Complications of Peritoneal Dialysis, by Dr. Sharon Su.
Introduction.
Hello, my name is Doctor Sharon Su, I'm a Pediatric Nephrologist.
Today I'm going to talk to you about peritoneal dialysis.
Dialysis Catheters.
One question that often comes up is, "When can you use a dialysis catheter?"
This depends on the situation of the patient.
If it is acute peritoneal dialysis, the reason you put in the catheter is because you need
to start dialysis immediately.
However, if it's chronic, as in it's planned, for a patient that is reaching end-stage renal
disease or currently has a vascular catheter for hemodialysis but will be transitioning
to peritoneal dialysis, then you have a little bit more time.
If you're going to use the catheter or to perform peritoneal dialysis immediately, it's
very important to just start with very slow or small fill volumes.
That way you will reduce the chance of leakage.
Ideally, if you do have time to wait, you'll want the site to heal well and seal off from
leakage.
So if you put it in a catheter and you can wait, because you have other forms of renal
replacement therapy, such as hemodialysis, then I would recommend waiting two to four
weeks before starting peritoneal dialysis.
Another thing to consider is that there are different types of catheters.
In general, for chronic peritoneal dialysis, catheters that are cuffed, as well as swan
neck-- which means they curl up at the end so that they reduce the risk of touching other
organs and causing blockage-- those theoretically reduce the risk of infection.
They are used for patients who will be on chronic peritoneal dialysis.
Cuffed catheters are also tunneled.
So they're tunneled through different layers of the skin from the epidermis to the sub-Q
layers, and then into the abdominal cavity.
So those are made so that the risk of infection is less.
They have to be removed in the OR because they are tunneled and cuffed.
So you can't just cut the stitches and pull it out.
Simple straight catheters that are not cuffed are easily placed and also easily removed.
But these have a higher chance of leakage.
If a patient has a G-tube that's been in place and well-healed and sealed, one can put in
a peritoneal dialysis catheter and there should be no problems.
Or, sometimes, a G-tube is placed at the same time as a peritoneal dialysis catheter.
In that case, one should be pretty careful in how much fill volume you're going to fill
into the peritoneal cavity.
Complications with Peritoneal Dialysis.
Peritonitis is a major complication of peritoneal dialysis.
50% of the organisms come from Gram-positive such as Staph aureus, Staph epidermis, Streptococcus
or Enterococcus.
15% come from Gram-negative organisms, such as Pseudomonas, Anaerobes, or E. coli.
Others have polymicrobial, so a component of both Gram-positive and Gram-negative.
This accounts for 4%.
And less than 2% are caused by fungal.
What are the signs and symptoms of peritonitis?
This includes fever greater than 38 degrees Celsius, abdominal pain, nausea and vomiting,
cloudy effluent, increased fibrin, and slow or difficult flow of dialysis fluid, whether
this is filling or draining.
Diagnosing peritonitis includes identifying the cloudy effluent, fever greater than 38
degrees Celsius, a cell differential count where the WBC is greater than 100, and 50%
of the white cells are neutrophils.
A positive gram stain can also help you diagnose peritonitis, as well as positive cultures
from the peritoneal dialysis fluid.
The wonderful thing about peritoneal dialysis is that you can treat the peritonitis by giving
or adding the antibiotic right into the peritoneal dialysis fluid.
So you do not need to give systemic antibiotics.
In fact, getting it into the peritoneal dialysis fluid is more efficacious, as it hits the
source of the infection.
There are many antibiotics that can be added into the peritoneal dialysis bag.
This would be dependent on the institution, what you have available.
And there are different doses that are recommended.
There are loading doses as well as maintenance doses.
If you look at this table, there is a list of the medications such as cefazolin, cefepine,
ceftazidime, as well as gentomicin, vancomycin, ciprofloxicin, fluconazole.
For the latest update on antibiotic doses, see ISPD guidelines and recommendations.
In general, the loading dose you want to leave in for about three hours.
And then you change the dose to a maintenance dose, which means you change the dialysis
fluid bag, and you add in a different concentration of antibiotic.
Usually, treatment doses, you want to do about two-hour cycles.
And you want to do this around the clock.
So continuous dialysis until you notice that the drain fluid is clear.
Generally, you treat for 14 days.
You can do shorter cycles.
Again, if you do more exchanges, the idea is you flush out the organisms.
So you do not have to do two-hour cycles.
You can do one-hour cycles.
However, this may be more labor intensive, as then you have to continue to add antibiotics
to your dialysis bags.
Another complication is leakage of peritoneal dialysis fluid.
This causes many problems such as infection, not just for peritonitis, but as well as cellulitis,
as well as poor efficacy of dialysis.
Dialysis fluid is caustic to the skin because it includes electrolytes, and the leakage
can irritate the exit site.
Furthermore, the dextrose is a perfect energy source for organisms like bacteria.
And so leakage places a high risk for developing infections.
Manage the leakage by decreasing the fill volume.
Sometimes, you may have to stop dialysis, and allow the area to heal, and then start
again at a lower fill volume.
A third complication is decreased ultrafiltration.
This can occur if the catheter is blocked by such thing as blood, fibrin, sticking to
the omentum, the bowel, the bladder, or the liver-- basically any organ.
Catheters may be blocked if you drain too long and dry out the patient.
That is why, usually, the drain time is about 10 minutes.
It is good to leave a little bit of fluid in the peritoneal cavity, and so that the
catheter is more freely floating and not sitting there and have access to other organs.
The way to remove the blockage is to flush the catheter.
It's best to flush and not aspirate or pull back-- better to just flush into the peritoneal
cavity.
It's very important that you do this with sterile technique, and you can flush with
10 to 20 milliliters of normal saline.
I would recommend at least two flushes.
Sometimes you can reposition the patient to try to move the catheter from whatever organ
it's touching.
And you can also get an abdominal x-ray to check the location of the catheter.
A fourth complication is the presence of fibrin in the effluent.
And this can occur from bleeding, and this often occurs when the catheter is initially
placed.
To remove the fibrin you can flush the catheter.
Again, same method as managing the blockage.
You can also flush through increasing the cycles.
So you flush the entire tubing set and the catheter.
And finally, as long as the patient is not at high risk for bleeding, you can add heparin
into the dialysate.
In general, this does not lead to systemic anti-coagulation.
Recommended doses of adding heparin into the dialysate is about 250 units per liter or
500 units per liter.
This concludes the video on complications of peritoneal dialysis.
Thank you.
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