Download #052 Biel

Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Objectives
Certification Review
Course
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
Peritoneal Dialysis
Laurie Biel, RN, BSN, CNN
Sunday, April 22, 2007
Dallas, TX
Non Infectious Complications
Adequacy
Fluid Balance assessment of the PD patient.
Peritoneal Membrane
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
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
1
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Diffusion
Tea Bag = Peritoneal Membrane
Water = PD Fluid
Scheme of semi-permeable membrane:
red = blood
Tea Leaves = Waste
blue = PD fluid
yellow = membrane
.wikipedia.org/
Osmotic Pressure of Dextrose Solution
Osmosis
1.5 %
Solution
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.
2.5 %
Solution
4.25 %
Solution
Miller-Keane 6th Edition
The Peritoneal Dialysis
Process


Definition- intra (within)
corporeal dialysis
Three Phases to the
Exchange process



Drain
Fill
Dwell
2
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
How Does PD Work?
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”
state” of toxin clearance and fluid
management is achieved due to daily
performance of dialysis.

K. Kelly , RN
NNJ Sept-Oct 2004
Peritoneal 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
water removal due to
osmotic gradient between the hyperosmolar
PD fluid and the capillary bed
Kelley 2004

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.
Baxter®
Baxter®
Ultra-filtration:
Dialysis solution is infused and drained via
a catheter that is surgically placed in the
peritoneal cavity.
Drain
Infusion or Fill
Dialysis

Historical Perspectives








Acute-Predominant use of PD prior to 1960’
1960’s
1966- Automated cycler
1967- Tenckhoff catheter
1975- CAPD
1978- Polyvinyl bags and -manufactured
1980’
1980’s- New catheter designs
1987- PET and tidal PD -Twardowski
-Twardowski
1990’
1990’s-Alternative dialysate solutions,
updated system designs
3
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Who Are the PD Patients ?
PD Patient Selection
Inclusion Criteria Include
Patients who:

Choose PD as Renal Replacement Therapy

Hemodialysis Patient without Access

Failed allograft (transplanted kidney)

Have CHF or CVD which exempts them
from hemodialysis
CVD, CHF
Often people without the benefit of CKD
education
Pediatric
Choose the modality

Want “control”
control”
Prefer home for dialysis
Have residual renal function
Geriatric
Social support system
Surgical Evaluation
Catheter Insertion
Surgical Evaluation





Abdominal wall weakness or hernia
Repair hernia preemptively or when
symptomatic
Previous abdominal surgeries
Likelihood of adhesions
Abdominal wall obesity



Peri Operative Routines
Anesthesia



Local infiltration with sedation.
Intravenous propofol with MAC.
General anesthesia.
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
Insertion Techniques




Bedside-temporary catheters
Laparoscopic placement
Surgical dissection
Buried Catheter technique
4
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Pre Catheter Insertion
Insertion Techniques
Buried catheter:
catheter:
 Entire catheter placed in
subcutaneous pocket for 4-6 weeks or
longer, allowing cuff to heal
 Exit site is externalized in a separate
procedure
 Reduced bacterial colonization(?)
 Do not have long term outcomes yet
Flanigan,
Flanigan, Gokal,
Gokal, 2005
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.
Catheter History
•Early
catheters were glass cannulas
with straight or with mushroom ends
•1920’
1920’s-stainless
steel coil with rubber
drain first used in NYC (Rosenak
(Rosenak))
•1940’
1940’s-urinary
•1950’
1950’s-nylon
catheters at UCLA
•1960’
1960’s-button
Boen)
Boen)
catheters utilized
catheters (Scribner,



