Download PD Peritonitis - Renal Pharmacy Group

Peritoneal Dialysis
Julie Stinson
Specialist Nurse, Renal Community Team
University Hospitals of Leicester
Aims and Objectives
 To
give an overview of Peritoneal Dialysis
– how it works, therapy options
 To discuss the solutions used for PD
 To discuss the pharmacological
considerations in PD
Peritoneal Dialysis
 Introduced
late 1970’s
 Alternative treatment to Haemodialysis for
End-stage Renal failure
 Home therapy, self-managed by patient
 Uses patients own natural membrane –
the Peritoneum – for dialysis
What is Peritoneal Dialysis?
•Peritoneal Dialysis (PD)
utilises one of the
bodies natural
membranes
•Fluid flows through a
small plastic tube
(catheter) into the
peritoneal cavity
•Whilst the fluid is inside
the peritoneal cavity
dialysis takes place
Catheter
Peritoneal
cavity
•The fluid is changed
every few hours, this is
called an exchange
The Peritoneal Cavity
How peritoneal dialysis works
 Removal
of solutes by DIFFUSION
 Removal
of fluid by OSMOSIS
Peritoneal Dialysis
Diffusion
Movement of solutes from a strong solution to a weak solution
across a semi - permeable membrane
1
Blood
Membrane
Dialysate
2
1 - Red blood cell
2 - Bacteria
Sodium
Potassium
Chloride
Bicarbonate
Urea
Creatinine
Uric acid
Beta 2-m
Peritoneal Dialysis
Osmosis
Movement of water from an area of low solute
concentration to an area of high solute concentration.
Blood
Dialysis Solution
Water
Solute
Water
Solute
Suitable patients

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
Well motivated/ independent
Diabetic
Elderly
Patients with residual renal function
Needle phobic patients
Patients with cardiac disease
Have adequate storage space for fluids/
equipment
Contraindications for PD
 Chronic
back pain
 COPD
 Diverticular
disease
 Previous abdominal surgery
 Social circumstances -Lack of space at
home for supplies
 Inability to self- manage treatment:
physical or cognitive function
More advantages
 Less
dietary restrictions
 Treatment of choice for diabetics
 No needles involved!
Catheter
A flexible, silicone catheter is inserted into
the Peritoneal cavity usually
laproscopically (under local or general
anaesthetic)
Dacron cuffs secure in position in
peritoneum
Can be used after 2-4wks (post-operatively
if necessary)
Position of PD Catheter
Types of Peritoneal Dialysis
 CAPD
 APD
What is CAPD?
•CAPD stands for Continuous
Ambulatory Peritoneal Dialysis
•CAPD can be performed in
any clean and convenient
place
•The manual exchanges use
gravity to drain the used fluid
out of the peritoneal cavity and
replace it with fresh fluid
•Most CAPD patients need to
do 4 bag exchanges per day
CAPD
 Continuous Ambulatory
Peritoneal Dialysis
 Dialysis takes place whilst patient
continues normal daily activities
 Performed manually (usually) 4 times
every day
 1.5 – 2.5 litres of fluid per exchange
 Each exchange takes 30-40 minutes
Automated Peritoneal
Dialysis
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
Dialysis is performed by an automated machine and
exchanges are done at night while patient sleeps
Machine has 3 main functions:



