Download Certification Review Course Peritoneal Dialysis Ray Agnello, BSN

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
 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
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

Peritoneal Membrane
 Semi-permeable
 Bi-directional
 Membrane size- 1-2 m2
 Vascular wall, interstitium,
mesothelium , and adjacent fluid
films
 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
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 6th Edition
Osmotic Pressure of Dextrose Solution
1.5 %
Solution
2.5 %
Solution
4.25 %
Solution
The Peritoneal Dialysis
Process


Definition- intra (within)
corporeal dialysis
Three Phases to the
Exchange process



Drain
Fill
Dwell
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
osmosis.
 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
Drain
Baxter®
Peritoneal Dialysis
Dialysis
occurs during the dwell phase
Diffusion:
solutes cross from area of greater
concentration to lesser one
-depends on concentration gradient
-enough peritoneal surface area
-size of fill volume
Ultra-filtration:
water removal due to
osmotic gradient between the hyperosmolar
PD fluid and the capillary bed
Kelley 2004
Historical Perspectives

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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 ?

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
education
PD Patient Selection
Inclusion Criteria Include
Patients who:
Choose the modality
Want “control”
Prefer home for dialysis
Have residual renal function
CVD, CHF
Geriatric
Pediatric
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
candidate.

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
healing.
Some units advocate insertion
months in advance.(burying the
catheter)
In most situations, PD access is
elective
Surgical Evaluation




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



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, 5th Edition. American Nephrology
Nurses’ Association
Peri Operative Routines
Anesthesia

Local infiltration with sedation

Intravenous propofol with
Monitored Anesthesia Care

General anesthesia
Insertion Techniques




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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
procedure
 Reduced bacterial colonization(?)
 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 1st reported use
in humans.
•1950’s-Nylon
catheters, polyethylene, plastic with
rounded tip & numerous tiny side holes
ANNA Core Curriculum 5th Ed
Catheter History



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
1960’s
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
Catheters
Straight
(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
Cuffs
 Single
 Double
 Elongated
 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, 5th Edition. American
Nephrology Nurses’ Association
Adaptors
 Plastic
 Titanium
PD Catheter Access Complication

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 2000mL. Upon draining,
the patient’s volume is 1500mL. 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, 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

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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
Remove
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
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
 Provide a quiet, relaxed atmosphere for
learning
 Identify patient’s learning style
 Individualized with respect to patient’s
expectations, cultural beliefs, and coping
abilities
 Length of training based on patient’s
clinical condition

O
N
Warming the Solution

Use warm, dry heat
At home- PD heating pad

NEVER MICROWAVE!!
Uneven heating of dextrose can create a
1st or 2nd degree burn to peritoneum
Leaching of plastics into dialysate can
Create a chemical peritonitis

NEVER MICROWAVE!!
Patients at risk for inadequate
dialysis
No residual renal function
 Low membrane permeability
 Large patients
 Patients not doing their
treatments

PD Equilibration Test
AKA: PET





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
High-average
Low-average
Low
Transporter
Waste
removal
Water
removal
Best type of
PD
High or Fast
Fast
Poor
Frequent exchanges,
short dwells – APD
Average
Okay
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?
 24 hour collection of dialysate and
urine

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
prescription

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
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:

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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, 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
Treatment:
 Culture exudate if possible
 Specific antibiotic protocol
 Oral or IV/IP antibiotics depending on extent of
infection
 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
peritonitis.

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
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

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
Peritonitis

Inflammation of the peritoneal cavity

Defined as the presence of WBC in the effluent
numbering 100 or greater & 50 polys (neutrophil) or
segs

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.
Peritonitis





Portals of Entry:
Transluminal- technique failure,
contamination
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
sampling
 Sample port is disinfected before
sampling
 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, 5th Edition. American Nephrology Nurses’
Association
Peritonitis

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.
Peritonitis


Organisms:
Gram positiveStaphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Enterococcus
Gram NegativePseudomonas
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, 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
monitored.
Hydrothorax: secondary to a pleuroperitoneal
communication.
PD Affects Drug Transport By:
Systemic drug removal via
effluent
 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
results
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
clearances
 Recurrent abdominal pain
 Intermittent nausea and vomiting
 Partial and/or complete bowel
obstruction
 Intervention – emergency laparotomy
Clinical Management Issues
for the PD Patient

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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

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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 ??