Single peritoneal dialysis
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Acute single peritoneal dialysis is a commonly used procedure for managing acute renal failure. It can be initiated quickly and is useful for patients who are hemodynamically unstable or have limited access to other dialysis methods. The procedure involves inserting a catheter into the peritoneal cavity and exchanging dialysate fluid in cycles to remove waste and correct electrolyte imbalances. Potential complications include pain, bleeding, bowel injury, and peritonitis. Care must be taken to aseptically perform exchanges and avoid malposition of the catheter.
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Single peritoneal dialysis
- 1. Acute single peritoneal dialysis Dr Sandeep Kumar
- 2. Introduction Commonly used procedure for managing renal failure Life saving in hyperkalemia, pulmonary edema, uremic encephalopathy, marked acidosis Technique can be initiated simply and quickly Can be used in debilitated, malnourished, hemodynamically unstable . Systemic anticoagulation not needed Buying time in investigating and planning for definitive treatment Useful in devolving nations and centers with limited HD, CAPD facilities APD was started in 1959
- 3. Composition Constituent Sodium (mmol/L) Potassium (mmol/L) Calcium (mmol/L) Magnesium (mmol/L) Chloride (mmol/L) Lactate (mmol/L) Glucose (g/dL) pH Value 132–134 0–2 1.25–1.75 0.25–0.75 95–106 35–40 1.5–4.25 5.5
- 4. Why use is limited 1 - Extracorporeal methods – easier per cutaneous vessel cannulation Low dose heparinization in improved circuits Reduced bleeding risk Better bio materials 2 - Newer HD techniques Bicarbonate dialysis with UF control Hemofilteration Hemodiafilteration 3 – better cardio stability with CRRT
- 5. Indications 1-Renal failure ( acute or chronic) with Hyperkalemia Pulmonary edema Marked acidosis ( definite if HCO3 <10mEq/L) Encephalopathy Uremic pericarditis or encephalopathy Oliguria in hemodynamically unstable patient Presence of bleeding diathesis or hemorrhagic conditions Difficulty in obtaining blood access
- 6. Indication 2-Non uremic conditions (ARF may or may not be present) Poisonings (barbiturates or poisons with mol wt > 10 kD) Intractable heart failure Profound hypothermia or hyperthermia Severe hypercalcemia Life threatening fluid overload Correction of electrolyte and acid base disturbances Acute pancreatitis Hepatic failure Infusion of drugs and nutrients – supportive to allow total parenteral and fluid nutrition
- 7. Relative contraindication Recent abdominal or cardiothoracic surgery Diaphragmatic peritoneopleural connections Fecal or fungal peritonitis Severe respiratory failure Abdominal wall cellulitis Severe gastroesophageal reflux disease Low peritoneal clearances Life-threatening hyperkalemia Severe acute pulmonary edema Extremely high catabolysis Colostomy and bowel fistulae Hernias
- 8. Procedure Pre-requisites Confirm the indication Rule out any contraindication Informed written consent P/A or USG to rule out distended gut loops, fecolith, distended bladder in case of urinary retention Decompress the bladder or give enema, if indicated Prepare part from xiphisternum to inguinal region
- 9. Materials required Disposable syringes with needles Silk suture Mosquito artery forcep Sponge holding forcep Providine iodine solution Sterile dressing 2% local anaesthetic APD Catheter set,Y connector , 5 liter can Needle holder Adhesive tape Drip stand with two hangers Heparin
- 10. Procedure summary Insertion of a semi-rigid catheter or a single-cuffTenckhoff catheter at the bed- side using a fluoroscopy table and guidewire direction or a peritoneoscopic technique.
