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PERITONEAL DIALYSISMODERATOR : PRESENTOR:Madam Manju Singh Yogesh Kumar Tiwari LECTURER M.Sc .Nursing 1st year CON,AIIMS

Objectives At the end of the class students will be able to : Define peritoneal dialysisAnatomy and physiology of peritoneal membraneThe goals of peritoneal dialysis Indications and contra indications of PDPeritoneal dialysis access and insertion procedureThe procedure of PDDifferent types of PDComplications of PDThe advantages of PD over HDNursing management of patients undergoing PD

Anatomy

Peritoneum covers abdominal cavity,,semi permeable membrane.,,.highly vascular,,,BSA1.5-2 m2.two layers parietal &visceral...pariet-attached to abdo wall,,,viscer is wrapped arund internal organs,,,space b/w these layers peritoneal cavity,,large no. Of arteries &veins in cavity 3

PhysiologyThe semipermeable peritoneal membrane allows solutes and water to be transported from the vascular system to the peritoneal cavity and vice versa.

Peritoneal dialysis: IntroductionPeritonealdialysis(PD) is a treatment for patients with severe chronickidney disease. Adialysistechnique that uses the patient's own body tissue-peritoneal membrane inside the abdominal cavity as a filter.

Very simple and effective technique...HD uses an artificial membrane...here natural membrane is used5

Goals of PDRemove toxic substances and metabolic wastesReverse the symptoms of uremia Reestablish normal fluid and electrolyte balanceMaintain a positive nitrogen balance Prolong lifeHave the maximum level of quality of life

Uremia-urea in the blood,,,disorientation,confusion,drowsiness,,slurred speech,,coma//seizure,,hypertension,,hypocalcemia,hyponatremia,hyperphosphatemia,hyperkalemia6

Principles underlying peritoneal dialysisThree processes take place simultaneouslyDiffusion Osmosis Ultrafiltration

Treatment of choice for. Patients with RF unable or unwilling to undergo HD or renal transplantation Diabetic patients Patients with cardiovascular diseases eg:heart failure Older patients Patients at risk of adverse effects of systemic heparin Patients with severe hypertension

During HD rapid fluid & electrolyte changes occur,,pts. Who r susceptible to these prob..experience fewer prob. With PD..bcz it occurs in a slower rate...8

Contra indicationsAbsolute contra indicationsPeritoneal fibrosis and adhesions following intra abdominal operations Inflammatory gut diseases

1)Fibrotic encasement of the small intestine,,some toxins stimulate fibro blastic proliferation&reactive fibrosis 2)fibrous bands dt form b/w tissues &organs3)grp.of inflammatory condi.. Of small intes &colon 4)excess breakdown of specific substance or body tissue leads to wt.loss&wasting9

Relative contra indicationsHerniasSignificant loin painPsychosis Diverticulosis Colostomy Obesity Significant decrease of lung functions

PD catheters

Catheters for long-term use (Tenckhoff, Swan, Cruz) are usually made of silicone and are radioopaque to permit visualization on x-ray. These catheters have three sections: An intraperitoneal section with numerous openings and an open tip to let dialysate flow freely; A subcutaneous section that passes from the peritoneal membrane and tunnels through muscle and subcutaneous fat to the skin An external section for connection to the dialysate section

Catheters have two cuffs, which are made of Dacron polyester. The cuffs:stabilize the catheter limit movementprevent leakprovide a barrier against microorganism Cuff placement : adjacent to the peritoneum subcutaneously. The subcutaneous tunnel (5 to 10 cm long) further protects against bacterial infection

Types of catheters The design of a peritoneal catheter need to be such that It should give maximum inflow and outputDiscourage infectionFour main typesStraight TenckhoffCurled TenckhoffSwan-neck T- fluted

PD catheters

PD catheters

T fluted catheterTwo cuff tenckhoff catheter

Insertion techniquesBlind placement using Tenckhoff trocarBlind placement using guide wireSurgical placement by dissectionMini trocar placement using peritoneoscopy

Preinsertion preparation of the patientDetermine the catheter exit siteSite :Midline 3 cm below umbilicus Lateral site At the lateral border of the rectus musclesOn a line, half way between the umbilicus and anterior superior iliac spine Left lateral side is preferred as it avoids caecum

Pre operative care of the patientTake bath or have a shower in the morningAbdominal hair should be clippedEmpty bowel and bladder before catheter insertionEnema can be givenStaphylococcus aureus screeningAdminister antibiotics prophylactically

