PERITONEAL DIALYSIS

drugs of choice for peritonitis

-cefazolin or cephalothin -gentamicin -netilmicin -tobramycin -amikacin -vancomycin or clindamycin if MRSA

continuous cycling Peritoneal Dialysis-CCPD

3-5 exchanges are performed nightly with a full diurnal(daily) dwell. The diurnal dwell improves the clearance of middle molecules

nocturnal intermittent PD-NIPD

3-5 exchanges are performed nightly, but there is minimal or no diurnal dwell. NIPD is indicated in pts. who are unable to tolerate a diurnal dwell and in those with problems exacerbated by increased intraabdominal pressure, including hernias, low back pain and cardiopulmonary compromise.

What causes hemoperitoneum in the PD pt.?

Peritonitis or retrograde menstruation(in menstruating women) trauma ovarian cysts ovulation injury from colonoscopy or enema

what is a sign of fibrin formation?

whitish strands or clots seen in the effluent or catheter

what happens if air gets into the abdomen

air can get into abdomen via loose connections . the pt may complain of shoulder pain & peritoneal eosinophilia may be seen. - intervention includes draining the patient of the effluent and placing the pt. in the knee-chest or trendelenburg position -the air will be absorbed over time -tighten all connections and inspect lines for presence of air

what is "solute drag"?

further removal of solute occurs when a hypertonic dialysate is used, which increases ultrafiltration(uf) and causes additional low molecular weight solutes to be dragged along with the ultrafiltrate by convective transport.

what is used to prevent fibrin formation?

heparin is added to the dialysate to reduce fibrin production and the formation of adhesions.

when there is a dialysate leak arount the exit site or into the subcutaneous tissue during PD , the following s & s may be noted.

- Drainage of clear fuluid from the exit site -abdominal edema -penile edema -scrotal edema

Steps that need to be taken when a leak is determined include .....

- use a dextrostick to ascertain presence of glucose - resuture the exit site -d/c PD for a minimum of 2 wks to allow healing -if unable to stop therapy, decrease the volume with APD in the supine position -stabilize or replace the catheter

Management of peritonitis

-initially use cephalosporin or vanc in combination with an antibiotic to treat gram-negative organisms such as ceftazidime. administering a loading dose of the antibiotic and heparin. let it dwell in the peritoneum for 3-4hrs and resume the CAPD schedule -drain abdomen -obtain a cell count and culture, -change the transfer set

what does PET do?

-it evaluates the characteristics of the peritoneum by measuring its solute transfer and ultrafiltration

tx options for inflow or outflow problems

-relieving constipation -x ray for internal catheter kink -inspect catheter for external kinks -irrigate catheter with heparinized saline or a thrombolytic -reposition or replace catheter -peritoneogram with contrast medium to identify loculation

what are inflow or ourflow problems?

1. air in the abdomen 2. obstruction due to fibrin, blood, or omentum occluding the opening 3. catheter position due to its migration out of the pelvis 4. loculation caused by adhesions or constipation

what are the different forms of automated PD

1. ccpd- continuous cycling peritoneal dialysis 2. NIPD- nocturnal intermittent peritoneal dialysis 3. IPD- intermittent peritoneal dialysis 4. TPD-tidal peritoneal dialysis

pt care of exit site after it is healed up

1. daily cleansing with antibacterial soap and water while showering with careful attention to rinsing and drying 2. antibacterial solution is applied in a circular motion to the skin around the exit site. ****No submerging in hot tubs or baths. May swim in clorinated pools or oceans after healing 4-6wks. After healing dsg. may or may not be worn. ****extremely important to secure cath. to prevent trauma and infection from tugging.

what are the two potential complications of PD

1. fibrin formation 2. hemoperitoneum

How to care for pt. post PD cath insertion

1. full volume dialysis especially CAPD, should be avoided 10-14 days. 2. pt. may need temp. hemodialysis if fluid overload and uremic. 3. postoperatively the pt. should remain supine when possible 4. avoid activities that increase intraabdominal pressure( straining to defecate, excessive coughing, crying and lifting.)