Heats PD fluid to body temperature
Controls time of exchange and amount of fluid used
Monitors treatment (safety alarms)
APD
 Automated
Peritoneal Dialysis
 Performed every night
 Free from exchanges during the day
 Greater flexibility in volume and time of
exchanges
 Can be performed by a carer so possible
for for patients unable to self manage
Types of PD fluids
 Primarily
made up of glucose as this
provides the osmotic gradient required to
remove water
 Other constituents include
 Lactate/bicarbonate as a buffer
 Electrolytes i.e. sodium, calcium, etc
 Amino Acids/bicarbonate
 Varies from 1.5L to 3Litres
Types of PD Fluids
 Glucose
 Icodextrin
- Extraneal
 Amino acids - Nutrineal
 Bicarbonate - Physioneal
 (Baxter
Healthcare)
Glucose
 Traditional PD fluids are glucose based
and use Lactate as buffer Bioincompatible
 Glucose (as osmotic agent) in different
concentrations:
 1.36%, 2.27% 3.86%
 More glucose = more fluid removal
 High concentrations of glucose – 1.36%
bag = 75mmol/litre, 3.86% = 215mmol/l
 Constant
exposure to glucose can
damage Peritoneum in time
 Absorption of glucose leads to
hyperglycaemia in Diabetics, insulin
resistance, obesity
Extraneal
polymer, starch based fluid –
7.5% Icodextrin
 Allows better ultrafiltration
 Used once daily for longer dwell time (at
least 8 hours)
 Reduces glucose load, so maintains better
glycaemic control for diabetics; reduces
weight gain
 Glucose
Nutrineal
acid – 87mmol/litre
 One bag per day – at mealtime exchange
in CAPD, with o/night mix in APD
 Absorption rate 70-80% amino acids,
hence can use in malnourished pts
 1.1% Amino
Physioneal
Bicarbonate + Lactate as buffer –
Biocompatible
 Prolongs efficiency of peritoneum as
dialysis membrane
 Uses
PHARMACOLOGICAL
CONSIDERATIONS IN PD
Complications of PD (with
Pharmacy involvement)
 Peritonitis
 Exit
site and Tunnel infection
 Constipation
 Mechanical
 Treatment
protocols given are specific to
University Hospitals of Leicester
 Most PD units will have variations in
protocols! – Please refer to your local
policies
Constipation
Constipation can lead to PD catheter
problems- fluid will not drain out/in
 Important to take regular laxatives
 Usually Lactulose and Senna
 Some patients may need Sodium
Docusate
 Picolax if severe constipation
Blocked catheter caused by Fibrin
 May
require UROKINASE lock
 Urokinase
5000u in 5mls Saline - for 2
hour dwell into catheter
PD Peritonitis
 Inflammation
of peritoneum usually due to
infection
 Signs and symptoms: Cloudy PD fluid +/abdominal pain, ?fever, nausea, D and V
 Diagnosis based on symptoms of cloudy
fluid, pain
 Fluid will show > 100 white cells;
Identification of organisms on Gram stain
or subsequent culture of fluid
Treatment of peritonitis
Outpatient ‘APD regime’
 Gram positive - Bolus IP Vancomycin – 1-2gram
dependant on body weight
 Gram negative - oral Ciprofloxacin (500mg bd)
 No organism – both Vanc and Cipro
 Day 4 – vanc level checked; <15mg/ml=further
dose: Repeat at days 8 and 12
Inpatients regime
Gram positive organisms  IP Vancomycin 25mg/litre for 10days
Gram negative –
IP Gentamycin 5mg/litre
No growth – give both

Special considerations for Pseudomonas, fungal
Pseudomonas IP Gentamycin 7.5mg/l alternate bags +
Oral Ciprofloxacin 750mg bd
Continued for 4 weeks (weekly Gent levels)? Tube
removed if recurrent, non-resolving
peritonitis
Fungal – Tube removal
(Ref: UHL Policy – PD peritonitis diagnosis and treatment)
 Recurrent
peritonitis:
 Rifampicin 600mg once day for 4 weeks
 (weekly LFTs) + Urokinase flush
5000u/5mls on day 4 and 7/8
Exit Site and Tunnel infections
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Exit site
Commonly caused by skin commensals
Clinical signs of infection:swab taken; Instigate abx treatmentFlucloxacillin 500mg qds x 5days (as
appropriate) /Erythromicin 500mgs qds if
Penicillin sensitive
Gram positive organism -continue 7 days
Gram negative – Ciprofloxacin 500mg bd
x7days
)
 If
pt is Staph Aureus carrier, treated with
nasal and topical Mupiricin (Swab each
clinic visit
 (ref:
UHL policy: PD catheter ESI)
 Tunnel
infection
 Cause usually unresolved ESI.
 Inflammed tract under skin along tube
tunnel= erythema, tenderness
 Treated with IV Vancomycin 1g; likely
admission
 Tube removal if unresolved (r/v 48hrs)
THANK YOU!