peritoneal dialysis (pd) protocols...

Peritoneal Dialysis (PD) Protocols Manual

By: Sonia Champoux B.Sc.(N), C.Neph(C)

(PD nurse, Renal clinic)

Designed by: Alexander Tom B.Sc.

Giuseppe Pascale

Staff consultants:

Dr. Lorraine Bell

Dr. Martin Bitzan

Dr. Beth Foster

Dr. Indra. Gupta

Dr. Paul Goodyer

Dr. Michael Zappitelli

August 2018

Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 © 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale

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TABLE OF CONTENT

1 PRE-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS ................. 6 1.1 Purpose: Patient preparation ........................................................................................................ 6 1.2 Target audience ............................................................................................................................ 6 1.3 Elements of clinical activity ........................................................................................................... 6

1.3.1 Medication Protocol .................................................................................................. 6 2 POST-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS ............... 7

2.1 Purpose: Catheter break-in ........................................................................................................... 7 2.2 Target audience ............................................................................................................................ 7 2.3 Elements of clinical activity ........................................................................................................... 7

2.3.1 Theory ...................................................................................................................... 7 2.3.2 Break-In Protocol ...................................................................................................... 8 2.3.3 Maintenance phase .................................................................................................10

2.4 Summary Reference Table ......................................................................................................... 12 3 NON-INFECTIOUS PERITONEAL DIALYSIS COMPLICATIONS ................................................ 13

3.1 Purpose: PD complications ......................................................................................................... 13 3.2 Target audience .......................................................................................................................... 13 3.3 Elements of clinical activity ......................................................................................................... 13

3.3.0 Summary of PD Complications and Corrective Measures .......................................14 3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK ...........................15 3.3.2 Protocol for the Treatment of OUTFLOW FAILURE ................................................17 3.3.3 Protocol for the Treatment of DEHYDRATION ........................................................17 3.3.4 Protocol for the Treatment of FLUID OVERLOAD ...................................................18 3.3.5 Protocol for the Treatment of MUSCLE CRAMPS ...................................................18 3.3.6 Protocol for the Treatment of AIR in the PERITONEAL CAVITY .............................18 3.3.7 Protocol for the BLOOD IN PD EFFLUENT .............................................................19 3.3.8 Protocol for the Protein Loss ...................................................................................19 3.3.9 Protocol for ACCIDENTAL DISCONNECTION (Refer to Section 10.4) ...................19 3.3.10 Protocol for PAIN DURING DIALYSATE INFLOW ...................................................19 3.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORING SYSTEM ............................................................................................................................20 3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING ................................................24 3.3.13 Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections 31 3.3.14 Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients ..........32

4 CHOICE OF PD SOLUTIONS & COMPOSITIONS ....................................................................... 33 4.1 Purpose ....................................................................................................................................... 33 4.2 Target audience .......................................................................................................................... 33 4.3 Elements of clinical activity – Summary ...................................................................................... 33

4.3.1 PHYSIONEAL Physiological requirements .............................................................34 4.3.2 Other solutions available: NUTRINEAL ..............................................................36 4.3.3 Other solutions available: EXTRANEAL ..............................................................37

5 ROUTINE PD CARE, PRECAUTIONS & MISCELLANEOUS INFORMATION ............................ 38 5.1 Purpose ....................................................................................................................................... 38 5.2 Target audience .......................................................................................................................... 38 5.3 Elements of clinical activity ......................................................................................................... 38

5.3.1 Shower & Bath ........................................................................................................38 5.3.2 Activities & Sports ...................................................................................................39

6 BASIC PREPARATION PROCEDURE .......................................................................................... 40 6.1 Purpose ....................................................................................................................................... 40


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6.2 Target audience .......................................................................................................................... 40 6.3 Elements of clinical activity ......................................................................................................... 40

6.3.1 Basic preparation procedure ....................................................................................40 6.3.2 EXIT SITE CARE – DRESSING CHANGE ..............................................................43

7 HOMECHOICE CYCLER PREPARATION PROCEDURE ............................................................ 48 7.1 Elements of clinical activity ......................................................................................................... 48

7.1.1 BAG PREPARATION: Physioneal 5 liters ................................................................48 7.1.1 BAG PREPARATION: Physioneal 5 liters (continued) .............................................51 7.1.2 BAG PREPARATION: Procedure for adding medication with Physioneal 5 liters ....52

7.2 Purpose ....................................................................................................................................... 53 7.3 Target audience .......................................................................................................................... 53 7.4 Elements of clinical activity ......................................................................................................... 53

7.4.1 CYCLER PREPARATION .......................................................................................53 61 7.4.3 CYCLER PREPARATION – Prime the lines ............................................................62 7.4.4 CYCLER PREPARATION – Nurses Menu ..............................................................63 7.4.5 CYCLER PREPARATION – Connection with a PEDIATRIC Cycler Tubing with Cassette .............................................................................................................................68 7.4.5 CYCLER PREPARATION –Connection with a PEDIATRIC Cycler Tubing ..............69 7.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing.........70 7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System ........................................................................72 7.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system or CAPD Twin Bag Manual System ........................................................................................75

8 PERITONEAL DIALYSIS BAG PREPARATION ........................................................................... 78 8.1 Purpose ....................................................................................................................................... 78 8.2 Target audience .......................................................................................................................... 78 8.3 Elements of clinical activity ......................................................................................................... 78

8.3.1 How to ADD a Bag During Dialysis ..........................................................................79 8.3.2 How to CHANGE a Bag During Dialysis ..................................................................82

9 MANUAL CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) ............................. 85 9.1 Purpose ....................................................................................................................................... 85 9.2 Target audience .......................................................................................................................... 85 9.3 Elements of clinical activity ......................................................................................................... 85

9.3.1 CAPD manual set-up with TWIN BAGS ...................................................................86 10 PROCEDURE FOR ATTACHMENT OF EXTENSION TUBING .................................................... 96

10.1 Purpose ....................................................................................................................................... 96 10.2 Target audience .......................................................................................................................... 96 10.3 Elements of clinical activity ......................................................................................................... 97

10.3.1 How to attach TITANIUM adaptor to Pd catheter ....................................................97 10.4 Accidental Disconnection ............................................................................................................ 98 10.5 ACCIDENTAL CONTAMINATION ............................................................................................. 99

10.5.1 Basic Rules .............................................................................................................99 10.5.2 Accidental Contamination prior to PD Treatment ................................................... 100 10.5.3 Accidental Contamination at the start of PD Treatment ......................................... 101 10.5.4 Accidental Disconnection Between the Extension and Tubing ............................... 102

10.6 Elements of clinical activity ACCIDENTAL DISCONNECTION ............................................. 104 10.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET ............. 104 10.6.2 How to change the Transfer Set and a titanium connector of the PD catheter when it is damaged ....................................................................................................................... 107


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11 PROCEDURE TO COLLECT A DIALYSATE EFFLUENT SAMPLE .......................................... 111 11.1 Purpose To maintain an aseptic environment while collecting a dialysate effluent sample ..... 111 11.2 Target audience ........................................................................................................................ 111 11.3 Elements of clinical activity ....................................................................................................... 111

