESRD therapy. Seminars in Dialysis, 15(3), 149 -150. Heaf, J. (2004). Underutilization of peritoneal dialysis. Journal of the American Medical Society, 291(6), 740 -742. Knowles, M. S. (1990). The adult leaner. A neglected species (4 th ed. ). Houston: Gulf Publishing.
Additional Readings Luongo, M. , & Kennedy, S. (2004) Interviewing prospective patients for peritoneal dialysis: A five-step approach Nephrology Nursing Journal, 31(5), 513 -520. Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues. Nephrology Nursing Journal, 31(5), 521 -532. Miller, D. , Mac. Donald, D. , Kolnack, K. , & Simek, T. (2004). Challenges for nephrology nurses in the management of children with chronic kidney disease. Nephrology Nursing Journal, 31(3), 287 -294. Mujais, S. , Nolph, K. , Gokal, R. , Blake, P, Burkart, J. , Coles, G. , et al. (2000). Evaluation and management of ultrafiltration problems in peritoneal dialysis. Peritoneal Dialysis International, 20(Suppl 4), S 5 -S 21. Oreopoulos, D. G. , Lobbedez, T. , & Gupta, S. (2004) Peritoneal dialysis: Where is it now and where is it going? International Journal of Artificial Organs, 27(2), 88 -94. Paniagua, R. , Amato, D. , Vonesh, E. , Correa-Rotter, R. , Ramos, A. , Moran, J. , et al. (2002). Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized controlled trial. Journal of American Society of Nephrology, 13(5), 1307 -1320. Piraino, B. (2005) Peritoneal Dialysis-Related inrections recommendations: 2005 Update. Peritoneal Dialysis International. Vol 25(2) 107 -131 Prasad, N. , & Gupta, A. (2005) Fungal peritonitis in peritoneal dialysis patients. Peritoneal Dialysis International, 25(3), 207 -222.
Additional Readings Pritchard, S. (2005). Will peritoneal dialysis be left behind? Seminars in Dialysis, 18(3), 167 -170. Prowant, B. (2001) Peritoneal dialysis. In L. E. Lancaster (Ed. ), ANNA core curriculum for nurses (4 th ed. ) (pp. 331 -375) Pitman, NJ: American Nephrology Nurses’ Association (ANNA). Prowant, B. , & Twardowski, Z. (1996) Recommendations for exit care. Peritoneal Dialysis International, 16(Suppl. 3), S 94 -S 99. Ramon, G. (1998). Hydrothorax in peritoneal dialysis. Peritoneal Dialysis International, 18(1), 5 -10. Robinson, K. (2001). Does pre-ESRD education make a difference? The patient’s perspective. Dialysis & Transplantation, 30(9), 571 -574. Rubin, H. R. , Fink, N. E. , Plantinga, L. C. , Sadler, J. H. , Kliger, A. S. , & Powe, N. R. (2004) Patient ratings of dialysis care with peritoneal dialysis vs. hemodialysis. Journal of the American Medical Society, 291(6), 697 -703. Salzer, W. (2005). Antimicrobial-resistant gram positive bacteria in PD peritonitis and the newer antibiotics used to treat them. Peritoneal Dialysis International, 25(4), 313 -319. Schatell, D. , Ellstrom-Calder, A. , Alt, P. S. , & Garland, J. S. (2003). Survey of CKD patients reveals significant gaps in knowledge about kidney disease. Nephrology News & Issues, 17(6), 17 -19. Sturdivant, R. , & Mc. Arthur, J. (2004). Eosinophilic peritonitis associated with atopy. Dialysis & Transplantation, 33(2), 97 -104. Twardowski, Z. J. , & Nichols, W. K. (2001). Peritoneal dialysis access and exit-site care including surgical aspects. Textbook of peritoneal dialysis (2 nd ed. ). London: Kluwer Academic Publishers. Twardowski, Z. (1987). Peritoneal equilibration test. Peritoneal Dialysis Bulletin, 7, 138 -147.
Additional Readings Van Dijk, C. , Ledesma, S. , & Teitelbaum, I. (2005). Patient characteristics associated with defects of the peritoneal cavity boundary. Peritoneal Dialysis International, 25(40), 367 -373. Von Biesen, W. (2002). Peritoneal dialysis in anuric patients: Concerns and cautions. Seminars in Dialysis, 15(5), 305 -310. Von Biesen, W. et al. (2004). Improving salt balance in peritoneal dialysis patients. Peritoneal Dialysis International, 25(Suppl 3), S 73 -S 75. Wingard, R. (2005). Patient education and the nursing process: Meeting the patient’s needs. Nephrology Nursing Journal, 31(3), 211 -214. Wolfson, M. (2002). A randomized controlled trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis. American Journal of Kidney Diseases, 40(5), 1055 -1065. Zorzanello, M. Fleming, W. , & Prowant, B. (2004). Use of tissue plasminogen activator in peritoneal dialysis catheters: a literature review and one center’s experience. Nephrology Nursing Journal, 31(5), 534 -537.
Скачать презентацию Peritoneal dialysis Presented by Ray Agnello BSN RN
b7a79b96ff043b46f5f79867f434f599.ppt