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Certification Review Course Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph


Peritoneal Dialysis ... dialysis No residual renal function Low membrane permeability Large patients Patients not doing their treatments PD Equilibration Test ... – PowerPoint PPT presentation

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Title: Certification Review Course Peritoneal Dialysis Ray Agnello, BSN, RN, CNN Educator Saint Joseph

Certification Review CoursePeritoneal
DialysisRay Agnello, BSN, RN,
CNNEducatorSaint Josephs Regional Medical
CenterPaterson, New Jersey
To provide attendees with a summarized
review of peritoneal dialysis To highlight
key points in the clinical care of a PD patient
Catheter Placement Care of Catheter Infectious
Complication Non Infectious Complications Adequac
y Fluid Balance assessment of the PD patient.
Peritoneal Dialysis
  • Alternative to hemodialysis
  • Patient is taught to perform dialysis exchanges
    in the home setting
  • Focus is on patient autonomy and self care
  • Patient must be followed by a licensed Peritoneal
    Dialysis unit Nephrologist

Peritoneal Membrane
  • Translucent
  • Vascular membrane
  • Two layers
  • Parietal (inner surface of abdominal wall)
  • Receives blood supply from the arteries of the
    abdominal wall
  • Visceral (covers abdominal viscera)
  • Covers the abdominal organs
  • Blood is carried by the mesenteric and celiac
  • Most vascular layer where most of the dialysis
  • Envelope of space between layers called
    peritoneal cavity
  • Semi-permeable-acts as a Filter
  • Kelley 2004

Anatomy and Physiology
  • Peritoneal Membrane
  • Semi-permeable
  • Bi-directional
  • Membrane size- 1-2 m2
  • Vascular wall, interstitium, mesothelium , and
    adjacent fluid films
  • Closed in males
  • Women- ovaries and fallopian tubes open into the
    peritoneal cavity
  • Peritoneal cavity normally contains about 100 ml

Kinetics of Peritoneal Dialysis
  • Diffusion
  • Osmosis
  • Ultrafiltration
  • Drug Transport

Tea Bag Peritoneal Membrane
Water PD Fluid
Tea Leaves Waste
Scheme of semi-permeable membranered
blood blue PD fluidyellow membrane
  • The diffusion of pure solvent across a membrane
    in response to a concentration gradient, usually
    from a solution of lesser to one of greater
    solute concentration.

Miller-Keane 6th Edition
Osmotic Pressure of Dextrose Solution
1.5 Solution
2.5 Solution
4.25 Solution
The Peritoneal Dialysis Process
  • Definition- intra (within) corporeal dialysis
  • Three Phases to the Exchange process
  • Drain
  • Fill
  • Dwell

How Does PD Work?
  • The semi-permeable peritoneal membrane lines the
    abdominal cavity and covers the abdominal
  • The membrane allows (via diffusion) the passage
    of toxins and electrolytes into the dialysis
  • Ultra-filtration (removal of fluid) occurs via
  • A steady state of toxin clearance and fluid
    management is achieved due to daily performance
    of dialysis.
  • K. Kelly , RN
  • NNJ Sept-Oct 2004

How Does PD Work?
  • Dialysis solution is infused and drained via a
    catheter that is surgically placed in the
    peritoneal cavity.
  • The action of draining and infusing dialysis
    solution is called an exchange.
  • The frequency of exchanges and volume is
    determined by the presence of residual renal
    function and the individual membrane

Infusion or Fill
Peritoneal Dialysis
  • Dialysis occurs during the dwell phase
  • Diffusion solutes cross from area of greater
    concentration to lesser one
  • -depends on concentration gradient
  • -enough peritoneal surface area
  • -size of fill volume
  • Ultra-filtration water removal due to osmotic
    gradient between the hyperosmolar PD fluid and
    the capillary bed
  • Kelley 2004

Historical Perspectives
  • Acute-Predominant use of PD prior to 1960s
  • 1966- Automated cycler
  • 1967- Tenckhoff catheter
  • 1975- CAPD
  • 1978- Polyvinyl bags and manufactured in the US
    (prior PD fluid was available in glass bottles)
  • 1980s- New catheter designs
  • 1987- PET and tidal PD -Twardowski
  • 1990s-Alternative dialysate solutions,
  • updated system designs ANNA Core
    Curriculum 5th Ed

