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PD Access

PD Access. Peritoneal Catheters. PD catheter is patients lifeline Several advances have made access safer and longer lasting Successful outcome is dependent on meticulous care and attention to detail

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PD Access

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  1. PD Access

  2. Peritoneal Catheters • PD catheter is patients lifeline • Several advances have made access safer and longer lasting • Successful outcome is dependent on meticulous care and attention to detail • Adherence to principles of catheter insertion and subsequent management and care remain the cornerstone of successful PD access

  3. The ideal PD Catheter • Rapid rate of dialysate flow • Minimal or no - leaks - migration - exit and tunnel infections - peritonitis • Ease of insertion by all techniques • Long lasting • Inert material - durability - resistant ot infection/biofilm - antimicrobial properties

  4. Peritoneal Catheters and Exit Site Practices - Towards Optimum Peritoneal Access - 1998 Update Gokal R et al Perit Dial Int 1998;18:11-33

  5. Peritoneal Catheters and Exit Site Practices Areas Covered • Peritoneal Catheters • Catheter Choice and Catheter Outcomes • Catheter Insertion • Immediate post - operative care • Chronic care of healed exit-site

  6. Peritoneal Catheters Intraperitoneal Segment Straight Coiled Silicone discs T-fluted Subcutaneous Tract straight permanent bend - Swan-neck/Missouri Swan-neck presternal Anchorage Dacron cuffs Bead-and-flange - Swan-neck

  7. P Currently available chronic peritoneal catheters Gokal et al PDI 1998;18:11-33

  8. Catheter Insertion • Prevention of complications begins with the decision to place a patient on peritoneal dialysis

  9. Appropriate candidates • Motivated ESRD patient • Patient support – family, carer, etc • Ability to understand and use sterile technique • Physical capability • Ideal candidate would have no prior abdominal procedures

  10. EARLY Leak Obstruction to flow Bleeding Infection Intestinal perforation Inability to insert catheter LATE Obstruction to flow Hernia Hydrothorax Peritonitis Exit-site erosion / infection Other surgical problems * diverticulitis * cholecystitis Insertion Complications

  11. Catheter Insertion • Who should place the PD catheter? The Surgeon!

  12. Communication is Essential Surgeon Nephrologist Nurse

  13. Peritoneal Catheters Outcome in relation to exit direction • Downward directed exit site recommended • Golper T et al AJKD 1996;38:428-36 - 38% decreased risk of peritonitis associated with ESI • USRDS 1996 Report - peritonitis less with permanent bent catheter

  14. Peritoneal Catheters Outcome in relation to number of cuffs RECOMMENDATIONS • Double cuffed catheters should be used for chronic peritoneal dialysis • USRDS 1992 , Warady 1996, Honda 1996 - single cuff associated with shorter time to first peritonitis • Linblad et al PDI 1988;8:129-33 and Favazza et al PDI 1995;15:357-62 - more frequent exit site complications and shorter survival times for single cuff • Eklund et al NDT 1997;12:2664-6 - no difference between single or double cuffs (RCT)

  15. Catheter Choice and Outcomes RECOMMENDATIONS • Catheter survival of >80% at one year desirable • Double cuffed catheter preferred to single cuff • Downward directed exit-site decreases the risk of catheter related infections (advantage being its- preformed arcuate bend) • No catheter appears to be superior to the 2 cuff standard Tenckhoff catheter - experience with swan-neck catheters is promising.

  16. Catheter Insertion PRE-IMPLANTATION PREPARATION • Fully inform patient of details of procedure • Pre-surgical assessment (e.g. hernias) • Determination of exit-site • Skin preparation • Bowel preparation • Prophylactic antibiotics - Evidence suggests that peri-op antibiotics diminishes wound infection

  17. Catheter Implantation Techniques RECOMMENDATIONS • Implantation to be performed by competent, experienced operator, in a planned manner. Care and attention to detail is important • Peritoneal entry - lateral or paramedian • Deep cuff - placed in musculature of anterior abdominal wall or within posterior rectus fascia. • Subcutaneous cuff - 2cm from exit site • Catheter patency needs checking • Exit-site facing downward or laterally

  18. A Healthy Exit Site

  19. Immediate Post Operative Care AIMS • Minimise bacterial colonisation • Prevent trauma to exit-site and traction on cuffs • Minimise intra-abdominal pressure to prevent leakage • Several approaches to post operative care • No evidence to support superiority of any one RECOMMENDATIONS • Minimise catheter movement • Minimise catheter handling until healing of wound and tract - 3-4 weeks

  20. Post implantation Dialysis RECOMMENDATIONS • Flush catheter with small volumes (e.g. 500ml) until effluent is clear • Starting CAPD depends on type of implantation technique - generally catheter should be capped for 2 weeks before starting PD • PD in the interim should be - intermittent - small volumes - gradual increase in volume - patient in a supine position

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