11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag with cycler 112 11.3.2 How to collect a sterile effluent sample via a seringe attached to the extension .... 117 11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE ................................................................................................................... 118 11.3.4 How to collect an effluent sample via the PEDIATRIC SETUP .............................. 121

12 SET-UP PROCEDURE FOR A PEDIATRIC MANUAL CAPD SYSTEM .................................... 122 12.1 Purpose ..................................................................................................................................... 122 12.2 Target audience ........................................................................................................................ 122 12.3 Elements of clinical activity ....................................................................................................... 122

12.3.1 FRESENIUS STAYSAFE SETUP.......................................................................... 122 122 12.3.2 How to set-up the pediatric manual CAPD system ................................................ 123

12.4 How to set-up the pediatric manual CAPD system: Quick reference ....................................... 123 12.4.1 How to set-up the pediatric manual CAPD system ................................................ 125

12.5 Procedure for Connection/Disconnection with Pediatric Setup - STAYSAFE Connection Procedure .............................................................................................................................................. 130

12.5.1 Purpose ................................................................................................................. 130 12.5.2 Target audience .................................................................................................... 130 12.5.3 Elements of clinical activity .................................................................................... 130 12.5.4 FRESENIUS STAYSAFE CONNECTION procedure ............................................. 131 12.5.5 FRESENIUS STAYSAFE DISCONNECTION procedure ....................................... 133

13 PROCEDURE FOR STAYSAFE CATHETER ADAPTER INSTALLATION................................ 134 13.1 Elements of clinical activity ....................................................................................................... 134

13.1.1 FRESENIUS STAYSAFE CATHETER ADAPTER INSTALLATION procedure ...... 134 14 PROCEDURE FOR HEPARINIZATION WITH PEDIATRIC SETUP ........................................... 136

14.1 Elements of clinical activity ....................................................................................................... 136 14.1.1 FRESENIUS STAYSAFE SAMPLE PORT CONNECTION PROCEDURE ............ 136

15 PROCEDURE TO SAFELY DISPOSE OF BIOLOGICAL DIALYSATE EFFLUENT .................. 138 15.1 Purpose ..................................................................................................................................... 138 15.2 Target audience ........................................................................................................................ 138 15.3 Elements of clinical activity ....................................................................................................... 138

16 PROCEDURE TO CHART DIALYSIS EXCHANGES .................................................................. 139 16.1 Purpose ..................................................................................................................................... 139 16.2 Target audience ........................................................................................................................ 139 16.3 Elements of clinical activity ....................................................................................................... 139 16.4 PROCEDURE TO CHART DIALYSIS EXCHANGES ............................................................... 140 PERITONEAL DIALYSIS RECORD ...................................................................................................... 140

17 PROCEDURE TO MANAGE A BLOCKED PD CATHETER WITH TPA (rt-PA) PROTOCOL (ALTEPLASE) .......................................................................................................................................... 141

17.1 Purpose ..................................................................................................................................... 141 17.2 Target audience ........................................................................................................................ 141 17.3 Elements of clinical activity ....................................................................................................... 141

18 PROCEDURE TO PERFORM A PERITONEAL EQUILIBRATION TEST (PET PROTOCOL) .. 142 18.1 Purpose ..................................................................................................................................... 142 18.2 Target audience ........................................................................................................................ 142 18.3 Elements of clinical activity ....................................................................................................... 142

18.3.1 How to perform a PET test .................................................................................... 143


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19 PROCEDURE TO PERFORM AN INTRAABDOMINAL PRESSURE MESUREMENTS (IPP) .. 147 19.1 Purpose ..................................................................................................................................... 147 19.2 Target audience ........................................................................................................................ 147 19.3 Elements of clinical activity ....................................................................................................... 147


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1 PRE-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS

1.1 Purpose: Patient preparation

This protocol has been developed to prepare the patient for the OR and minimize the chances of infection post-op.

1.2 Target audience

Nursing and medical staff responsible for the care of the peritoneal dialysis patient.

1.3 Elements of clinical activity

1.3.1 Medication Protocol

The following medications should be administered as per instructions listed in Table 1-1.

Table 1-1: Medications pre-OR

Step Medication Dose Maximum dose Instructions

1 Saline enema until clear

10–20 cc / kg The day of surgery or the evening before.

2 DDAVP (IV) 0.3 mcg / kg in 50 cc NS

Maximum final concentration: 0.5 mcg / ml

Maximum dose : 20 mcg

To be given 30-60 min before OR (peak activity at 1 hour).

3 CEFAZOLIN (Ancef) (IV)

20 mg / kg 1 gram 1 hour pre-op or with induction of anesthesia

4 BACTROBAN (Mupirocin)

If needed1

5 days in the nose Bid

Q month2

Apply for a positive nose culture for staphylococcus aureus.

5 BACTROBAN (Mupirocin)

or Gentamicin cream If needed

3

Small quantity at the exit site Only when the exit site is healed

Requested by the nephrologist

Apply for positive culture for staphylococcus aureus

¹ Nasal swab for culture: swab the two nostrils with the same swab. If patient is positive in the nose for S. Aureus, then treat with bactroban

² If the patient is using BACTROBAN in the nose, the patient should then be treated the first 5 days of each month bid.

Note: Nose cultures are to do be done monthly in the renal follow-up clinic. No more cultures are required if staphylococcus aureus carrier status is positive. We should test the care giver as well.

3 . If positive for S. Aureus, nephrologist should order antibiotic cream as described in the Table 1-1.

For all medications listed above, please refer to their policy for indications, contraindications, dosages

and precautions.


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2 POST-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS

2.1 Purpose: Catheter break-in

This protocol has been developed to care for the patient and peritoneal catheter immediately post-OR.

2.2 Target audience



2.3.1 Theory

The break-in period refers to the time immediately following catheter insertion.

The purpose of the break-in procedure is to:

a. clear the intra-peritoneal blood and fibrin from the catheter, and

b. minimize the possibility of omental adhesion, and

c. reduce the incidence of leakage by maintaining low intra-abdominal pressure.

i. Leakage delays the ingrowth of fibrous tissue into the catheter cuff which provides a medium for bacterial growth. This may lead to peritonitis or an exit-site infection.

ii. Intra-abdominal pressure is minimized by the restriction of:

dialysate volume, and

patient activity.

It is preferable to delay continuous ambulatory peritoneal dialysis (CAPD) (i.e., chronic dialysis), if possible for 2 to 4 weeks after catheter implantation.


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2.3.2 Break-In Protocol

Table 2-1: Break-In Protocol: Immediate post-insertion period, usually 12-16 hours

Step Procedure Instructions

1 X-Ray (plain film) To be done in recovery room and should be reviewed. Break-in protocol (i.e., peritoneal dialysis) can be initiated as soon as patient is back on the medical-nephrology floor.

2a Rapid in-out exchanges until clear (about 3 exchanges) by infusing into peritoneal cavity.