Who Are the PD Patients ?
  • Choose PD as Renal Replacement Therapy
  • Hemodialysis Patient without Access
  • Failed allograft (transplanted kidney)
  • Have CHF or CVD which exempts them
  • from hemodialysis
  • Often people with the benefit of CKD education

  • PD Patient Selection
  • Inclusion Criteria Include
  • Patients who
  • Choose the modality
  • Want control
  • Prefer home for dialysis
  • Have residual renal function
  • CVD, CHF
  • Geriatric
  • Pediatric
  • Vascular Access Failure
  • Social support system available

Selection Continued
  • Exclusion Criteria
  • Patients who
  • Have abdominal aortic aneurysm AAA (size
  • Derm. disease of the abdominal wall
  • Morbid abdominal obesity
  • Altered mental status, poor coping styles
  • Solitary life style
  • Patient states lack of interest in modality
  • Multiple abdominal surgeries- adhesions
  • Ostomies (increase risk of infection)
  • Recurrent hernias

Steps to PD Catheter Access
  • Evaluation by Nephrologist for PD catheter
    placement and identified as candidate.
  • Educated about catheter placement, pre and post
    operative care routines.
  • Referred to surgeon for evaluation that includes
    determination of exit site,clinical anesthesia
    work-up, contraindications, completion of consent
    forms and scheduling of surgery.

Surgical EvaluationCatheter Insertion
  • Some units advocate insertion 2 to 6 weeks prior
    to dialysis to optimize healing.
  • Some units advocate insertion months in
    advance.(burying the catheter)
  • In most situations, PD access is elective

Surgical Evaluation
  • Abdominal wall weakness or hernia
  • Repair hernia preemptively or when symptomatic
  • Previous abdominal surgeries multiple surgeries
    increased likelihood of adhesions
  • Abdominal wall obesity

Pre Catheter Insertion
  • Patient Education and consent signed
  • Examination of the patients abdomen
  • Avoid scars and fat folds
  • Avoid beltline
  • Mark the abdomen
  • Surgical prep
  • Empty bladder
  • Patient showers with disinfectant soap
  • Bowel prep

  • Evidence-based practice suggests which of the
    following upon PD catheter implantation?
  • Large fill volumes immediately post-op
  • No need to wear a mask while performing PD
  • Incision site to be exposed to air during
    immediate post-op period
  • Administration of prophylactic IV antibiotics
    prior to catheter implantation to reduce the risk
    of peritonitis
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

Peri Operative RoutinesAnesthesia
  • Local infiltration with sedation
  • Intravenous propofol with Monitored Anesthesia
  • General anesthesia

Insertion Techniques
  • Bedside-temporary catheters
  • Laparoscopic placement
  • Surgical dissection
  • Buried Catheter technique
  • Percutaneous placement per Interventional

Insertion Techniques
  • Buried catheter
  • Entire catheter placed in subcutaneous pocket for
    4-6 weeks or longer, allowing cuff tunnel to
  • Exit site is externalized in a separate
  • Reduced bacterial colonization(?)
  • Do not have long term outcomes yet
  • Flanigan, Gokal, 2005

Catheter History
  • Early catheters were glass cannulas with straight
    or with mushroom ends
  • 1920-40s Various medical devices were used in
    the beginning of PD needles, glass cannulas,
    sump drains, stainless steel coils, Foley
  • 1923-Ganter used a needle for the 1st reported
    use in humans.
  • 1950s-Nylon catheters, polyethylene, plastic
    with rounded tip numerous tiny side holes
  • ANNA Core Curriculum 5th Ed

Catheter History
  • 1960s-
  • silicon rubber catheters, with coiled
    intraperitoneal segment (Palmer, Quinton)
  • Tenckhoff Schechter published results with
    silicone elastomer (Silastic ) for chronic
    dialysis with 2 Dacron polyester felt cuffs
  • 1968-Tenckhoff cuffed straight catheter
  • 1970s-single/double cuff coiled catheter
    Toronto Western with 3 silicone disc
  • 1980s-swan neck configuration ( bent or curved
    SQ segment Toronto Western with 2 silicone disc
  • 1990s-t shaped catheter (Ash) Moncrief
    Popovich technique for leaving the exterior
    segment buried SQ for 4 wk
  • The future..?
  • ANNA Core Curriculum 5th Ed

