PD the Good Catheter

Size: px

Start display at page:

Download "PD the Good Catheter"

Madeleine Maxwell
8 years ago
Views:

1 PD the Good Catheter Joseph J. Naoum, MD., FACS. Assistant Professor, Weill Cornell Medical College The Methodist Hospital, Division of Vascular Surgery Cardiovascular Surgery Associates 6550 Fannin St., Suite 1401 Houston, Texas Tel: (713) Fax: (713) Nothing to Disclose

Hospital, Division of Vascular Surgery Cardiovascular Surgery Associates

2 PD on the RISE Because we want to encourage home dialysis, in which PD is currently the prevailing mode of treatment, we are proposing.. Establishing prospective payment rates that are higher for PD patients than they otherwise would be if separate payments were established based on modality. We believe home dialysis will be encouraged for patients able to use PD. CENTERS FOR MEDICARE AND MEDICAID SERVICES Proposed rule, CMS 1418 P

. Establishing prospective payment rates that are higher for PD patients than they otherwise would be if

3 Indications for PD Patients who prefer PD or will not do hemodialysis (HD). Patients who cannot tolerate HD (ie:, some patients with congestive or ischemic heart disease, extensive vascular disease, or in whom vascular access is problematic, including the majority of young children). Some patients with severe cardiac disease may be better managed on PD since these acute changes are avoided. PD has been proposed as a method of managing refractory heart failure even in patients without renal failure. Rationale There is a rapid change in solute transport as well as rapid shifting of volume within compartments during HD. Patients who prefer home dialysis but have no assistant for HD, or whose assistant cannot be trained for home HD. KDOQI Guidelines 2000 and 2006

$PD has been proposed as a method of managing refractory heart failure even in patients without renal failure.$

4 Absolute contraindications for PD Documented loss of peritoneal function or extensive abdominal adhesions that limit dialysate flow. In the absence of a suitable assistant, a patient who is physically or mentally incapable of performing PD. Uncorrectable mechanical defects that prevent effective PD or increase the risk of infection (ie:, surgically irreparable hernia, omphalocele, gastroschisis, diaphragmatic hernia, and bladder extrophy). KDOQI Guidelines 2000 and 2006

In the absence of a suitable assistant, a patient who is physically or mentally incapable of performing PD.

5 Relative contraindications for PD Fresh intra abdominal foreign bodies (ie: 4 month wait after abdominal vascular prostheses, recent ventricular peritoneal shunt). Peritoneal leaks. Body size limitations. Intolerance to PD volumes necessary to achieve adequate PD dose. Inflammatory or ischemic bowel disease. Abdominal wall or skin infection. Morbid obesity (in short individuals). Severe malnutrition. Frequent episodes of diverticulitis. Living related Kidney transplant within 6 months. KDOQI Guidelines 2000 and 2006

Intolerance to PD volumes necessary to achieve adequate PD dose. Inflammatory or ischemic bowel disease.

6 The Referral Timing of PD catheter insertion should be planned to accommodate patient convenience, and commencement of training. Between 10 days and 6 weeks before therapy is essential to enable correction of early catheterrelated problems without the need for temporary hemodialysis. Woodrow G, Davies S. Nephron Clin Pract 2011;118(suppl 1):c287 c310

Between 10 days and 6 weeks before therapy is essential to enable correction of early

7 Currently Available Methods for Catheter Placement Bedside insertion or percutaneous implantation involving a trocar or guide wire inserted into the abdomen and advancement of the dialysis catheter into the abdomen without visualization Surgical insertion or open dissection, in which small dissection of the peritoneum allows limited visualization of the peritoneal cavity Peritoneoscopic insertion, in which a Y TEC peritoneoscope is inserted to inspect the peritoneal cavity, thus identifying the best location for the dialysis catheter Laparoscopic insertion,, in which adhesiolysis or more sophisticated surgery is possible during catheter placement

allows limited visualization of the peritoneal cavity Peritoneoscopic insertion, in which a Y TEC peritoneoscope is inserted to inspect the peritoneal cavity, thus

8 Comparison of techniques LAP PD PD vs. Open PD Lower failed insertion rate (0% to 2.4%) Lower short term complication rate (0% to 9.5%), Higher long term catheter survival rate (63% to 85%) Lower rate of early catheter migration(2.7% versus 15.0%) Longer operative time (68.32 ± versus ±15.99 min; P < 0.001) Higher costs Percutaneous vs. LAP PD PD The percutaneous technique is associated sometimes life threatening complications. The incidence of omental wrapping, catheter displacement, and intraabdominal complications, bowel and bladder perforation, can be higher with this method. Jwo S-C, et al. Journal of Surgical Research 159, (2010) Batey CA, et al. J Endourology2002; 16(9): Lund L. Int Urol Nephrol 2007; 39: Asif A. Minerva Chir 2005; 60: Adamson AS. Nephrol Dial Transplant 1992; 7: Perakis KE, et al. Seminars in Dialysis 2009; 22(5):

001) Higher costs Percutaneous vs. LAP PD PD The percutaneous technique is associated sometimes life threatening complications.

