THE CHOICE OF DIALYSIS ACCES THE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCE CONTROVERSY AND EVIDENCE PART 3 : Peritoneal Dialysis PART 3 : Peritoneal

THE CHOICE OF DIALYSIS ACCESTHE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCECONTROVERSY AND EVIDENCE

PART 3 : Peritoneal DialysisPART 3 : Peritoneal Dialysis

Teaching pointTeaching point

EBM ?EBM ?

What’s new ?What’s new ?

CONTROVERSY ?CONTROVERSY ?

EXPERT BASEDEXPERT BASEDGUIDELINESGUIDELINES

Guidelines by an ad hoc European Guidelines by an ad hoc European committe on elective chronic committe on elective chronic peritoneal dialysis in pediatric peritoneal dialysis in pediatric patientspatients

A.A. Watson, on behalve of the European pediatric dialysis Watson, on behalve of the European pediatric dialysis working groupworking group

– Comprehensive pediatric nephrology Comprehensive pediatric nephrology Geary SchaeferGeary Schaefer

CONTROVERSYCONTROVERSY

PRE-DIALYSIS INORMATION PRE-DIALYSIS INORMATION

>POST DIALYSIS FOLLOW UP>POST DIALYSIS FOLLOW UP

>PERI- OPERATIVE CARE>PERI- OPERATIVE CARE

> SURGEON> SURGEON

> CATHETER> CATHETER

CHOICE OF CATHETERCHOICE OF CATHETER

CathetersCatheters LengthLength Length between cuff’sLength between cuff’s

Place left / right fossaPlace left / right fossa Swan neck / straightSwan neck / straight Straight / CurrlStraight / Currl

CONTROVERSYCONTROVERSY

PRE-DIALYSIS INORMATIONPRE-DIALYSIS INORMATION

>POST DIALYS FOLLOW UP>POST DIALYS FOLLOW UP

>PERI- OPERATIVE CARE>PERI- OPERATIVE CARE

> SURGEON> SURGEON

> CATHETER> CATHETER

Preparation of the patient and the Preparation of the patient and the familyfamily

1) It is essential that the child and family are 1) It is essential that the child and family are prepared by a pediatric nurse experienced prepared by a pediatric nurse experienced in chronic peritoneal dialysis with access in chronic peritoneal dialysis with access to appropriate written information and to appropriate written information and other teaching aids such as dolls or videos.other teaching aids such as dolls or videos.

2) If the child has phobias then a child 2) If the child has phobias then a child psychologist should be consultedpsychologist should be consulted

3) Home visit / School visit3) Home visit / School visit

4) Contact with other child /parents4) Contact with other child /parents

A nutritional assessmentA nutritional assessment will be required for all dialysis will be required for all dialysis patients. If nutritional support is required then the patients. If nutritional support is required then the appropriate route for supplementation (oral. appropriate route for supplementation (oral. Nasogastric or gastrostomy) should ho discussed Nasogastric or gastrostomy) should ho discussed with the pediatric renal dietitian and team members.with the pediatric renal dietitian and team members.

If it is appropriate to consider a gastrostomy then this If it is appropriate to consider a gastrostomy then this can be placed at the time of the PD catheter under can be placed at the time of the PD catheter under the same anaesthesie with minimal additional the same anaesthesie with minimal additional morbidity.morbidity.

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Preparation of the patient and the Preparation of the patient and the familyfamily

Use of Catheter and Surgical Use of Catheter and Surgical ProcedureProcedure

1)1) The placement of a peritoneal dialysis The placement of a peritoneal dialysis catheter requires catheter requires an experienced an experienced surgeonsurgeon and should be given appropriate and should be given appropriate priority, priority,

2)2) A dialysis-catheter is a “LIFE”-line..with A dialysis-catheter is a “LIFE”-line..with only few alternative options during the only few alternative options during the life-span of the patient.life-span of the patient.

““early days” nephrologist was in the theatre..early days” nephrologist was in the theatre.. Now???Now???


1)1) Open techniqueOpen technique

2)2) Laparoscopic techniqueLaparoscopic technique

3)3) Percutaneous techniquePercutaneous technique


2) 2) Double cuff curledDouble cuff curled catheters are preferred catheters are preferred in most children in most children pediatric size in patients 3-10 kgs body pediatric size in patients 3-10 kgs body

weight weight and adult catheter >10 kg. and adult catheter >10 kg.

A single cuff catheter may be needed in A single cuff catheter may be needed in infants <3kg.infants <3kg.

Data from the NAPRTCS registry suggestData from the NAPRTCS registry suggest swan neck tunnels, swan neck tunnels, two cuff two cuff and downward pointing exit sitesand downward pointing exit sites..


