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Peritoneal Dialysis Catheters
Contents:
Chronic Peritoneal Dialysis Catheters
Break In Procedure for New Chronic PD catheter
Care of Peritoneal Dialysis Catheter
Catheters for peritoneal dialysis must transport the fluid into and out of the
peritoneal cavity as rapidly as possible and maintain normal structure and
function of the tissues near the catheter tract [i.e. biocompatible]. Tenchkoff
catheters are generally used for chronic peritoneal dialysis. A more recent
modifications of Tenckhoff catheter are described to improve the performance and
decreases the catheter complications.
Peritoneal dialysis in
situ
Important features of Tenckhoff catheters:
Material of the catheters:
Tenckhoff catheters are made of
silicone or polyurethane with radiopaque stripe for x-ray visualization.
Shape:
It may be straight or coiled; coiled catheters are believed to minimize catheter
migration out of the pelvis and have fewer outflow problems.
Cuffs:
Catheters have one or two dacron cuffs made of Dacron polyester or velour and
provide for tissue ingrowths to stabilize the catheter. The standard distance
between the two cuffs is 5 cm.When double cuffs catheters are placed the
internal cuff is placed the rectus muscle and the external cuff is placed in the
subcutaneous tissue proximal to the exit site. Cuffs intended to prevent
migration of bacteria along the subcutaneous tunnel into the peritoneum.
Parts:
It consists of, Intraperitoneal segment containing side holes and open tip for
fluid flow , Subcutaneous segment that passes through the peritoneal membrane,
muscles, and subcutaneous tissues ; External segment that extends from the
external cuff out to exit site.
Sizes
are different to accommodate neonate
to adults. For obese patients with pendulous abdomen the distance between the
two cuffs is more than 5 cm. Standard adult catheter size; Intraperitoneal
segment 15-20 cm , Subcutaneous segment 5-7cm; External segment 10 cm
Placement procedure
Details of catheter placement is
beyond the scope of the Tips.
-Chronic catheters are placed, surgically, using Tenckhoff trocar, using guide
wire, using a Pull-Apart introducer and by peritonescopy.The usual site of
implantation is about 3 cm below the umbilicus.
-The exit site should be in the right [or left] midquadrant area avoiding the
belt line and skin folds. The direction of the exit site is directed upwards or
downwards depending on the catheter used. The superficial cuff should be 2 cm
distance from the skin exit site It is useful to consider the patient
preferences and whether he or she is right or left handed. Furthermore the
intestinal peristalses movement push the catheter to the pelvis when the exit
site in the right midquadrant.
-As a rule the required intra-abdominal length for adults corresponds closely to
the distance between the upper rim of symphysis pubis and the umbilicus when the
patient in recumbent position except in obese patients. If the catheter is to
long ; up to 5 cm may be pared off the distal intra-abdominal segment
-Drainage problem, sepsis, exit and tunnel infection, peritoneal bleed,
subcutaneous hematoma, bowel perforation, ileus, pericatheter leak, pain, and
catheter kink are potential complications for catheter insertion.
-Partial omentectomy may be necessary in some if it is prominent [3-4 inches are
removed]
-The proper location of the catheter tip with the standard Tenckhoff catheter
should be just beneath the left inguinal ligament, between the anterior
abdominal wall, mass of omentum and bowel loops, [or cul-de-sac of the pelvis if
it is feasible]
-Tight closure of the peritoneum using running lockstitch is mandatory.
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There are several other versions
of chronic catheters including modifications features intended to improve
dialysate flow and decrease catheter complications
a-To minimize outflow obstruction
-Curled Tenckhoff Catheter to separate visceral and parietal layers of
the peritoneum by increasing the bulk of the tubing.
-The Toronto Western Catheter
[Oreoulous-Zellerman] with two perpendicular disks to hold the momentum
and bowel away from the exit holes
-The lifecath catheter has performed 90 bend in the subcutaneous portion
which terminates in two discs separated by numerous columns , this large area of
disc decreases the attraction of the omentum towards the catheter
b- To minimize leakage and fix the catheter in
position
-Modifications includes the deep cuff by adding a silicone bead posterior to the
deep cuff.
c- To lower the rate of cuff extrusion and exit
site infection.
-The swan neck catheter with a V-shaped arc between the deep and
superficial cuffs with exit site facing towards the pelvis.
-Moncerief-popvich catheter with longer external cuff to allow tissue
ingrowth into the external cuff.
Break In Procedure for New Chronic PD catheter
The break in period is that period which immediately follows catheter insertion.