  • Straight (single or double cuff)
  • Coiled (single or double cuff )
  • Swan neck (single or double cuff)
  • Pre sternal swan neck
  • Toronto Western
  • Missouri catheters
  • Disc catheters

  • Single
  • Double
  • Elongated
  • Bead/flange configuration

  • What is one advantage of implanting a cuffed PD
  • Acts as a barrier to prevent infection
  • Can only be used for CAPD
  • Ensures optimal adequacy
  • Can be implanted at the bedside
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

  • Plastic
  • Titanium

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PD Catheter Access Complication
  • Immediate/Early
  • Bloody effluent
  • Pain with infusion
  • Leak at exit site
  • Exit site infection
  • Migration of catheter tip
  • Poor fill or drain, with or without pain
  • Non-infectious cloudy effluent
  • (lymphatic leak or eosinophilic peritonitis)

  • The patients fill volume is 2000mL. Upon
    draining, the patients volume is 1500mL. The
    nurse should assess the patient for which of the
  • a. Peritonitis
  • b. Catheter removal
  • c. Constipation
  • d. Subcutaneous tunnel infection
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

PD Catheter Access Complication
  • Later Issues
  • Exit site leaks or subcutaneous leaks
  • Pleural communications
  • Excessive granulation tissue
  • Chronic site or tunnel infection
  • Cuff extrusion
  • Cracked, brittle catheter
  • Repetitive episodes of peritonitis
  • Bowel perforations

Post Op
  • Follow up appointment with surgeon
  • Instructions (written verbal) to patient, which
    include emergency contact numbers
  • Follow-up in PD unit within
  • 48 to 72 hours of discharge
  • Pain medication/prescription
  • Reinforce dressing as needed
  • Teach patient to secure catheter
  • Flush catheter during training sessions

Post Operative Discharge Plan
  • Remove primary dressing in 5 to 7 days by PD
  • Dressing changed by PD nurse
  • Replace dressing with DSD, non-occlusive
  • Establish training schedule
  • Bowel regimen
  • No heavy lifting
  • Allow catheter to heal for 14 days or
    longer if possible before use

Prevent Constipation
Peritoneal Dialysis Therapies
  • IPD (Intermittent Peritoneal Dialysis)
  • CAPD (Continuous Ambulatory Peritoneal Dialysis )
  • CCPD (Continuous Cycling Peritoneal Dialysis)
    also known as APD (Automated Peritoneal Dialysis)

Training Sessions for the PD Patient
  • Assess readiness to learn
  • Provide a quiet, relaxed atmosphere for learning
  • Identify patients learning style
  • Individualized with respect to patients
    expectations, cultural beliefs, and coping
  • Length of training based on patients clinical

On Call RN
ON Call RN
ON Call
Warming the Solution
  • Use warm, dry heat
  • At home- PD heating pad
  • Uneven heating of dextrose can create a
  • 1st or 2nd degree burn to peritoneum
  • Leaching of plastics into dialysate can
  • Create a chemical peritonitis

Patients at risk for inadequate dialysis
  • No residual renal function
  • Low membrane permeability
  • Large patients
  • Patients not doing their treatments

PD Equilibration TestAKA PET
  • First developed by Z. Twardowski at the
    University of Missouri
  • A four hour study that assesses membrane
    transport characteristics.
  • Assessment of membrane function allows for
    accurate prescription planning.
  • Usually completed within the first six weeks of
    initiating PD
  • Repeated per each units protocol

PD Equilibration Test continued
  • What does this tell us?
  • The results indicate the following transport
  • High
  • High-average
  • Low-average
  • Low

Transporter Waste removal Water removal Best type of PD
High or Fast Fast Poor Frequent exchanges, short dwells APD
Average Okay Okay CAPD or APD
Low Slow Good CAPD, 5 evenly spaced exchanges 1 exchange at night using a small machine.
KT/V Test
  • What is measured?
  • 24 hour collection of dialysate and urine
  • Serum values of BUN and Creatinine
  • Frequency of test is determined by each units
    protocols and interpretation of K/DOQI
    guidelines. (Unit specific, usually quarterly or

KT/V Test continued
  • What does it tell us?
  • The adequacy of the current prescription
  • Need for adjustments to insure appropriate
    dialysis prescription