2) Presumed advantages of 2) Presumed advantages of curledcurled catheters catheters better separation between abdominal wall better separation between abdominal wall

and boweland bowel More catheter holesMore catheter holes Less inflow painLess inflow pain Less tendency for migrationLess tendency for migration Less prone for omental wrappingLess prone for omental wrapping Potentially less trauma to the bowelPotentially less trauma to the bowel

Prior to theatre the exit site for the catheter should Prior to theatre the exit site for the catheter should be agreed with the child and marked on the be agreed with the child and marked on the abdomen by either the dialysis nurse or surgeon. abdomen by either the dialysis nurse or surgeon.

The exit site should The exit site should avoid the belt line and be avoid the belt line and be above the nappy or diaper line in infants. above the nappy or diaper line in infants.

In all but the smallest infants the exit site should In all but the smallest infants the exit site should he he downward facingdownward facing..

The exit site should be located as far as possible The exit site should be located as far as possible from other exits, ie gastrostomies, colostomies, from other exits, ie gastrostomies, colostomies, urostomies to prevent infections.urostomies to prevent infections.



1.1. LaxativesLaxatives should be given pre-operatively should be given pre-operatively to children who suffer from constipationto children who suffer from constipation

2.2. Empty bladderEmpty bladder3.3. Partial Partial omentectomyomentectomy may reduce may reduce

postoperative obstruction but there postoperative obstruction but there are no prospective pediatric series are no prospective pediatric series addressing this issue.addressing this issue.

4.4. Consider Consider elective herniotomvelective herniotomv if any if any evidence of inguinal or other hernia prior evidence of inguinal or other hernia prior to or during catheter placement.to or during catheter placement.


Entry into the peritoneum should be Entry into the peritoneum should be lateral or paramedian lateral or paramedian

with with the deep cuff outsidethe deep cuff outside the peritoneum. the peritoneum.

The peritoneum is closed tightly around the catheter The peritoneum is closed tightly around the catheter

Below the level of the deep cuff using a Below the level of the deep cuff using a purse string suturepurse string suture..

A tunneling device with a sharp point is recommended for A tunneling device with a sharp point is recommended for creating the catheter tunnel creating the catheter tunnel

and and strict haemostasisstrict haemostasis is required. is required.

No incision should be made at the exit site.No incision should be made at the exit site.

The The subcutaneous cuff should be at least 2cmssubcutaneous cuff should be at least 2cms from the exit from the exit site.site.

A cephalosporin antibiotic should he given intravenously at A cephalosporin antibiotic should he given intravenously at the time of catheter implantationthe time of catheter implantation..


Procedure in TheatreProcedure in Theatre

1) Catheter should be tested in theatre 1) Catheter should be tested in theatre for patency and leaks for patency and leaks with dialysis with dialysis nurse or nephrologist present.nurse or nephrologist present.

2) 2) No sutureNo suture should be placed at the should be placed at the exit site which should be downward exit site which should be downward facing with the possible exveption of facing with the possible exveption of infants.infants.

The catheter will be irrigated in theatre The catheter will be irrigated in theatre until the dialysate is until the dialysate is clearclear then capped off. then capped off.

The PD fluid should contain The PD fluid should contain Heparin 5OOiu/LHeparin 5OOiu/L..

Catheter must be immobilisedCatheter must be immobilised at all times and no keyhole at all times and no keyhole dressing applied.dressing applied.

If the catheter has to be used for immediate dialysis then use If the catheter has to be used for immediate dialysis then use only low volumes, 10ml/kg/cycle. In this situation keeping the only low volumes, 10ml/kg/cycle. In this situation keeping the patient supine for the first few days and adequate analgesia patient supine for the first few days and adequate analgesia will also help to avoid high intraperitoneal pressure and will also help to avoid high intraperitoneal pressure and possible leaks.possible leaks.

If possible If possible leave catheter for two weeksleave catheter for two weeks until the patient until the patient returns for training. This will allow initial healing to take returns for training. This will allow initial healing to take place.place.

IMMEDIATE POST OPERATIVE CAREIMMEDIATE POST OPERATIVE CARE

Pain controle.Pain controle. Multiple low volume exchanges until Multiple low volume exchanges until

clear effluent.clear effluent. Dry abdomen as long as possibleDry abdomen as long as possible Dressing is remained for 5 days.Dressing is remained for 5 days. Bedrest for 7 days.Bedrest for 7 days.

