Certification Review Course Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph’s Regional Medical Cente

1. Certification Review CoursePeritoneal DialysisRay Agnello, BSN, RN, CNNEducatorSaint Joseph’s Regional Medical CenterPaterson, New Jersey

2. 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.

3. 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

4. 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

5. 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

6. Kinetics of Peritoneal Dialysis • Diffusion • Osmosis • Ultrafiltration • Drug Transport

7. Diffusion Tea Bag = Peritoneal Membrane Water = PD Fluid Tea Leaves = Waste

8. Scheme of semi-permeable membrane:red = blood blue = PD fluidyellow = membrane .wikipedia.org/

9. 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

10. Osmotic Pressure of Dextrose Solution 1.5 % Solution 2.5 % Solution 4.25 % Solution

11. The Peritoneal Dialysis Process • Definition- intra (within) corporeal dialysis • Three Phases to the Exchange process • Drain • Fill • Dwell

12. 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

13. 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.

14. Infusion or Fill Baxter®

15. Drain Baxter®

16. 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

17. Historical Perspectives • 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 5th Ed

18. 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

19. 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

20. 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

21. 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.

22. Surgical EvaluationCatheter 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

23. 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

24. 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

25. Question Evidence-based practice suggests which of the following upon PD catheter implantation? • 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

26. Peri Operative RoutinesAnesthesia • Local infiltration with sedation • Intravenous propofol with Monitored Anesthesia Care • General anesthesia

27. Insertion Techniques • Bedside-temporary catheters • Laparoscopic placement • Surgical dissection • Buried Catheter technique • Percutaneous placement per Interventional Radiology

28. 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

29. 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

30. Catheter History • 1960’s- • silicon rubber catheters, with coiled intraperitoneal 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..? • segment (Palmer, Quinton) • ANNA Core Curriculum 5th Ed

31. 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

32. Cuffs • Single • Double • Elongated • Bead/flange configuration

33. Question… What is one advantage of implanting a cuffed PD catheter? • 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

34. Adaptors • Plastic • Titanium

41. 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)

42. 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

43. 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

44. 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

45. 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 Post Operative Discharge Plan Prevent Constipation

46. Peritoneal Dialysis Therapies • IPD (Intermittent Peritoneal Dialysis) • CAPD (Continuous Ambulatory Peritoneal Dialysis ) • CCPD (Continuous Cycling Peritoneal Dialysis) also known as APD (Automated Peritoneal Dialysis)

47. 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

48. On Call RN ON Call RN ON Call

49. 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!!

50. Patients at risk for inadequate dialysis • No residual renal function • Low membrane permeability • Large patients • Patients not doing their treatments