- 11. Procedure Asepsis LocalAnaesthesia is adequate In restless, irritable – consider diazepam or IV morphine (3-6mg) Orthopnea – backrest with 45 degree tilt Clean with iodine and spirit Drap with sterile clothing LA – 2% , 3-5 ml of lignocaine with adrenaline, one inch infraumblical, infiltrating upto PP, using 23G needle. 5 min wait. ConnectY connector to two PD fluid bottles, make circuit air-free Each bottle containing 250 units of heparin
- 12. Procedure Using 16G IV cannula, pierce through anesthetized part, to reach peritoneal cavity. Connect toY-connector , and allow 15ml/Kg of PD fluid to go in Allows fullness of abdomen and floating of bowels – minimizing risk of bowel injury Remove IV CANNULA after priming is done Mosquito forcep to widen the hole or a nick using sharp end of surgical blade in the PD set. Using forcep – blunt dissection until the gritty sensation of parietal peritoneum is reached. Using blade – IP bleed and catheter block Touch the PD catheter minimally and pierce PP mechanically Remove stylet, as soon as peritoneum is pierced, and place Catheter in POD. Nearly 3/4th goes in easily. Left iliac fossa mostly contains large bowel full of fecal matter
- 13. Procedure Once catheter is in allow 20 ml/kg fluid in, until 35ml/kg, then let the fluid drain out. If catheter is rightly placed – 3/4th fluid comes out Put the purse string sutures Seal the tubing
- 14. Performing the Dialysis NOT DYSPOENIC – 35-50 ml/kg (approx 2 Literes) Smaller quantity in – smaller BSA & compromised PFT. 2 – isotonic / hypertonic solution To remove extra fluid use D-25 % - 100ml 3 – potassium Hyperkalemia – initial rapid exchanges without K Target – K= 4.5mEq/L <3.5 – add 4 mEq/L in PD fluid >3.5 but <5 mEq/L – Add 3 mEq/L KCl 4 – Heparin – 1000 units heparin in each exchange 5 – Dwell time – 15 – 30 minutes To remove more fluid - 15-20 minutes Conventionally DT is kept 30 minutes
- 15. Performing the dialysis 6 – DRAIN OUT Takes 20 – 30 minutes for draining out fluid If less fluid is drained – it's PLUS CUMULATIVE BALANCE is to be calculated at the end of dialysis In case of undesired Positive balance – check catheter for clots,may need catheter repositioning, or Enema for constipation, else patient may go in volume overload. Negative balance – manage with IV fluids. 7 – NUMBEROF EXCHANGES CONVENTIONALLY – 60 liters/ 30 exchanges , increased in Azotemia – Smaller quantity of fluid used Short dwell time 8 – Close the PD
- 16. Problems and complications Pain Bleeding Bowel injury (0.1 – 3% ) Bladder injury Leakage Catheter malfunction Dialysis related complications Hypoalbuminemia
- 17. Albumin loss The frequent exchanges used in acute PD may produce hypoalbuminemia; protein losses via the di- alysate can be as high as 10 – 20 g in 24 hours and up to twice that amount during episodes of peritonitis.To compensate for dialysate protein losses, oral or intravenous protein supplementation may be requ
- 18. Bowel injury (0.1 – 3% ) 1 - Prevention Fill peritoneal cavity with adequate fluid Withdrawing stylet as soon as peritoneum is punctured 2 – minor injury is harmless 3 – significant injury Turbid and foul smelling exchanges Poor outflow of fluid Watery diarrhea - fluid coming PR Broad spectrum antibiotics Frank peritonitis and septicemia warrant and conservative management Occasional laparotomy
- 19. Catheter malfunction (Poor inflow) Possible cause Kinked tubing Fibrin / Blood clot Obstruction Malposition Treatment Correct Flush catheter with Heparinized fluid Streptokinase,stylet insertion Reposition / Replace
- 20. Catheter malfunction (Poor outflow) Possible causes Kinked tubing Air in line Clot / Fibrin obstruction Malposition Catheter encasement by omentum or fibrous tissue Treatment Correct Flush the line Flush catheter with Heparinized fluid Reposition ReplaceCatheter and consider partial omentectomy
- 22. Pain during inflow Possible causes Low dialysate pH Over distention Catheter tip irritation Low/High temperature of dialysate Treatment NaHCO3 Decrease cycle volume Observe, give plain water enema Use water bath
- 23. Pain during dwell Over-distention treat by decreasing cycle volume
- 24. Pain after dialysis Observe recumbent position
- 25. Constant pain Possible cause Diffuse peritonitis Pelvic area : irritation by catheter Shoulder : Air under diaphragm Treatment Antibiotic lavage, analgesics Observe, withdraw tip of catheter a little Observe, recumbent position
- 26. Other Hypovolemia Hypervolemia Hyperglycemia Hypokalemia (20%) Collapse of lower lobes & respiratory distress ( use small cycle volume & semi-supine position) Cardiovascular – tachyarrythmias in patients with underlying heart disease (conventional treatment ) Infection – (5-6% to 10-30%)
- 27. Preventable causes of infection Usually doesn't cause serious morbidity Poor technique Improper handling of tubes Poor placement of catheter requiring repositioning Open drainage system Leakage of fluid Early treatment – cephalosporins + aminoglycoside Modify treatment later as per culture sensitivity
- 28. Recommendation Health and public policy committee , American college of physicians
- 29. Images Introduction of APD , mechanism of APD
- 31. Comparison
- 32. Thank you