These exchanges may be done

a) manually (i.e., nurse infuses dialysis fluid using a “twin bag” system), or

b) using the cycler, on “Hi-dose” mode (or OCPD mode).

Done by ward nurse or PD nurse

PD solution: Suggest using 1.36% physioneal solution unless MD suggests otherwise.

Volume 10ml/kg

ADD to PD solution:

HEPARIN 1000 units/L in dialysate bag

250 units/L for NICU & PICU baby

Continue adding heparin to the PD solution for the 1st week, then reassess

CEFAZOLIN 250 mg/ L for the first 12–16 hrs. Stop the morning post-catheter insertion. Individualize according to patient’s status.

2b When dialysate (effluent) is clear, begin hourly exchanges

i. 50 min. dwell (including filling time),

10 min. drain. Note: when using cycler, the cycler will determine the drain time.

2c Repeat cycles hourly for 12-16 hours or less

Individualize according to patient’s status.

2d Repeat all of Step 2 for 8 more hours ONLY IF criteria to the right is fulfilled

i. Only if after 16 hours there is unclear and/or coloured dialysate and/or with inappropriate draining.

Reassess.

2e Proceed to the Maintenance Phase (i.e., wait for chronic dialysis or if necessary, start)

After ~12-16 hours of clear & colourless dialysate with appropriate draining.

3 Prescribe antiemetic PRN for nausea/ vomiting and for pain

See nausea and pain post-PD catheter insertion protocol next page.

Suggest First line: :Ondansetron 0.1 mg/kg iv every 6 hours PRN or

Second line: Dimenhydrinate 0.5 -1mg/Kg/dose iv every 6 hours PRN

4 Pain Management See nausea and pain post-PD catheter insertion protocol. Suggest Dilaudid or morphine, depending on age and PO status.

5 Use stool softeners Colace or Docusate: 5 mg / kg / day bid

Or Lax- a- Day

For all medications listed, refer to their policy for indications, contraindications, dosages and

precautions.


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2.3.2 Break-In Protocol (continued)

Table 2-1a: Nausea and pain protocol post Peritoneal Dialysis Catheter insertion

1 Antiemetics First line: Ondansetron 0.1 mg/kg IV every 6 hours PRN (max 4 mg/dose)

Second line: Dimenhydrinate 0.5mg/kg/dose PO/IV every 6 hours PRN (max 25 mg/dose if less 6 years old; max dose 35mg if 6-12 years old; max dose 50 mg if over 12 years old)

2a Pain management

Non-opioid analgesic

Acetaminophen (refer to MUHC Pediatric drug formulary for updated dosage

recommendations):

i. Term infants more than 10 days old and children/adolescents: 10-

15 mg/kg/dose (max. 75 mg/kg/day) every 6 hours regular for 48

hours then PRN

GFR <10mL/min./1.73m2, intermittent peritoneal dialysis: adjust

administration frequency to every 8 hours.

2b Pain management

Opioids IV

First line: HYDROmorphone

i. 0.01 mg/kg IV every 4 hours PRN (For small patient, dilution may be

required for a final concentration of 0.1 mg/mL = 2 mg of

hydromorphone in 19 mL of NS)

Second line: Morphine

ii. Avoid Morphine (active metabolites may increase duration of action and

increases risk of accumulation with renal dysfunction). If used, adjust

interval: e.g. 0.03-0.05 mg/kg every 6-8 hours PRN. Evaluate the effect

and readjust the dose/interval. Avoid in children less than 3 months old.

Max dose 3 mg iv.

Antidote for Morphine: Nalaxone

< 20 kg: 0.01– 0.1 mg/ kg / dose q 3-5 min

> 20 kg: 2 mg / dose q 3-5 min IV, SC, IM.

2c Pain management

Opioids ORAL

>35 kg: HYDROmorphone 0.03 mg/kg PO every 4 hours PRN (tablet) max dose 15 mg

≤35 kg: Morphine 0.15 mg/kg PO every 4 hours PRN (pill or suspension)

Recommendations from APS 2017 05 19

Dr Chantal Frigon

Annik Otis CSN


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2.3.3 Maintenance phase

Table 2-2: Maintenance Phase for patients not in need of immediate dialysis


1 Perform an In/Out exchange

(zero dwell-time)

This will be done by PD nurse, either by manual exchange or using cycler.

i. Once per week (or as assessed by Nephrologist), perform an In/Out exchange (zero dwell-time),

ii. Using 15 ml / kg or volume of last fill (e.g., if previous fill volume was 10 ml/kg) of 1.36% Dextrose dialysate (Physioneal).

Ideally, if patient’s condition is allowing it, we should not use the catheter for 2 weeks to a month for dialysis. The PD nurse should perform an in/out exchange once per week. ADD heparinized 1000 units per liter or 250 units per liter for baby in NICU & PICU to dialysis fluid. We could increase frequency of exchanges if presence of fibrin.

2 Heparinize PD catheter with transfer set extension or catheter adapter

Patients > 15 kg:

i. Infuse 5 – 10 ml/kg as last fill volume (same solution as box1 of this table)

ii. Inject 4.0 cc heparinized saline into the catheter using the syringe that is attached at the end of the Baxter transfer set (MMS 068746)

iii. HepNS: Heparin 300 Units/ml concentration for a total of 4.0 cc [ mix: 1.2 ml Heparin (1000 U/ml) + 2.8 ml NS ]

After HepNS injection, close the system with a proviodine Mini Cap (MMS 023005)

Patients < 15 kg:

i. Infuse 5 – 10 ml/kg as last fill volume (same solution as box1 of this table)

ii. Inject 3.0 cc HEPALEAN (100 Units/ml) into the catheter using a syringe attached at the end of the Baxter transfer set (MMS 068746)

After HepNS injection, close the system with a proviodine Mini Cap (MMS 023005)

NICU & PICU babies: ask nephrologist for heparin concentration

i. Infuse 5 – 10 ml/kg as last cycle volume, (same solution as box1 of this table)

Inject 2.5 cc [25, 50, or 100 Units/mL HEPALEAN] Using the Fresenius Stay-Safe sample port (MMS 91532 )

Close the system with a Fresenius Stay Safe Cap (MMS 072101).

Should be done by the PD nurse

3 Notify the nephrologist for any fibrin strands


and precautions.


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2.3.3 Maintenance phase (continued)

Table 2-3: Maintenance Phase for patients in immediate need dialysis


1 Infuse dextrose dialysate containing 1000 Units/Liter of Heparin: (concentration ordered by nephrologist).

Use dialysate with 250 units/Liter of Heparin for the NICU & PICU.

Time Period Volume (ml / kg)

1st 24 hours 10 ml / kg,

2nd

24 hours 15 ml / kg,

3rd

24 hours 20 ml / kg for 4 weeks,

then 25 ml / kg for 1 week,

then 30 ml / kg for 4 -8 weeks.

To be reassessed after 8 weeks.