Exit Site Care
  • Healthy exit site surrounding skin natural,
    darkened, or light Pink no drainage or crusting
    visible sinus is dry
  • Goal prevent exit site infection and identify
    problems early
  • ES Care daily or 3-4 times weekly may be in
    conjunction with showering

Infection Prevention
  • Exit Site Care
  • No dressing needed for established catheter exit
    site (unit or pt specific)
  • Keep catheter secured to abdomen with 2 inch tape
  • Daily showers with liquid soap
  • Mupirocin (Bactroban ) or Gentamycin Cream at
    exit site of known staph. Carrier
  • Inpatients-dry dressing to protect site, cleaned
    with soap and water, No occlusive membrane
    dressings (Tegaderm )
  • A healed and non-infected exit site is crucial to
    longevity on Peritoneal Dialysis

  • Following peritoneal dialysis catheter
    implantation, a patient is instructed that
  • The exit will always be tender
  • Baggy clothes will have to be worn
  • The catheter will need to be changed monthly
  • Well-healed healthy exit-sites make swimming
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

Infectious Complications
Exit Site Infection
  • Teach patient to identify and report immediately
    to the PD Unit
  • Redness, tenderness, edema, presence of exudate
    either at exit site or insertion site
  • Treatment
  • Culture exudate if possible
  • Specific antibiotic protocol
  • Oral or IV/IP antibiotics depending on extent of
  • Saline soaks/dressing changes for care of local
    cellulitis (unit/Nephrologist specific)

Exit Site Infection
  • S S redness, swelling, tenderness or pain and
    purulent drainage
  • Risk Factors poor catheter healing, sutures at
    the exit site, trauma to the exit site, cuff
    extrusion and improper catheter care
  • Diagnosis Observation and culture
  • Treatment Antibiotics, IP,PO, or IV
  • vigilant daily exit site care

Exit Site Infection
  • A chronic exit site infection can produce a
    systemic inflammatory response.
  • Inflammation can lead to poor nutrition,
    inadequate dialysis and possible antibiotic
    resistance. Vital role of Dietitian
  • Chronic exit site infections may result in
  • Multiple infections can lead to removal and
    replacement of catheter.
  • Consistent assessment and documentation is needed
    to appropriately track infections.

Responsible Organisms
  • Staphylococcus Aureus
  • Pseudomonas species
  • Other Gram positive species
  • Serratia species
  • Other gram-negative organisms
  • Fungi

Tunnel Infection
  • S S
  • erythema over the tunnel
  • pain and tenderness
  • drainage from exit site no other signs of an
  • Risk factors
  • exit-site infection
  • exit site trauma
  • leak
  • external cuff extrusion
  • Treatment- antibiotic therapy to prevent need
    for catheter removal

Prevention of Peritonitis
  • Careful individualized patient training
  • Adequate daily hygiene
  • Meticulous hand washing
  • On going retraining

Prevention of Peritonitis
  • Basics of Aseptic Technique 5 min. hand scrub,
    face masks during exchanges, warming of PD bags
    using dry heat, aseptic technique for adding
  • Aseptic technique when making critical
    connections to solution containers and the
    patients transfer set
  • Masks reduce the risk of contamination with
    nasopharyngeal organisms

  • Inflammation of the peritoneal cavity
  • Defined as the presence of WBC in the effluent
    numbering 100 or greater 50 polys (neutrophil)
    or segs
  • Effluent appears cloudy and milky.
  • Patient may have fever, chills, abdominal pain,
    nausea, vomiting and diarrhea.
  • Some present initially with cloudy fluid as the
    first sign and no symptoms.
  • Patient must be taught to contact their PD Nurse
    or Nephrologist immediately for cloudy effluent.