9 Catheter Configuration Catheter configuration (straight tip vs. curled) does not influence the catheter related mechanical or infectious complications Equally good results can be obtained with both catheter types studied. Eklund BH, et al. Peritoneal Dialysis International, Vol. 15, pp

Equally good results can be obtained with both catheter types studied. http://www.

10 The most appropriate peritoneal dialysis catheter : A BALANCE OF LOCATION Deep pelvic position of the catheter tip places the drainage side holes usually beyond the reach of the omentum and assures good hydraulic function. The exit site must be easily manageable and visible to the patient and avoid irritation produced by the belt line, skin creases, and mobile skin folds. The catheter should course through the abdominal wall with the least amount of tubing stress. Excessive tension may cause superficial cuff migration towards the exit site resulting in cuff infection and extrusion. In addition, undue tubing stress can lead to catheter tip migration out of the pelvis into a position of poor drainage function. Crabtree JH, Burchette RJ, Siddiqi NA. ASAIO Journal 2005; 51:

The catheter should course through the abdominal wall with the least amount of tubing stress.

11 LAParoscopic Peritoneal Dialysis Catheter Placement (LAP PD) PD)

12 Access entry into the Abdomen The two most common techniques used to gain entry into the peritoneal cavity during laparoscopic general surgery are: Blind Veress needle/trocar insertion Open trocar placement under direct visualisation. Once entry to the peritoneal cavity has been achieved, gas insufflation is used to establish pneumoperitoneum and enable visualisation of abdominal structures. Many of the complications associated with operative laparoscopy arise from creation of the pneumo peritoneum, such as subcutaneous emphysema and gas embolism, or from injury to internal structures during abdominal entry. McKernan JB, Champion JK. Endosc Surg Allied Technol Feb;3(1):35-8. Review.

Once entry to the peritoneal cavity has been achieved, gas insufflation is used to establish pneumoperitoneum and enable visualisation of abdominal structures.

13 Pneumoperitoneum

14 Identify the Pelvis and Location to Position Distal Catheter Tip

15 Customize the Catheter Location to Accommodate Each Patient s Anatomy

16 Customize the Catheter Location to Accommodate Each Patient s Anatomy Obesity Abdominal skin folds Presence of stomas Incontinence of urine or feces Catheter modifications that provide for a variety of exit site locations customized to each individual patient. Crabtree JH. Kidney International (2006) 70, S27 S37. Crabtree JH, Burchette RJ, Siddiqi NA. ASAIO Journal 2005; 51:

a variety of exit site locations customized to each individual patient. Crabtree JH.

17 Marking of exit site: Makeshift Compass

18 Soak catheter in saline

19 Tunneling: Tracking over the peritoneum and puncturing through

20 Rectus Sheath Tunneling Crabtree JH. Kidney International (2006) 70, S27 S37.

21 Inserting the Catheter

22 Position the distal cuff above the peritoneum in the pre peritoneal space/rectus muscle

23 Schmidt SC, et al. J of Laparoendoscopic & Advanced Techniques 2007, 17(5):

24 Laparoscopy assisted PD catheter insertion with an intraperitoneal loop fixation Li J-r, et al. Surg Laparosc Endosc Percutan Tech 2011;21:

25 Tunnel Catheter Through the Marked Exit Site

26 Gravity Flush

27 Gravity Empty

28 Gravity Empty

29 Gravity Empty

30 Skin Closure

31 Dressings

32 Protect the Catheter

33 Protect the Catheter

34 Peritonitis Peritonitis rates of less than 1 episode per 18 months in adults and 12 months in children A primary cure rate of 80% A culture negative rate of >20% No reduction in the incidence of peritonitis has be shown from catheter related related interventions for peritoneal dialysis. The frequency and quality of available trials are suboptimal. Woodrow G,Davies S. Nephron Clin Pract 2011;118(suppl 1):c287 c310 Strippoli GFM, et al. The Cochrane Library 2010; Issue 2:1-56

35 Peritonitis Causative Organisms Outcome of Different Types of Bacterial Peritonitis Exit site infection: Psudomonas Aeruginosa (58%) Alwakeel JS, et al.saudi J Kidney Dis Tranpl 2011; 22(2): Krishnan M, et al. Perit Dial Int 2002; 22:

36 Can flush, but can t pull fluid back Likely bowel or omentum wrapped around the catheter. Laparoscopic reposition Free the catheter from any fibrinous material that may have accumulated within the lumen And really, there is no role for TPA

37 Conclusions There is an incentive to increase peritoneal dialysis Expect an increase in referrals Catheter placement should be tailored to the patient s anatomy LAP PD offers some advantages Address patient expectations

38 THANK YOU

PD Catheter Placement and Management

PD Catheter Placement and Management Rajnish Mehrotra 1 and John Crabtree 2 1 Harbor-UCLA Medical Center, Torrance, CA and 2 Kaiser Permanente, Bellflower, CA 1 Importance of PD Access Status of PD Patients