If needed, 10 or 15 ml/kg volumes may be continued for a longer period (e.g., respiratory compromise; leak risk)

Notes:

i. Ambulation is not permitted when the abdomen is filled with the regular volume for the first 6 weeks. Mobilization is permitted if the patient is filled with the last fill.

ii. The sitting position is not permitted when filled with the regular volume for the first 2 weeks (except the last low-volume fill).

iii. Heparin in the dialysate should be started at 1000 Units / liter for the first week, then decreased to 500 Units / litre for the 2

nd week – if no fibrin. Use 250 units per liter in the NICU

& PICU.

iv. If there is no presence of fibrin strands or blood clots, Heparin can be discontinued from the dialysis solution two weeks post-catheter insertion.

v. CAPD or manual dialysis may be started 2-4 weeks post PD catheter insertion with volume starting at 20 ml/kg

vi. The healing period of the PD catheter exit site may take 6 – 12 weeks.


and precautions.


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2.4 Summary Reference Table

Table 2-4: Summary of Initial Treatment Protocols & Adminstration

Protocol Pre-catheter insertion Week 1

Week 2 1

st 24hrs 2

nd 24hrs 3

rd 24hrs

Antibiotics Cefazolin IV Cefazolin IP

x 12 hrs – 16 hrs

Heparin

1000 units/L

250 units/L NICU & PICU

Decrease to 500 units/L and D/C if no presence of fibrin or blood clots

Medication PRN

antiemetic

Investigation Treatment

Saline enema evening prior to surgery -nasal swab

X-Ray (Plain film)

Table 2-5: Summary of PD Prescription

Protocol

Week 1

Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 1st

24hrs 2

nd

24hrs 3

rd

24hrs

CAPD No Possible

as per MD Yes

Cycles 3x In & Out until clear

reassess with MD

Effluent Procurement

x 1 x 1 x 1 Q

week Q

month

PD Volume 10

mL / kg 15

mL / kg

20

mL / kg 25

mL / kg

30 mL / kg x 4–8 weeks.

Reassess with MD

Solution 1.36%

Physioneal reassess with MD

reassess with MD

Exit Site (drsg change)

x 1 Q

week at least

3x week

Table 2-6: Summary of PD Precautions

Protocol Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Ambulation only with last fill allowed at all times

Shower x 1/week with

waterproof dressing

Prefer exit site covered. Could be allowed at all times with exit site exposed to air if well healed after assessment of the PD nurse.

Sitting only with last fill Allowed at all times

Sports / Swimming

No After 8 weeks. See Special Recommendations in Protocol

For all medications listed above, please refer to their policy for indications, contraindications, dosages and precautions.


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3 NON-INFECTIOUS PERITONEAL DIALYSIS COMPLICATIONS

3.1 Purpose: PD complications

This protocol has been developed to describe the possible complications associated with peritoneal dialysis treatments.

3.2 Target audience



Executive Summary - The following table (Table 3-0: Summary of PD Complications and Corrective Measures) describes in brief the most well-established complications associated with peritoneal dialysis treatments. This is by no means a comprehensive list, and any signs, symptoms or unanticipated complications should be referred to the nephrologist on-call.


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3.3 Elements of clinical activity (continued)

3.3.0 Summary of PD Complications and Corrective Measures

Table 3-0: Summary of PD Complications and Corrective Measures

PD complications Confirm Diagnosis Corrective measures

1. PD catheter leak (refer to Section 3.3.1)

a. Confirm leak with glucose dipstick

b. Imaging with peritoneal infusion

i. Discontinue dialysis for 7 to 10 days.

Low volume dialysis

2. Outflow failure (refer to Section 3.3.2 )

Abdominal X-ray (plain film & lateral) for catheter position

i. Improve bowel motility/treat constipation

Heparinize dialysis fluid and/or Infuse TPA in PD catheter

Reposition PD catheter under fluoroscopy

3. Dehydration (refer to Section 3.3.3)

a. Excessive UF, past patient dry weight

b. Unadjusted fluid loss / fluid intake

c. Nausea/vomiting (R/O peritonitis)

i. Notify nephrology staff. Reassess dry weight

↑ BP: hold PD exchange/dwell, ↑ fluid/salt intake

↓ PD dextrose concentration

Bed rest with legs elevated or restrict activity

4. Fluid overload (refer to Section 3.3.4)

a. Inadequate UF, over patient dry weight

b. Unadjusted fluid loss / fluid intake

c. Hypotonic PD solution

d. Excessive dwell time

i. Notify nephrology staff. Reassess dry weight

↓ fluid / salt intake

↑ PD dextrose concentration

Reassess fluid intake and output

5. Muscle cramps (refer to 3.3.5)

a. Excessive UF

b. Too rapid UF (esp.3.86% solution 4.25%)

c. Electrolyte imbalance (↓Ca++

, ↓K+)

i. Notify nephrology staff

Check serum electrolytes and calcium

Relief measures: apply heat to area, rub cramp

6. Air in peritoneal cavity (refer to 3.3.6)

a. Infusion of air with the dialysate

b. Misplacement of the catheter

c. Bowel perforation

i. Usually resolves in a few days (shoulder pain)

Notify physician if pain persists

Lie patient on back, pillow under hips & drain patient

7. Blood in effluent (refer to 3.3.7)

a. Menstruation / ovulation

b. Rupture of tiny peritoneal capillaries, 2º to ↑ Tº solution or activities

c. Possible serious abdominal injury

Call nephrology staff immediately

i. Pink: clears up in 2-3 exchanges w/o treatment

Bloody fluid: check BP and HR. Observe patient. Adjust Heparin → prevent clotting of PD catheter

8. Protein loss (refer to 3.3.8)

Avg protein in effluent: 9 gm/day

a. protein through PD membrane

b. Peritonitis can ↑ protein loss

i. Check serum Albumin and Total Protein

Call nephrology & dietician to modify protein diet

9. Accidental disconnection (refer to Section 11.3.1) refer to Accidental Disconnection Protocol

10. Pain during dialysate inflow (refer to Section 3.3.10)

a. “Jet “ effect

b. Abnormally high Tº PD solution

c. Omental attachment to PD catheter

d. Excessive pressure elsewhere

i. Slower infusion rate

Incomplete drainage

Reposition PD catheter

11. Infection (refer to Section 3.3.11)

a. Exit site infection

b. Tunnel infection

c. Peritonitis

i. Call nephrologist

Manage with cultures and antibiotics required

MCH guidelines 3.3.11 (consult ISPD guidelines)


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3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK

A peritoneal catheter leak is a consequence of the loss of peritoneal membrane integrity (an opening or a tear in the membrane). This usually becomes apparent in the first weeks or months of use, as the patient becomes more active. There are 2 types of leaks: early (within 30 days of PD catheter insertion) and late leaks.

Table 3-1: Peritoneal catheter leak and Corrective Measures

Signs & Symptoms Confirm Diagnosis Corrective measures

Overt fluid leakage at the skin exit site

Subcutaneous swelling, local or generalized edema and/or local pallor

Weight gain

Diminished outflow volume or outflow failure (or “ultrafiltration failure”)

a. Confirm leak with glucose dipstick at exit site. The glucose dipsticks are in the PD cart in the PD teaching room or you may use the UA dipstick in the microscope room.

b. CT scan for peritoneal infusion

Nuclear scan or CT with peritoneal infusion is preferred with a suspected leak. May not be needed if leak is obvious.