  • Portals of Entry
  • Transluminal- technique failure, contamination
  • Periluminal- incomplete healing ,leaking
  • Hematogenous- bacteremia
  • Transmural- through the bowel wall
  • ANNA Core Curriculum

Peritonitis Presentation
  • S S fever, abdominal pain, N V, diarrhea,
    and cloudy effluent
  • Incubation 24-48 hours if within 6 hours
    suspect an enteric source
  • Kinetic effects increased solute removal and
    protein loss increased glucose absorption
    leading to a decreased osmotic gradient and
    decreased ultrafiltration

Diagnosis of Peritonitis
  • Effective culture techniques
  • Minimum sample volume of 50-100 ml. Large samples
    reduce false negative results
  • Dialysate must be mixed well by inverting bag
    several times before sampling
  • Sample port is disinfected before sampling
  • Sample is obtained using aseptic technique

  • A PD effluent cell count differential can
    determine if peritonitis is present when there is
    an elevation in ?
  • a. eosinophils
  • b. neutrophils
  • c. lymphocytes
  • d. granulocytes
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

  • Treatment protocols
  • Patient may be treated in PD unit or Emergency
    Room depending on severity of symptoms and
    availability of resources.
  • Effluent is sent for cell count, CS and gram
  • Fungal cultures should be included if patient is
    immunosuppressed or had had frequent infections
    requiring antibiotics
  • PD Unit should have specific antibiotic protocols
    for gram positive and gram negative coverage.

  • Organisms
  • Gram positive-
  • Staphylococcus epidermidis
  • Staphylococcus aureus
  • Streptococcus species
  • Enterococcus
  • Gram Negative-
  • Pseudomonas
  • Klebsiella
  • Escherichia coli
  • Enterobacter
  • Fungal organisms

  • Catheter removal is recommended when the patient
    has peritonitis associated by which of the
    following organisms?
  • Staph aureus
  • Fungal
  • Staph epi
  • Pseudomonas
  • Core curriculum for Nephrology Nursing, 5th
    Edition. American Nephrology Nurses Association

Non Infectious Complications
Non Infectious Complications
  • Pericatheter and Subcutaneous Leaks
  • Peritoneal Catheter Obstruction most commonly
    early, yet can occur at any time.
  • Hernia significant abdominal wall hernias
    should be surgically repaired prior to initiation
    of PD. Enlargement may occur due to increased
    abdominal wall pressure.

Non Infectious Complications
  • Pneumoperitoneum (Shoulder Pain) usually
    resulting from air infusion
  • Hemoperitoneum blood loss into the peritoneal
    cavity. A few drops of blood will produce
    grossly bloody effluent. Most common in women in
    menses. Any bleeding needs to be monitored.
  • Hydrothorax secondary to a pleuroperitoneal

PD Affects Drug Transport By
  • Systemic drug removal via effluent
  • Drugs can be administered IP
  • Dose related to Urine output and mechanism for
    elimination of drug

Non Infectious Complications
  • Catheter Adapter Disconnect or Fracture of
    Peritoneal Catheter. Stop Dialysis, obtain
    culture, replace or repair, prophylactic
    antibiotics pending culture results

Membrane changes
  • Sclerosing, Encapsulating Peritonitis serious,
    yet rare, not exclusive to PD
  • A thick fibrous layer of tissue encapsulates the
  • Membrane becomes thick and opaque
  • Onset gradual or rapid
  • Presentation
  • Decreased ultrafiltration and solute clearances
  • Recurrent abdominal pain
  • Intermittent nausea and vomiting
  • Partial and/or complete bowel obstruction
  • Intervention emergency laparotomy

Clinical Management Issues for the PD Patient
  • Catheter insertion and Healing of exit site
  • Prevention of infection
  • Blood pressure control Fluid management
  • Nutrition evaluation and interventions
  • Systems assessment
  • Medication evaluation
  • Anemia,Ca/Phos./PTH management
  • PET and initial Kt/V
  • Coping with stress of chronic illness
  • Transplantation

Current Issues in Peritoneal Dialysis
  • Revision of K/DOQI
  • Co-morbidities
  • Role of sodium
  • Volume Control
  • Blood pressure control
  • Utilization of Icodextrin
  • Role of inflammation
  • Integrated dialysis care
  • Improving nephrology fellow education
  • CKD education for patients and families
  • ADEMEX study-adequacy
  • European APD Outcome Study (2003)
  • Underutilization of Peritoneal Dialysis

Final Note
  • The success of PD can be attributed to the
    combined efforts of researchers, individuals on
    PD, and healthcare professionals who, in
    collaboration with the industrial community, have
    realized the potential benefits of the treatment.
    Despite a slow start in comparison to HD, PD has
    evolved into a modality that equals HD in long
    term outcomes.
  • Contemporary Nephrology Nursing p 633

Questions ??
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