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8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
ASDIN Advanced Techniques Pre-course
Peritoneal Dialysis Catheter Placement
Feb. 24, 2012
New Orleans, La
Randall L. Rasmussen, MD
Special thank you to Drs. Rajeev Narayan, San
Antonio, Tx and Hemant Dhingra, Fresno Ca for
lending me slides from their teaching files to use
for this talk.
Peritoneal Dialysis Catheter Placement
Permanent CAPD catheters
Peritoneal Dialysis Catheter Placement
Four placement techniques:
• straight or arcuate inter-cuff segment
• two cuffs
– deep cuff that is implanted in
the rectus muscle
– superficial cuff that is positioned
two cm from the exit site
• variable length from the deep cuff to the
coil
• a coiled distal end
Peritoneal Dialysis Catheter Placement
Peritoneoscopic and fluoroscopic techniques
are favored by interventional doctors
- but placing these catheters requires a different skill
set than those interventional doctors are use to
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Peritoneoscopic
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Fluoroscopic
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Surgical
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Laparoscopic
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Blind technique - abandoned
Peritoneal Dialysis Catheter Placement
There are advantages to both the peritoneoscopic and
the fluoroscopic technique
- peritoneoscopic procedure offers visualization of
the peritoneal cavity which is important in
patients with a history of extensive surgery or
adhesions
- fluoroscopic placement is the least invasive
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
PrePre-procedure assessment
History
– meds, allergies, previous surgery
– regular bowel pattern and not constipated
Physical exam
Laboratory
– obesity, hernias
Peritoneal Dialysis Catheter Placement
Immediately prepre-procedure
document emptied bladder
mark the belt line with the patient sitting
start prophylactic antibiotics
– Cefazolin 1 gram IVPB
– Vancomycin 1 gram IVPB
– coagulation profile
Evaluation by CAPD nurse
– assess the patient’
patient’s ability to learn
Peritoneal Dialysis Catheter Placement
- demonstrated in workshops
Peritoneoscopic and fluoroscopic techniques both
require:
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abdominal ultrasound
incision to expose the anterior sheath on the
lateral border of the rectus muscle
gain entry into the peritoneal cavity
confirm entry into the peritoneal cavity
insert the catheter
check catheter function and close the incision
administer IV sedation
Both peritoneoscopic and fluoroscopic
techniques start with an abdominal US
Sub Q fat
Measure distance skin to rectus
Ant rectus sheath
Rectus muscle
Measure thickness of rectus
Post rectus sheath
Peritoneal cavity
Document free movement
Peritoneal Dialysis Catheter Placement
US is used to identify any major vascular structure
Peritoneoscopic and fluoroscopic techniques
The second step is an incision, ½ distance between the
ASIS and “normal location” of the umbilicus, to expose
the anterior sheath on the lateral border of the rectus
muscle.
Inferior epigastric artery arises from the external iliac artery and courses
cephalad along with the inferior epigastric vein between the posterior wall of
the rectus muscle and the posterior rectus sheath
The incision should be:
- off the belt line
- as long as it is deep
Expose an area the size of a half dollar (3 cm in diameter)
–> to get good visualization of the rectus sheath
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
Peritoneal Dialysis Catheter Placement
Peritoneoscopic and fluoroscopic techniques
The third step is to gain entry into the peritoneal space
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access to the peritoneal cavity can be visualized
with real time ultrasound
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need to avoid the pre-peritoneal space
• an incision is made to expose the anterior sheath
on the lateral border of the rectus muscle
• ligate or bovie any bleeders
Need to avoid the pre-peritoneal space
Need to avoid the pre-peritoneal space
Pre-peritoneal space
Posterior rectus sheath
Parietal peritoneum
Rectus muscle
Pre-peritoneal space
Parietal peritoneum
The pre-peritoneal space is the space between the
posterior rectus sheath and parietal peritoneum
Peritoneoscopic technique entrance to the peritoneal
cavity is done using a quill guide assembly set
The pre-peritoneal space is less likely to be entered if an
insertion site is selected above the level of the anterior
superior iliac spine.
Fluoroscopic technique(s) entrance to the peritoneal
cavity is done using a Veress needle
Veress needle
Quill guide assembly set
Quill guide, cannula & trocar are inserted through the
rectus at a 3030-450 angle directed towards the coccyx
Rectus muscle
Rectus
“Pops” can be felt when the Veress needle pierces the
anterior and posterior rectus sheath.
Note that saline will run freely once the peritoneal cavity
is entered.