The nephrologist will arrange the Nuclear Medicine scan with the radiologist.

c. Ultrasound of abdominal wall may sometimes be useful to document leak.

i. Discontinue dialysis for 7 to 10 days.

If discontinuation is not possible due to the patient’s condition, return to the Break-in Schedule (10–20 ml per kg or 250-500 ml/m2) for 2–3 weeks. Perform dialysis only in the supine position, to minimize intra-abdominal pressure.

If leakage persists, stop PD and switch to hemodialysis for 3–6 weeks.

If the leakage remains refractory, the PD catheter must be

replaced.

Surgery repair needs to be considered in some situations.


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3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK (continued)

CT scan: Computed Tomography with radio contrast material


Table 3-1a: The Nuclear Scan

Procedure to prepare the patient for a Nuclear Medicine scan with a suspected PD catheter leak

i. Empty the peritoneal cavity

The radiologist will come to inject the radioactive dye using a syringe attached to the transfer set prepared by the PD nurse (must do the basic procedure). Ideally to be done by PD nurse. Thus, the dye is being injected into the peritoneal cavity.

As per nephrology recommendations, fill the patient’s regular infusion volume with Physioneal1.36% or Dianeal 1.5% Dextrose.

Make sure patient remains in a supine position. After a 2 hours dwell, the patient will go to Nuclear Medicine to have some images taken.

Drain the abdominal cavity completely, followed by a peritoneal lavage with Physioneal 1.36% Dextrose (PD nurse does this – using twin bag set up). Leave the abdominal cavity empty. Heparinize the PD catheter as per protocol if not used.

Table 3-1b: The CT Scan

Procedure to prepare the patient for a CT scan with a suspected PD catheter leak

i. Empty the peritoneal cavity. Have emergency medications at the bedside (diphenhydramine 1.5 mg/kg, max 50mg IV; hydrocortisone 5 mg/kg, max 200 mg IV; epinephrine SC (1:1000 solution) 0.01ml or 0.01 mg/kg, max 0.5 mg.

Add 50 ml of OMNIOPAQUE 300 (Iohexol 300 mg/ml) in a 2 liter bag. (Add 62.5 ml in 2.5 liter bag).

Note: This is being done using the twin bag set up by the PD nurse. (they are 2L bags)

Infuse the intraperitoneal volume prescribed by the physician. Call 22138 Radiology when the infusion is complete.

Approximatively one hour after the infusion, CT scan can take place.

After the CT, drain the abdomen and perform 2 – 3 In’s & Out’s by manual exchange (can be done with cycler, on the Hi-dose (or OCPD)


17

3.3.2 Protocol for the Treatment of OUTFLOW FAILURE

Table 3-2: Peritoneal Outflow Failure and Corrective Measures


The effluent volume is consistently less than inflow volume, with no evidence of a pericatheter leak

It is often associated with irregular outflow, fibrin in the effluent, or constipation

Often associated with catheter migration and omental wrapping

May occur with peritonitis

Abdominal X-ray (plain film & lateral)

Look for catheter malposition or constipation

i. Improve bowel motility (laxative or saline enema, ambulation).

Heparinize dialysis fluid if fibrin strands are visible (500–1000 units per liter).

Infuse TPA into the catheter (see protocol attached section 18.1)

Reposition PD catheter under fluoroscopy(peritoneoscopy). Consult Surgeon.

If none of the above applies, refer to Pericatheter Leak (i.e., consider leak).

3.3.3 Protocol for the Treatment of DEHYDRATION

Table 3-3: Dehydration and Corrective Measures


Hypotension

Cramping in patient's fingers, feet, or toes

Orthostatic drop in blood pressure

Weakness and dizziness

Decrease in body weight

Cloudy effluent (bladder & bowel perforation)

a. Inaccurate assessment of the patient’s dry weight

b. Removal of too much fluid from the patient

c. Inadequate fluid intake

d. Abnormal fluid loss

e. Diarrhea

f. Nausea and vomiting → this could be sign of peritonitis & may lead to dehydration


Reassess dry weight

Raise BP: Hold exchanges until BP is higher – keep in dwell – always reassess babies with nephrologist

Accurate oral fluid administration to patient

Increase salt intake. If unstable, NS fluid bolus.

Use lower strength of dextrose dialysate concentration

Restrict activity until BP is higher Bed rest with legs elevated



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3.3.4 Protocol for the Treatment of FLUID OVERLOAD

Table 3-4: Peritoneal Fluid Overload and Corrective Measures


Hypertension

Edema

Shortness of breath

Increase in weight

Congestive heart failure and / or pulmonary oedema

a. Inaccurate assessment of the patient’s dry weight

b. Imbalance of intake & output

c. Excessive oral fluid intake

d. Inadequate ultrafiltration through dialysis

e. Hypotonic solution

f. Too long of a dwelling time


Reassess dry weight

Rule out and treat clinical evidence of cardiac failure and pulmonary edema

Restrict fluid & salt intake

Use higher strength of dextrose dialysate concentration and or adjust dwell time (shorter)

Reassess fluid intake and output

Rarely, with urine output, loop diuretic may be useful.

3.3.5 Protocol for the Treatment of MUSCLE CRAMPS

Table 3-5: Muscle Cramps and Corrective Measures


Cramping in legs, feet, and hands

a. Excessive fluid removal

b. Too rapid fluid removal (especially with 3.86% or 4.25% solution)

c. Electrolyte imbalance (hypocalcemia, hypokalemia)


Check serum electrolytes and calcium

Relief measures: apply heat to area, rub cramp vigorously

3.3.6 Protocol for the Treatment of AIR in the PERITONEAL CAVITY

Table 3-6: Air in the Peritoneal Cavity and Corrective Measures


Shoulder pain

a. Infusion of air with the dialysate

b. Misplacement of the catheter

c. Bowel perforation

i. Usually resolves in a few days

Notify physician if pain persists

Lie patient on his back, place pillow under hips and drain patient. Could give Tylenol.


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3.3.7 Protocol for the BLOOD IN PD EFFLUENT

Table 3-7: Blood in PD Effluent and Corrective Measures


Pink to bloody effluent in drainage bag

a. Menstruation / ovulation

b. Rupture of tiny peritoneal capillaries, may be secondary to higher PD solution temperature or activities

c. Possible serious abdominal injury

i. Pink: clears up in 2-3 exchanges w/o treatment. Could do 3 fast in & out exchanges with same volume

Bloody fluid: check BP and HR. Observe patient. Adjust Heparin → to prevent clotting of PD cath. Bloody effluent can lead to clotting of PD catheter. So heparin may be added (decide on patient to patient basis, and only if bleeding not severe), to prevent clots.