A trocar is used to puncture the peritoneum as the patienttightens the abdominal muscles by raising the head. The catheter is threaded through the trocar and positioned. Previously prepared dialysate is infused into the peritoneal cavity, pushing the omentum (peritoneal lining extending from the abdominal organs) away from the catheter. The physician may then secure the catheter with a purse-string suture and apply antibacterial ointment and a sterile dressing over the site

Post operative care of the patientGoals: Minimise bacterial colonisation of exit site during early healing period Prevent trauma to exit site and traction on cuffs by immobilization of catheter Minimise intra abdominal pressure to prevent leakage Do not disturb the exit site for 7-10 days Flush the catheter with 500-1500 ml of PD fluid to check patency

Composition of PD solutionComponentsNa132 mmol/lCa1.25mmol/lMg0.5mmol/lCl100mmol/lLactate35mmol/lGlucose1.36-4.25g/dlOsmolarity347-486pH5.2

To ensure hyper osmolarity.22

PROCEDUREPatient preparationExplain the procedure & obtain informed consent.Baseline vital signs, weight, serum electrolyte levels are recorded. Assess patients anxiety about the procedure.Broad spectrum antibiotics prophylactically.

PROCEDUREEquipment preparationAssemble the equipments neededCheck physicians order for the concentration of dialysate and medications to be added Heparin : to prevent clottingKCl: to prevent hypokalemiaAntibiotics : peritonitis Insulin : for diabetic patients

PROCEDUREWarm the dialysate solution to body temperature: To prevent patient discomfort and abdominal pain To dilate the vessels of peritoneum Dry heating should be done Too cold solution causes pain, cramping, and reduce clearance

To increase urea clearance.. Dry heat-heating cabinet,incubator,heating pad25

Not recommended....Soaking the bag of solution in warm waterUse of microwave to heat the fluidAvoid too cold solution

Introduce bacteria to the exterior of bag and increase chance of peritonitis....increase the danger of burning peritoneum...to reduce amnt of air entering the catheter and peritoneal cavity26

Performing the exchange Exchange :Infusion Dwell or Equilibration time Drainage

defined as the infusion, dwell and drainage of the dialysate....clearance-proces of removal of substances from blood27

PERITONEAL DIALYSIS

Performing the exchange Infusion The dialysate is infused by gravity into the peritoneal cavity. A period of about 5 to 10 minutes is usually required to infuse 2 L of fluid.

Dwell or equilibration and drainage of dialysate

The prescribed dwell, or equilibration, time allows diffusion and osmosis to occur. Diffusion of small molecules, such as urea and creatinine, peaks in the first 5 to 10 minutes of the dwell time. At the end of the dwell time, the drainage portion of the exchange begins. The tube is unclamped and the solution drains from the peritoneal cavity by gravity through a closed system.Drainage is usually completed in 10 to 30 minutes.

Performing the exchange Drainage fluidColorless or straw-colored Should not be cloudyBloody drainage may be seen in the first few exchangesEntire exchange time1 to 4 hours (depending on prescribed dwell time)

Performing the exchange No.of exchanges According to patients physical status and acuity of illnessDextrose solutions Dextrose solutions of 1.5%, 2.5%, and 4.25% are available in several volumes, from 500 mL to 3,000 mL, allowing the dialysate selection to fit the patients tolerance, size, and physiologic need

Types of peritoneal dialysisContinuous ambulatory peritoneal dialysis (CAPD)Automated peritoneal dialysis (APD)Continuous cycling peritoneal dialysis ( CCPD) Intermittent peritoneal dialysisNocturnal(nightly)intermittent peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD)Carried out during day time , manually by patients or by caregivers Dialysis fluid is infused to the peritoneal cavity Dwell time for between 3 - 10 hrsMost suitable for patients whose membrane transport solutes at a slow to average rate

Automated peritoneal dialysis-is performed through a cycler machine. -during the night when thepatient is asleep.

Continuous cycling peritoneal dialysis

Patient carries PD solution in the abdominal cavity through out the day but performs no exchanges.At bedtime ,patient hooks upto the cycler ,which drains and refills the abdomen with solution three or more times in the course of the night.

Intermittent peritoneal dialysis(IPD)Intermittent peritoneal dialysis is offered topatients on a temporary basis when their blood pressure is low or in children with acute renal failure to tide over a crisis.It is performed for a short period of 12-24 hours,2-3 times weekly.Common routine hourly exchange consists of 10 min infusion, 30min dwell time and a 20 min drain time.