FIRST WEEK POST OPERATIVE CAREFIRST WEEK POST OPERATIVE CARE

Remove primary dressing Remove primary dressing at dayat day 5 5 Exit site care done by an experienced Exit site care done by an experienced

nurse.nurse. Secure normal position of the Secure normal position of the

catheter.catheter. Avoid lifting.Avoid lifting. Allow catheter to heal as long as Allow catheter to heal as long as

possible.possible.

GENERAL INSTRUCTIONSGENERAL INSTRUCTIONS

Forbidden:Forbidden:- to take a bath- to take a bath- to swim- to swim- contact sports (football…)- contact sports (football…)

Advice against:Advice against:- sand (beach)- sand (beach)- intensive sports (basket ball…)- intensive sports (basket ball…)

Tollerance of:Tollerance of:- shower- shower

CONCLUSIONS CONCLUSIONS

Catheter complications are to be expectedCatheter complications are to be expected when dressing is not remained intact for 5 to 7 day when dressing is not remained intact for 5 to 7 day

(difficult healing - tunnelinfection)(difficult healing - tunnelinfection) iimmediate use of the catheter (leakkage)mmediate use of the catheter (leakkage) poor fixation (difficult healing and outgrow cuff)poor fixation (difficult healing and outgrow cuff)Catheter characteristics are to be respected:Catheter characteristics are to be respected: to prevent malpositonto prevent malpositon to prevent outgrow cuffto prevent outgrow cuffExit site care is extremely important:Exit site care is extremely important: to prevent infection to prevent infection to assure a long life of the accessto assure a long life of the access

THE CHOICE OF DIALYSIS ACCESTHE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCECONTROVERSY AND EVIDENCE

EVIDENCE / CONTROVERSYEVIDENCE / CONTROVERSY

SOME THINGS ARE WRONGSOME THINGS ARE WRONG SOME THINGS ARE GOODSOME THINGS ARE GOOD MOST THINGS HAVE GOOD AND BAD MOST THINGS HAVE GOOD AND BAD

POINTS..where the final decision POINTS..where the final decision balances, depending on “choices” balances, depending on “choices” mademade

Fistula superior to catheter ?Fistula superior to catheter ? YesYes But if you choose for nighttime dialysis… But if you choose for nighttime dialysis…

not possible (A. Raes oral presentation not possible (A. Raes oral presentation ESPN)ESPN)

Fistula superior to catheter ?Fistula superior to catheter ? YesYes If you are going If you are going

for pre-emptive transplantation, for pre-emptive transplantation, and waiting list is rather short.. and waiting list is rather short.. And time to start dialysis is not predictableAnd time to start dialysis is not predictable

Integrated care model (Van Integrated care model (Van Biesen)Biesen)

Every patient with CKD.. may need every Every patient with CKD.. may need every method for renal replacement therapy method for renal replacement therapy such assuch as Peritoneal dialysisPeritoneal dialysis TransplantTransplant HemodialysisHemodialysis RetransplantRetransplant …… ……

Integrated care model (Van Integrated care model (Van Biesen)Biesen)

Peritoneal dialysisPeritoneal dialysis Is probably not the best choice in adultsIs probably not the best choice in adults

If there is no residual renal functionIf there is no residual renal function If BSA / BMI is very highIf BSA / BMI is very high IDDM??IDDM??

So PD… and PD catheter is treatment So PD… and PD catheter is treatment of choice in children becauseof choice in children because you preserve vascular access for later you preserve vascular access for later

Acute dialysisAcute dialysis

HemodialysisHemodialysis CatheterCatheter Single / double LumenSingle / double Lumen

Genius… then double lumenGenius… then double lumen Femoral catheterFemoral catheter

Often the choiceOften the choice To not interfere with other central cathetersTo not interfere with other central catheters

Acute dialysisAcute dialysis

Peritoneal catheterPeritoneal catheter SurgicalSurgical

Often time… to surgery is longOften time… to surgery is long Percutaneous TenckhoffPercutaneous Tenckhoff

Adults good experienceAdults good experience In children few reportsIn children few reports

Seldinger place acute catheter (pigtail) (Buchmann, Seldinger place acute catheter (pigtail) (Buchmann, Vande Walle adv Perit Dialysis)Vande Walle adv Perit Dialysis)

Especially in small childrenEspecially in small children Cardiac surgeryCardiac surgery To gain time when there is hyperkaliemia (Start dialysis in To gain time when there is hyperkaliemia (Start dialysis in

10min)10min) Two catheter techniqueTwo catheter technique

Continuous flow dialysis (Vande Walle Adv Perit Dial)Continuous flow dialysis (Vande Walle Adv Perit Dial)

Documents

THE CHOICE OF DIALYSIS ACCES THE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCE CONTROVERSY AND EVIDENCE PART 3 : Peritoneal Dialysis PART 3 : Peritoneal