Call nephrology staff immediately

3.3.8 Protocol for the Protein Loss

Table 3-8: Protein Loss and Corrective Measures


Protein loss average protein in effluent: 9 gm/day

Cloudy peritoneal fluid

a. Large amount of protein is lost through the peritoneal membrane

b. Peritonitis can worsen and increase the amount of protein loss

i. Check serum Albumin and Total Protein

ii. Call nephrology & dietician to modify protein diet Protein supplements as ordered by physician can help build and repair tissue and rebuild immunity.

3.3.9 Protocol for ACCIDENTAL DISCONNECTION (Refer to Section 10.4)

Refer to the Accidental Disconnection Protocol section 10.4

3.3.10 Protocol for PAIN DURING DIALYSATE INFLOW

Table 3-10: Pain during Dialysate Inflow and Corrective Measures


Pain during dialysate inflow a. " Jet" effect of rapidly flowing dialysis

solution (more common with straight than coiled catheter)

b. Abnormally high PD solution temperature

c. Omental attachment to the PD catheter

d. Excessive pressure in a neighbouring viscus (rectum, vagina, spermatic cord)

i. Slower infusion rate

ii. Incomplete drainage

iii. Reposition PD catheter


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3.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORING SYSTEM

Table 3-11a: Exit Site Infection (ESI) and Corrective Measures


Redness, tenderness, and/or discharge at the exit site

a. Patient should be examined by PD nurse and / or nephrologist (patients in outlying regions should be seen by their own pediatrician)

b. Consider obtaining pictures of site from family

c. Do a gram-stain and culture of the catheter insertion site (if discharge). Families have these items in the home. Use the exit site scoring system section 3.3.11 A diagnosis of a catheter exit site infection can be made in the presence of pericatheter swelling, redness, and tenderness (exit site scoring of 2 or greater in the presence of a pathogenic organism and 4 or greater regardless of culture results).

i. Do daily dressing change to assess the exit site or twice-daily dressing if significant discharge.

ii. If the exit site score is low and exit site has only some redness, nephrologist might begin local therapy only (usually BACTROBAN ointment or GENTAMYCIN cream) with every dressing change and to be reassessed regularly.

iii. The decision about whether to initiate therapy or to follow carefully should be based on the combination of clinical judgment and repeated assessment.

iv. Oral antibiotic therapy of uncomplicated catheter exit site infection (refer to c for scoring system) should be initiated upon receipt of culture results and susceptibilities, and that treatment be continued for a minimum of 2 weeks and for at least 7 days after complete resolution of the infection. Treatment for at least 3 weeks is recommended for exit site infections caused by staph aureus or pseudomonas aeruginosa.

v. Successful treatment of catheter ESI is important because failure of therapy may result in catheter removal or peritonitis.

vi. For infections caused by gram positive that fail to improve or resolve promptly, add rifampin to therapy after 3 days.

vii. In patients receiving prophylactic therapy, (by application of an antibiotic ointment or cream at the exit site), slower growth of the causative organism is possible, and the potential for resistance to any prophylactic antibiotic should be considered in the choice of empiric therapy.

viii. Follow ISPD 2012 Pediatric Guidelines (pages S66 to S69) Refer to table 3-3-11


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3.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORING SYSTEM (continued)

Table 3-11b: Tunnel Infection and Corrective Measures


Extension of a skin exit site infection with pain, swelling, nodularity and redness over the subcutaneous portion of the catheter

Systemic signs such as fever or malaise

" Relapsing " peritonitis due to the same organism

a. Patient should be examined by PD nurse and / or nephrologist (patients in outlying regions should be seen by their own pediatrician)

b. Do a gram-stain and culture of the catheter insertion site (if discharge). If exit site dry, If patient is unwell (e.g. fever) ideally obtain blood culture before starting systemic antibiotics.

c. A tunnel infection is defined by the presence of redness, edema and tenderness along the subcutaneous portion of the catheter, with or without purulent drainage from the exit site (exit site scoring of 6 or greater).

i. Most catheter Tunnel infections can be diagnosed by clinical exam alone; ultrasonographic examination of the catheter tunnel may be helpful.

ii. Antibiotic therapy for catheter tunnel infections should be initiated after culture and susceptibility results have been obtained unless signs of severe infection or a history of staph aureus or P. aeruginosa is present, for which initiation or empiric therapy should be considered.

iii. The route of antibiotic administration can be oral, intraperitoneal, or intravenous unless MRSA is the causative agent, in which case IP or IV glycopeptide therapy is indicated. Treatment duration should be 2 – 4 weeks.

iv. Successful treatment of catheter ESI is important because failure of therapy may result in catheter removal or peritonitis

v. Follow ISPD newest Pediatric Guideline 2012 (P S66 to S69). Refer to table 3-3-11



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Table 3-11b: Exit Site Infection (ESI) and Exit-Site Scoring System 1

Indication Score

2

0 1 2

Swelling No Exit only (<0.5 cm)

Including part of or the entire tunnel

Crust No < 0.5 cm > 0.5 cm

Redness No < 0.5 cm > 0.5 cm

Pain on pressure No Slight Severe

Secretion No Serous Purulent

1 Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 (exit site scoring system p.66)

2 Infection should be assumed with a cumulative exit-site score of 4 or greater regardless of culture results or in the presence of pericatheter swelling, redness, and tenderness (exit site score of 2 or greater in the presence of a pathogenic organism).


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Table 3-11c: Oral Antibiotics Used in Exit-Site and Tunnel Infection a

Antibiotic Recommended dose Dose frequency Per-Dose maximum

Amoxicillin 10–20 mg/kg/day Daily 1000 mg

Cephalexin 10–20 mg/kg/day Daily or 2 times daily 1000 mg

Ciprofloxacin 10–15 mg/kg/day Daily 500 mg

Clarithromycin 7.5 mg/kg/day Daily or 2 times daily 500 mg

Clindamycin 30 mg/kg/day 3 times daily 600 mg

Dicloxacillin

40 kg 25–50 mg/kg/day 4 times daily 500 mg

40 kg 125–500 mg/dose

Erythromycin (as base) 30–50 mg/kg/day 3 or 4 times daily 500 mg

Fluconazole 6 mg/kg/day Every 24–48 hours 400 mg

Levofloxacin 10mg/kg Every 48 hours Day 1: 500 mg; then 250 mg

Linezolid

5 years 10 mg/kg/dose 3 times daily 600 mg

5–11 years 10 mg/kg/dose 2 times daily

12 years 600 mg/dose 2 times daily

Metronidazole 30 mg/kg/day 3 times daily 500 mg

Rifampin b 10–20 mg/kg/day 2 times daily 600 mg

Trimethoprim– sulfamethoxazole (based on TMP)

5–10 mg/kg/day Daily 80 mg

a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86

b Should not be used as monotherapy, or used routinely in areas in which tuberculosis is endemic.


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3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING

NOTE: Please refer to Prophylaxis of Fungal Peritonitis, to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.