Nocturnal intermittent peritoneal dialysisPatient drains out fully at the end of the cycling period, so the abdomen is dry all day.Clearances are lower on NIPD.

Assessing peritoneal dialysis adequacyCreatinine clearanceA solute removal test based on the body surface area General well being

Creat clara >70/L/wk/1.73 m2....urea clear >2.1/wk creat molecular wt.113Da urea mole wt, 60 Da39

Dialysis related problems Protein lossProtein loss through the peritoneal membrane @ 6- 12g/day in a PD patientTo compensate for this PD patients need to eat between 1 1.2 g/ kg body weight/ dayThe loss is increased during peritonitis Other substances lost in dialysate are amino acids, water-soluble vitamins, hormones and some medications

Dialysis related problems Cardio vascular and lipid problemsIncreased glucose absorption from the PD fluidRaised intra abdominal pressure Can cause hernias & dialysate leakage around the insertion site If leakage occurs , PD must be ceased for a short period

Dialysis related problems

Drainage problemsReasons can be Kinks in the tubingConstipationFibrin formationMilking can be done Heparin administrationStreptokinase or urokinase in 0.9% NaClMalpositioned catheter

Dialysis related problems

Blood stained effluentIn menstruating females; due to endometriosis or retrograde bleeding through fallopian tubeSevere intraperitoneal bleeding ; due to straining while lifting a heavy object or suffering trauma to abdomenShoulder pain Following infusion of fresh dialysate Referred pain caused by intra abdominal pressure or air under the diaphragmResolve within 20 min; analgesics can be given

Infectious complicationsPeritonitis Most common and most serious complicationDiagnosis Cloudy PD effluent Abdominal pain , tenderness , pyrexia Identification of micro organisms in PD effluent in culture or positive gram staining

Infectious complications

Treatment Initial one to three rapid exchanges with 1.5% dextrose solution to wash out mediators of inflammation Drainage fluid examined for cell count , Grams stain, culture Intraperitoneal or intravenous antibioticsUnresolved peritonitis after 4 days of appropriate therapy necessitates catheter removal

Infectious complications

Exit site infectionThe presence of purulent drainage with or without erythema of the skin at catheter epidermal interface.Tunnel infection Can present as an extension of the exit site infection into the catheter tunnel. Swelling, pain and redness over the subcutaneous tunnel may be observed.Management Culture of drainage Antibiotic therapy

Advantages of PD over HDEasy to use without sophisticated equipmentsEasy to manage in home and community health care facilitiesmore independence and mobilityDialysis treatment of choice for childrenMay allow better blood pressure and volume control with cardiovascular benefits May give better quality of life Lower risk of Hepatitis CEqual or better survival in early years

Nursing management Potential for developing infection related to the catheter Assess the site for any signs of infection; any redness, rebound tenderness, swelling, drainage from the exit site or change in vital signs Maintain strict aseptic technique while carrying out the procedure

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Nursing management

Potential for developing cardiac and respiratory complications related to the uremic state and presence of fluid in the peritoneum Frequent cardiac and respiratory assessment Watch for signs of fluid accumulation; heart failure, and pulmonary edema Auscultate the base of lungs for crackles Assess for signs of pericarditis; substernal pain, low grade fever, and pericardial friction rub.

Nursing management

Acute pain and abdominal discomfort related to the dialysate infusion Warm the dialysate to body temperature

Altered nutrition less than body requirement related to the protein loss High protein, fiber rich well balanced diet Limit carbohydrate intake

Nursing management Knowledge deficit related to care of catheter site Teach the patient the possible signs of infection Catheter care should be done daily Avoid tub bath and exit site should not be submerged in water

Nursing management Altered body image related to the abdominal catheter and bag and tubing Assess for any such problem Allow the patient to express his feelings and concerns about body image disturbances. Assist in selecting of proper clothing Provide an opportunity to the patient to meet similar patients who are well adjusted with the condition

Nursing management Altered sexual patterns and sexual dysfunction Provide privacy to the patient so that he can discuss his problem Nurse can start the discussion by asking about any concerns related to sexuality

ConclusionLong term outcomes associated with peritoneal dialyses are good.The treatment is usually effective for years.However scarring of the peritoneum and repeated infections may require a change to hemodialysis.