treatment options after surgery

1. infusion of 25-100mL heparinized saline solutionevery 4-8 hrs for 1-3 days postoperatively. this will not detect cath. malposition or outflow problems. 2. low volume in and out exchanges with heparinized saline or dialysate several times a day until the effluent is no longer bloody, then daily for 1-2 wks and weekly thereafter until pt is undergoing PD. A small amt. of heparinized solution should remain in the peritoneum to inhibit the formation of fibrin and prevent adhesions. 3. low volume dilaysis in the pt. who needs immediate dialysis but is unable to undergo hemodialysis. Frequent, low volume exchanges(500-1000mL) are performed using a cycler with the pt. in the supine position. The volume is gradually increased to eliminate the signs and symptoms of uremia.

Cuffs

1. made of dacron polyester or velour and allow tissue ingrowth to stabilize the catheter. 2. cuffs are also intended to prevent migration of bacteria along the subcutaneous tunnel into the peritoneum. 3. double cuffs - 1st cuff placed in the rectus muscle(deep tissue) and the 2nd (external cuff) is placed in the subcutaneous tissue proximal to the exit site.

dressing change to exit site

1. trained professional for first change train pt. , 2. wear masks and gloves 3. look for s&s of infection(erythema, exudate, induration, tenderness) 4. palpate for tenderness 5. cleanse with antibacterial soap and water and covered with a sterile non occlusive dsg. Donot use Cytotoxic agents as it may interfere with wound epitheliazation until site is well healed. 6. catheter should be secured to pts. skin with tape ** Avoid showers or baths until healed.

Types of PD catheters

Catheters are made of silicone or polyurethane with a radiopaque strip for visualization. catheters may be straight or coiled and have one or two cuffs.

All of the following medications can typically be given intraperitoneal except? Digoxin Heparin Insulin Potassium

Correct Answer: Digoxin Digoxin is a medication that is not given by an intraperitoneal route. Medications that are typically given by this route include: Heparin Insulin Potassium Antibiotics Sodium bicarbonate Xylocaine Metoclopromide

The most widely used solution for peritoneal dialysis would be which of the following? Sodium-based with lactate as a buffer. Glucose-based with lactate as a buffer. Both A and B None of the above

Correct Answer: Glucose-based with lactate as a buffer. To be an effective dialysate, it must be a balanced composition of an osmotic agent, electrolytes, and a buffer. The most widely used at this time is glucose-based with lactate as a buffer.

If the peritoneal patient is experiencing pain associated with catheter position, which of the following interventions would not be appropriate? Immediate removal of the catheter. Administer a laxative to induce peristaltic activity to accomplish position shift of the catheter. Manipulation of the catheter by an interventional radiologist. Laparoscopic interventions

Correct Answer: Immediate removal of the catheter. The immediate removal of the catheter would not be the appropriate intervention. The use of a laxative can potentially help shift the catheter even if the patient is not constipated. Sometimes the catheter can be manipulated by an interventional radiologist and sometimes it may require laparoscopic intervention.

Which of the following routes of contamination would most likely cause the peritoneal dialysis patient to experience peritonitis? Transvaginal Hematogenous Transluminal None of the above

Correct Answer: Transluminal (through or across a lumen, particularly of a blood vessel) The other 3 options above are incorrect. The routes of contamination that would more than likely cause peritonitis in the peritoneal dialysis patient would include transluminal and periluminal.

why is dextrose used in the dialysate solution?

Dextrose is used to create an osmotic gradient that causes water to move into the peritoneal cavity.

what is a peritoneal dialysis exchange?