Table 3-12a:


Cloudy effluent, abdominal pain, fever & chills, nausea & vomiting, abdominal rebound.

a. Call Nephrologist immediately. Patient should be examined by PD nurse and nephrologist

b. Do a cell count and culture with gram-stain and fungal. Cell count WBC >100 /uL (or >1 X10

9/L),

>50% Polymorphonuclear neutrophil cells (PMN)

i. After taking a specimen for cell count and culture, do 3 in & out exchanges to relieve some pain (you may ask the families to do this at home if pain is severe – but will need guidance from PD nurse – use “bypass” function to do this). You need 10 ml for cell count, 50 ml for culture and

Blood culture bottles 4ml for aerobic (yellow), 5 ml for anaerobic (orange) and 1-3 ml for fungus.

ii. Start IP antibiotics with loading dose as soon as possible. Ensure gram-negative and gram-positive coverage. Allow loading dose to dwell for 6 hours. Add

heparin 1000 units per liter until complete resolution of dialysate cloudiness. Base selection on historical patient and center sensitivities. Refer to section 3.311

iii. When loading dose dwell is completed, set up the cycler for the maintenance dose of IP antibiotics. consider longer dwell time than regular therapy of about 2 hours for 1 to 2 days

iv. Continue assessment of therapy and modification of therapy based on culture and sensitivity results. Consult Pediatric ISPD Guidelines 2012. Guidelines for therapy in table section 3.311

v. Reduce the peritoneal fill volume during the initial 24-48 hours of therapy in patients with significant abdominal discomfort

vi. Assess improvement in therapy at 3 days. Symptoms should resolve and dialysate should clear. Re-evaluate treatment and reassess patient response to therapy.

vii. Send cell count and culture daily.

For all medications listed above, please refer to their policy for indications, contraindications, dosage and precautions.


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3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING (continued)

NOTE: Please refer to section 3.3.14 (anti-fungal prophylaxis is recommended), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.

Table 3-12c: Antibiotic Dosing Recommendations for the Treatment of Peritonitis

Therapy type

Continuous b

Antibiotic type Loading dose Maintenance dose Intermittent b

Aminoglycosides (IP)c

Gentamicin 8 mg/L 4 mg/L

Netilmycin 8 mg/L 4 mg/L Anuric: 0.6 mg/kg

Tobramycin 8 mg/L 4 mg/L Non-anuric: 0.75 mg/kg

Amikacin 25 mg/L 12 mg/L

Cephalosporins (IP)

Cefazolin 500 mg/L 125 mg/L 20 mg/kg

Cefepime 500 mg/L 125 mg/L 15 mg/kg

Cefotaxime 500 mg/L 250 mg/L 30 mg/kg

Ceftazidime 500 mg/L 125 mg/L 20 mg/kg

Glycopeptides (IP)d

Vancomycin 1000 mg/L 25 mg/L 30 mg/kg; repeat dosing: 15 mg/kg every 3–5 days

Teicoplanin 400 mg/L 20 mg/L 15 mg/kg every 5–7 days

Penicillins (IP)c

Ampicillin — 125 mg/L —

Quinolones (IP)

Ciprofloxacin 50 mg/L 25 mg/L —

Others

Aztreonam (IP) 1000 mg/L 250 mg/L —

Clindamycin (IP) 300 mg/L 150 mg/L —

Imipenem–cilastin (IP) 250 mg/L 50 mg/L —

Linezolid (PO) < 5 years: 30 mg/kg daily, divided into 3 doses 5–11 years: 20 mg/kg daily, divided into 2 doses ≥ 12 years: 600 mg/dose, twice daily

Metronidazole (PO) 30 mg/kg daily, divided into 3 doses (maximum: 1.2 g daily)

Rifampin (PO) 10–20 mg/kg daily, divided into 2 doses (maximum: 600 mg daily)

Antifungals

Fluconazole (IP, IV, or PO) 6–12 mg/kg every 24–48 h (maximum: 400 mg daily)

Caspofungin (IV only) 70 mg/m

2 on day 1

(maximum: 70 mg daily) 50 mg/m

2 daily

(maximum: 50 mg daily)

IP = intraperitoneally; IV = intravenously; PO = orally. a. Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b. For continuous therapy, the exchange with the loading dose should dwell for 3–6 hours; all subsequent exchanges during the

treatment course (including the last fill) should contain the maintenance dose. For intermittent therapy, the dose should be applied once daily in the long-dwell, unless otherwise specified.

c. Aminoglycosides and penicillins should not be mixed in dialysis fluid because of the potential for inactivation. d. In patients with residual renal function, glycopeptide elimination may be accelerated. If intermittent therapy is used in such a setting,

the second dose should be time-based on a blood level obtained 2–4 days after the initial dose. Re-dosing should occur when the blood level is <15 mg/L for vancomycin, or <8 mg/L for teicoplanin. Intermittent therapy is not recommended for patients with residual renal function unless serum levels of the drug can be monitored in a timely manner.


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a If the center’s rate of methicillin-resistant Staphylococcus aureus (MRSA) exceeds 10%, or if the patient has history of MRSA infection or colonization, glycopeptide (vancomycin or teicoplanin) should be added to cefepime or should replace the first-generation cephalosporin for gram-positive coverage. Glycopeptide use can also be considered if the patient has a history of severe allergy to penicillins and cephalosporins.

Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86

** Montreal Children’s Hospital: Cefazolin or Vancomycin

MCH 1st choice : cefepime

MCH 2nd choice: cefazoline or vancomycin and ceftazidime

** Montreal Children’s Hospital: Ceftazidime


27



** Montreal Children’s Hospital: Delayed response is defined as no

improvement after 3 days of empiric therapy


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NOTE: Please refer to section 3.3.14 (prophylaxis of fungal peritonitis), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.

Table 3-12c: Gram-Positive Bacteria : Recommended IP Antibiotics and Length of Therapya

Organism Recommended antibiotics b Length of therapy

Staphylococcus aureus Methicillin-resistant

Clindamycin or vancomycin (MCH first choice) or teicoplanin

3 weeks

Methicillin-susceptible Cefazolin or cefepime (MCH first choice)

3 weeks

Coagulase-negative staphylococci Cefazolin or cefepime or clindamycin or vancomycin or teicoplanin

2 weeks

Enterococcus species Ampicillin or vancomycin or teicoplanin Consider adding aminoglycoside

2 – 3 weeks

Vancomycin-resistant Ampicillin or linezolid 2 – 3 weeks

Streptococcus species Ampicillin or cefazolin or cefepime 2 weeks

a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b Listed in the preferred order of use, if susceptible. c Prolonged use of linezolid (>2 weeks) can lead to bone marrow suppression.