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
Peritoneal Dialysis Catheter Placement
Peritoneoscopic and fluoroscopic techniques
The fourth step is to confirm peritoneal location
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using the peritoneosope the white-pink appearance
of the peritoneum can be directly visualized and
moves with respiration
a white appearance means pre-peritoneal location
both techniques can confirm the location by
performing a peritoneogram
a .035 guidewire that easily curls across the midline
is good evidence of intraperitoneal location
saline runs wide open
Peritoneogram with free
flow of contrast in the
peritoneum
.035 Guidewire easily
curls across the midline
with minimal resistance
Complications of peritoneoscopic and fluoroscopic
CAPD catheter insertion occur with entry into the
peritoneal cavity
Peritoneogram
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usually requires 10cc of ½ strength contrast
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contrast can be injected through the cannula during
the peritoneoscopic approach
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contrast can be injected through a sheath or dilator
inserted over a guidewire during the fluoroscopic
technique
Peritoneogram demonstrates
contrast trapped in the
pre-peritoneal space
.035 Guidewire in the
pre-peritoneal space
meets resistance and
does not cross the midline
Peritoneal Dialysis Catheter Placement
* perforation of bowel, bladder or a vessel
* can usually be taken care of with minimal adverse
outcomes as long as the complication is recognized.
* aspirate after gaining entry to the peritoneal cavity
for blood, urine or bowel contents
Interpret this peritoneogram done at
the time of CAPD catheter insertion.
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
Peritoneal Dialysis Catheter Placement
The fifth step is to insert the catheter
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in both techniques, a small volume of NS
is first instilled into the peritoneal cavity
Interpret this peritoneogram done at
the time of CAPD catheter insertion.
Abdel-Aal A K et al. AJR 2009;192:1085-1089
Peritoneoscopic technique
Peritoneal Dialysis Catheter Placement
Insufflation of the peritoneal cavity with room air
Peritoneoscopic technique
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the CAPD catheter is mounted on a lubricated
stylet for insertion
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the catheter is inserted over the quill guide into
the clear space
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note that during catheter insertion, the stylet
should be inserted the minimal distance into the
peritoneal cavity
Peritoneoscopy allows the quill guide assembly
to be advanced into a clear space under direct
visualization using the peritoneoscope.
Peritoneal Dialysis Catheter Placement
Peritoneoscopic technique
Quill guide
Dilate
Cath insertion
Peritoneal Dialysis Catheter Placement
Fluoroscopic techniques
Tunnel
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a peel-away sheath is advanced over a .035 guidewire
then the guidewire is removed
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the CAPD catheter is mounted on a lubricated stylet
for insertion
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the CAPD catheter is inserted into the peritoneal cavity
through the peel-away catheter
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
Fluoroscopic techniques
CAPD catheter uncoiling
through 16 Fr peel-away
sheath
Peritoneal Dialysis Catheter Placement
After insertion of the catheter into the peritoneal cavity:
the deep cuff is anchored in the rectus muscle using an
implanter device
a tunnel is created for the exit so that the catheter is
off the belt line and oriented lateral or inferiorinferior-lateral
the superficial cuff is positioned 2 cm from the exit
site
CAPD catheter in position,
with contrast freely flowing
Note the stylet location
Peritoneal Dialysis Catheter Placement
Peritoneal Dialysis Catheter Placement
Lastly, check the catheter function and close the incision
Head
Feet
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confirm catheter position by contrast injection
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check catheter function with 250 cc of dialysate
or NS flush
The deep cuff is implanted into the rectus muscle
prior to tunneling the catheter to the exit site
Peritoneal Dialysis Catheter Placement
Head
Feet
The catheter is oriented
inferior-lateral
Sutures
absorbable subcutaneous sutures are used to close
dead space only if it is “excessive”
excessive”
nonnon-absorbable sutures are used to close the skin
sutures are not usually placed at the exit site
PostPost-procedure checklist
is the coil center no more than 5 cm cranial to the top of the
symphysis pubis ?
is the angle of the intraperitoneal straight portion more than
15 degrees from the horizontal?
is the coil of the catheter in its natural shape (meaning that
no part appears to cross any other part)?
are there any kinks in the catheter?
was the deep cuff visible in the rectus?
is the angle of the catheter at the exit site horizontal or
downward (not upward)?
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
PostPost-procedure
the patient must have a followfollow-up appointment for
dressing change and flush
consider Rx stool softeners postoperatively and
analgesic medications that do not cause constipation
patients should expect minimal postpost-operative discomfort
and must be given instructions to call for any sign of
symptom that requires medical attention