The dialysate is infused into the peritoneal cavity via a catheter, allowed to dwell for a predetermined amount of time, and then drained(effluent)

what is icodextrin

a starch derived osmotic agent made from a mixture of glucose polymers.

tidal peritoneal dialysis -TPD

an initial volume of the dilaysate is infused, followed by partial drainage of the effluent at the end of each exchange(leaving a constant reserve volume): finally a tidal volume of fresh dialysate is infused. TPD is intended to enhance clearance by maintaining continuous contact of the dialysate with the peritoneum and maintaining the dialysate/plasma gradient. disadvantages: increase cost for increase dialysate and drain pain in some pts.

signs of hemoperitoneum

blood tinged effluent (2ml of blood will cause visible blood in the effluent) a hct of 5%or more indicates a major bleed. bleeding usually resolves spontaneously

what will occur if pt has fibrin formation?

can obstruct the catheter

how long does the healing process take after pd cath is placed?

can take up to 6 wks. and includes scab formation , tissue granulation at the exit site, and sinus tract epithelialization.

what is the Peritoneum?

consists of the lining of the inner surface of the abdominal and pelvic walls, including the diaphram, as well as the covering of the abdominal organs. in males it is closed cavity and in females the fallopian tubes and ovaries open into the peritoneal cavity. The membrane is in contact with the rich blood supply to the abdomenal organs.

how are electrolytes and uremic toxins removed from the blood?

diffusion from an area of higher concentration(bloodstream) to an area of lower concentration(peritoneal cavity).

treatment for hemoperioneum in the PD pt.

flush with room temp dialysate for vasoconstriction with the addition of heparin to prevent obstruction

automated PD

is performed with a cycler, usually at night while pt. sleeps. it performs the following functions automatically 1. measures the volume of dialysate to be infused( 50-3000mL) 2. warms the dialysate to body temp. before infusion 3. times the frequency of exchanges 4. counts the number of exchanges 5. measures UF 6. alarms for inflow failure, overheating, and inadequate drainage

what is hemoperitoneum?

is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

do we use aminoglycosides to treat peritonitis?

it should be avoided in pts. with residual renal function, if possible, due to its nephrotoxic effects.

PD catheter placement

laproscopically placed with the exit site downward or lateral and should be located in the right or left midquadrant area, avoiding the belt line, scars, and skinfolds.

coiled catheters

minimize migration out of the pelvis and have fewer outflow problems than straight catheters. improve pt. comfort by keeping the tip of the catheter away from direct contact with the peritoneal membrane.

parameters for icodextrin use in PD

only intended for once daily, long dwell exchanges lasting 8-16 hrs. the dialysate solution should be used no more than one exchange in a 24 hr period

what does PET stand for?

peritoneal equlibration test. It measures the combined effect of diffusion and ultrafiltration rather than either one in isolation.

what is a "high transporter"?

pts who attain equilibrium most rapidly and thoroughly due to their large peritoneal surface area or high intrinsic membrane permeability during the PET test. these pts. tend to have the highest ultrafiltration, but due to their higher dialysate protein losses, they tend to have lower albumin levels.

intermittent peritoneal dialysis -IPD

several frequent exchanges 3-4x per wk. , with the peritoneum left "dry" between treatments. IPD was widely used in 70's and was replaced by newer modalities. Appropriate for pts. with residual renal function or for institutionalized pts. IPD is used in economically underdeveloped countries because of the financial constraints imposed by daily PD.

adverse reaction to icodextrin

skin rash, sterile peritonitis, htn, cold, headache, flulike symptoms, & abdominal pain

why does fibrin formation occur in the PD pt.?

the body's response to inflammation. It is the result of reduced fibrinolysis of fibrinogen that occurs due to peritonitis. White strands

exit site care

the goal is to stabilize the catheter, promote healing and prevent infection. dressing should not be changed for 5-7 days postoperatively by nurse.(unless excessive drainage) masks should be worn. skin should be pink or a brownish or purplish discoloration.

what is meant by catheter break in?

the period after the chronic catheter is placed during which healing and tissue ingrowth into the cuff(s) occur.

what is peritoneal dialysis

the peritoneal cavity acts as the reservoir for the dialysate and the peritoneum serves as the semipermeable membrane across which excess body fluid and solutes, including uremic toxins, are removed (ultrafiltrate)

what is a "low transporter"?

they have slower and less complete equilibrium for urea and creatinine and higher serum albumin levels

contraindications for use of icodextrin in PD

those with glycogen storage diseases or an allergy to corn starch.

why is healing time necessary after the PD cath is placed?

to prevent complications such as dilaysate leakage, infections, and catheter obstruction.