Patient Education and consent signed
Examination of the patient’
patient’s abdomen
•
Avoid scars and fat folds
•
Avoid beltline
•
Mark the abdomen
Surgical prep
•
Empty bladder
•
Patient showers with disinfectant soap
•
Bowel prep
Selection Continued
Exclusion Criteria
Patients who:
Have abdominal aortic aneurysm AAA
(size dependent)
Derm.
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
Catheter History
1964-silicon
rubber catheters(Palmer,
Quinton)
1965-Tenckhoff
1965-Tenckhoff intermittent catheter
1968-Tenckhoff
1968-Tenckhoff cuffed straight catheter
1970’
1970’s-single/double cuff coiled catheter
1980’
1980’s-swan neck configuration
2000’
2000’s-t shaped catheter(Ash)
The future..?
5
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Catheters
(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
Straight
 Single
 Double
 Elongated
 Bead/flange
configuration
Adaptors
 Plastic
 Titanium
6
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
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)
PD Catheter Access Complication









Post Op
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
 Follow
up appointment with surgeon
primary dressing in 5 to 7
 Remove
days
 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
7
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Post Operative Discharge Plan
Pain medication/prescription
Follow-up in PD unit within
48 to 72 hours of discharge
Dressing intact for 5 to 7 days
Reinforce dressing as needed
Dressing changed by PD nurse
Establish training schedule
Bowel regimen Prevent Constipation
No heavy lifting
Written instructions
Emergency phone numbers
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’
patient’s learning style
 Individualized with respect to patient’
patient’s
expectations, cultural beliefs, and coping
abilities
 Length of training based on patient’
patient’s
clinical condition


RN
Call
On
RN
ON
Call
O
N
C
a
l
l
Warming the Solution

Use warm, dry heat
At home- PD heating pad

Patients at risk for inadequate
dialysis
NEVER MICROWAVE!!

Uneven heating of dextrose can create a
1st or 2nd degree burn to peritoneum

No residual renal function
Low membrane permeability
 Large patients
Leaching of plastics into dialysate can
Create a chemical peritonitis
8
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
PD Equilibration Test





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’
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
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’
unit’s protocols and
interpretation of K/DOQI guidelines
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
Infectious Complications



Healthy exit site: surrounding skin
natural, darkened, or lt. Pink; no
drainage or crusting; visible sinus is
dry
Goal: prevent exit site infection and
identify problems early
Frequency: daily or 3-4 times
weekly; may be in conjunction with
showering
9
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Infection Prevention
Exit Site Infection
Exit Site Care:






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
(Tegaderm ®)
A healed and non-infected exit site is crucial
to longevity on Peritoneal Dialysis


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
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.
Teach patient to identify and report
immediately to the PD Unit:
Redness, tenderness, edema, presence of
exudate either at exit site or insertion site
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
Tunnel Infection
Responsible Organisms
Staphylococcus Aureus
Pseudomonas species
 Other Gram positive species
 Serratia species
 Other gram-negative organisms
 Fungi


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
10
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Peritonitis
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’
patient’s transfer set

Masks reduce the risk of contamination
with nasopharyngeal organisms

Diagnosis of Peritonitis


ANNA Core Curriculum



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
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


Portals of Entry:
Transluminal- technique failure,
contamination
Periluminal- incomplete healing ,leaking
Hematogenous- bacteremia
Transmurl- through the bowel wall

Kinetic effects: increased solute removal and
protein loss; increased glucose absorption
leading to a decreased osmotic gradient and
decreased ultrafiltration

Defined as the presence of WBC in the
effluent numbering 100 or greater.

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.
Prevention of Peritonitis

Careful individualized patient training

Adequate daily hygiene

Meticulous hand washing

On going retraining
11
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Peritonitis

Peritonitis

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

Organisms:
Gram positive-

Treatment protocols

Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Enterococcus
Gram NegativePseudomonas
Klebsiella
Escherichia coli
Enterobacter
PD Unit should have specific antibiotic protocols for
gram positive and gram negative coverage.
Fungal organisms
Membrane changes
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

Clinical Management Issues
for the PD Patient
Current Issues in Peritoneal Dialysis












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
Sclerosing,
Sclerosing, Encapsulating Peritonitis
 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











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
12
Laurie Biel
CNN Review Course – Peritoneal Dialysis
4/22/07
Questions ??
13