During that period the risk of pericatheter leak is high. The leak of fluid
around the catheter delays the growth of fibrous tissue into the cuff of the
catheter. Furthermore the risk of exit site, tunnel infection and peritonitis
increases.
Basis of break in:
1-Flushing the peritoneal cavity with heparinised dialysate is helpful to clear
intrapertoneal blood clots, fibrin and minimize omental adhesion.
2-Intraperitoneal pressure is minimized by restriction of the exchange volume
and patient activity. Patient should be instructed to avoid excessive strain
(e.g. constipation and cough)
3- Prophylactic antibiotics.
Break In Procedure:
A-First 24 hours:
1-Start flushing of peritoneal cavity immediately after insertion of the
catheter with low volume exchange; 500 ml of dialysate without dwelling time.
2-Add 500 U of heparin to dialysate.
3- Continue flushing till the effluent becomes clear (not bloody) then shift to
dialysis with dwelling time.
3-Observe for Excessive bleeding Pericathter leak
Outflow
failure Excessive urine
Unusual drained
fluid
4-Prophylactic antibiotic; 80 mg Gentamicin IV to be given at the start (if not
given before surgery)
5-Discontinue dialysis after 24 hours unless long dialysis is indicated.
B-Second day -2 weeks:
1- Organize dialysis with interdialytic phases according to patient needs.
2-Increase the exchange volume to 750 ml for 6 hours then to 1000 ml reaching
the desired exchange volume within two weeks.
3-Continue heparin 500 units /2L bag.
4- Observe for Late pericatheter leak Exit site and tunnel
infection
Evidence of
peritonitis Outflow failure
Catheter related
complications
Break in for Patients with
Pericatheter Leak:
1-Temporarily discontinue dialysis for at least 2 weeks.Hemodialysis supports
during that
Period.
2-Keep the catheter patent by flushing the peritoneal cavity three times per
week. Perform in-out exchange (zero dwell) using less than 500 ml of 1.5%
dialysate containing 1000 U heparin /2 L bag.
3-Refractory leak necessitate catheter replacement.
4-Reinstitution of dialysis with smaller volume after leak resolving.
5-Avoid hypertonic solution and treat the precipitating causes.
(Review the tip of pericatheter leak page)
Care of Peritoneal Dialysis Catheter
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Aseptic technique is mandatory
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Avoid trauma or traction on the
catheter.
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During the first 3 days after
catheter implantation, dressing need not to be changed, unless there catheter
leak or bleeding. The dressing should immobilize the catheter against the skin.
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Occlusive, air-impermeable
coverings should never be used, nor should ointments
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The patient and nurses should
avoid catheter movement at the exit site (it delays healing and can lead to exit
site infection).
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Subsequently gentle cleaning with
antimicrobial solution (e, g. Povidone-iodine solution and Hydrogen peroxide)
using sterile applicators followed by a dry gauze dressing.
·
Exit site dressing should be kept
dry all the time:
Moisture causes; Irritation, Maceration & Invites Infection.
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Crusts around the exit site my
persist for several weeks.It should be removed carefully (not forcefully) by
help of hydrogen peroxide soaks.
·
Reddening and tenderness about the
subcutaneous cuff is frequent during the first few days .Its normal or represent
exaggerated tissue reaction to foreign body.
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Complete healing of incision &
exit site is suspected within 4 weeks. After complete healing the catheter exit
site may be left unprotected (optional).
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Shower with liquid soap and water
is allowed when the catheter site is well sealed (bath only if the water below
the exit site) - dry with clean towel - paint with
betadine or
povidone-iodine solution followed by 2x2
gauze dressing. Swimming is not
permitted.
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All taping to the abdomen should
be done with paper tape or similar products of low irritation potential.
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Clothing should be comfortable to
avoid mechanical irritation. The catheter exit site should not be located under
the belt or tight clothing.
Examination
of exit site and tunnel
Clean exit site
Inspection of PD Catheter
1. Cracks 2.Tears 3.Debris
in the adaptor
Inspection of Exit site and Tunnel Focuses on
1. Redness, 2.Unusual
swelling, 3.Bulging of exit or tunnel, 4.Bleeding, 5.Crusting, 6.Discharge,
7.Erythema
Palpation of exit sit and tunnel
1. Tenderness,
2.Induration, 3.Irregularity, 4. Discharge on gentle squeezing, 5.Skin folds for
infection, 6.Abscess or sinus tract
WHAT TO DO?
1- Notify the physician to confirm the finding
2-A culture should be taken before the area is
painted with the antimicrobial agent.
3-The sooner antibiotic therapy initiated the
better the prognosis.
Infected exit site
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