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positive

MCH : suggests aminoglycosides


30


NOTE: Please refer to section 3.3.14 (anti-fungal prophylaxis is recommended), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis. d

a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b The antibiotics are listed in the preferred order of use, if the organism is susceptible. c Emerging resistance to extended-spectrum beta-lactamase has resulted in a wide variety of unique susceptibility profiles; consultation with an infectious disease expert about the antibiotics preferred for treating such organisms is recommended. d. Peritoneal Dialysis International 2016; vol. 36, NO. 5 P. 486 P 493

Table 3-12d: Gram-Negative Bacteria: Recommended Antibiotics and Length of Therapya

Organism Recommended antibiotics b Length of therapy

Escherichia coli, Klebsiella species

Cefepime or cefazolin or ceftazidime or ceftriaxone or cefotaxime

2 weeks

Resistant to third-generation cephalosporins

b

Imipenem or cefepime or fluoroquinolone

3 weeks

Enterobacter, Citrobacter, Serratia, and Proteus species

c

Cefepime or ceftazidime or imipenem

2 – 3 weeks

Acinetobacter species Cefepime or ceftazidime or imipenem

2 – 3 weeks

Pseudomonas species

Cefepime or ceftazidime or piperacillin or ticarcillin or imipenem plus aminoglycoside or fluoroquinolone

3 weeks-4weeks d

Stenotrophomonas maltophilia Trimethoprim– sulfamethoxazole or ticarcillin–clavulanic acid

3 weeks-4weeks


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3.3.13 Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections

Table 3-13: Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections a

Approach to catheter Indication Reinsertion

Definite removal Refractory bacterial peritonitis

Fungal peritonitis

ESI/TI in conjunction with peritonitis with the same organism (mainly Staphylococcus aureus and Pseudomonas aeruginosa; except coagulase-negative staphylococci)

After 2 – 3 weeks

At least 2 – 3 weeks

After 2 – 3 weeks

Simultaneous removal and replacement

Repeatedly relapsing or refractory ESI/TI (including P. aeruginosa)

Relapsing peritonitis (relapse within 30 days)

Relative removal Repeat peritonitis

Mycobacterial peritonitis

Peritonitis with multiple enteric organisms because of an intra-abdominal pathology or abscess; so-called surgical peritonitis

After 2 – 3 weeks

After 6 weeks

Depends on the clinical course of the patient; 2 – 3 weeks

a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86


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3.3.14 Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients

Table 3-14: Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients

Situation Indication Antimicrobial

Presence of risk factors for fungal peritonitis

High baseline rate of fungal peritonitis in the PD unit

PEG placement or GT (MCH: GT placement)

Nystatin PO 10 000 U/kg daily (MCH: first choice)

Fluconazole 3–6 mg/kg IV or PO every 24–48 hours (maximum: 200 mg)

Touch contamination

Instillation of PD fluid after

Disconnection during PD

(MCH : Cefepime 250 mg/L IP for 3 days)

Cefazolin (125 mg/L IP, recommended by ISPD guideline, however, We use ( MCH) Cefazolin 250 mg/L, or vancomycin (25 mg/L IP) if known colonization with MRSA

Culture result, if obtained, directs subsequent therapy

Invasive dental procedures

Manipulation of gingival tissue or of the periapical region of teeth, or perforation of the oral mucosa

Amoxicillin (50 mg/kg PO; maximum: 2 g) (MCH choice) or ampicillin (50 mg/kg IV or IM, ; maximum: 2 g) or cefazolin (25 mg/kg IV; maximum: 1 g) or ceftriaxone (50 mg/kg IV or IM; maximum: 1 g) or clindamycin (20 mg/kg PO; maximum: 600 mg) (MCH choice if allergic to penicillin) or clarithromycin (15 mg/kg PO; maximum: 500 mg) or azithromycin (15 mg/kg PO; maximum: 500 mg)

Give antibiotic 30-60 minutes pre-procedure

Gastrointestinal procedures

High-risk procedures (esophageal stricture dilation, treatment of varices, ERCP, and PEG/G-Tube)

Other gastrointestinal or genitourinary procedure

Cefazolin (25 mg/kg IV; maximum: 2 g) or clindamycin (10 mg/kg IV; maximum: 600 mg) or, if high risk for MRSA, vancomycin (10 mg/kg IV; maximum: 1 g)

Cefoxitin/cefotetan (30–40 mg/kg IV; maximum: 2 g) Alternatives: Cefazolin (25/kg IV; maximum: 2 g) plus metronidazole (10 mg/kg IV; maximum: 1 g) or clindamycin (10 mg/kg IV; maximum: 600 mg) plus aztreonam (30 mg/kg IV; maximum: 2 g)

Give antibiotics 30-60 minutes before procedure

IV = intravenously; PO = orally; IP = intraperitoneally; MRSA = methicillin-resistant Staphylococcus aureus; ERCP = endoscopic retrograde cholangiopancreatography; PEG = percutaneous endoscopic gastrostomy. a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86


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4 CHOICE OF PD SOLUTIONS & COMPOSITIONS

4.1 Purpose

This protocol has been developed to understand composition of different PD solutions

4.2 Target audience


4.3 Elements of clinical activity – Summary

The following 3 tables summarize the composition of the PD solutions used at the Montreal Children’s Hospital.

Table 4-1a. Composition of Dianeal peritoneal dialysis solutions

Dianeal

*PD1 PD1 PD1 PD4 PD4 PD4

Dextrose 0.5% 1.5% 2.5% 4.25% 1.5% 2.5% 4.25%

Glucose 1.36% 2.27% 3.86% 1.36% 2.27% 3.86%

iso medium hyper iso medium hyper

Dextrose Anhydre g/L 5.0 13.6 22.7 38.6 13.6 22.7 38.6

Glucose mmol/L 75.6 126.1 214.4 75.6 126.1 214.4

Sodium [Na+] mmol/L 132 132 132 132 132 132 132

Calcium [Ca++

] mmol/L 1.62 1.75 1.75 1.75 1.25 1.25 1.25

Magnesium [Mg++

] mmol/L 0.75 0.75 0.75 0.75 0.25 0.25 0.25

Chloride [Cl–] mmol/L 101 102 102 102 95 95 95

Lactate mmol/L 35 35 35 35 40 40 40

Bicarbonate mmol/L

Osmolarity (approx) mOsm/kg 295 340 390 480 340 390 480

pH 5.2 5.5 5.5 5.5 5.5 5.5 5.5

*The PD”1” and “4”: this is simply the company way of naming whether it is the “normal” (1.75 mmol/L) or “low” calcium (1.25 mmol/L) concentration Dianeal dialysate.

Table 4-1b. Composition of Physioneal, Nutrineal and Extraneal peritoneal dialysis solutions

Physioneal Nutrineal Extraneal

*PD2 PD2 PD2 PD4 Dextrose Glucose 1.36% 2.27% 3.86% 1.10% 7.50% iso medium hyper amino acid icodextrin

Dextrose Anhydre G/L 13.6 22.7 38.6 Glucose in mmol/L mmol/L 75.6 126.1 214.4

Sodium [Na+] mmol/L 132 132 132 132 133

Calcium [Ca++

] mmol/L 1.25 1.25 1.25 1.25 1.75

Magnesium [Mg++

] mmol/L 0.25 0.25 0.25 0.25 0.25

Chloride [Cl–] mmol/L 96 96 96 96 96

Lactate mmol/L 15 15 15 40 40

Bicarbonate mmol/L 25 25 25

Osmolarity (approx) mOsm/kg 340 390 480 340 282

pH 7.4 7.4 7.4 6.7 5.5

Note:

Nutrineal PD solution contains an additional 11 g/L of amino acids

Extraneal PD solution contains an additional 75 g/L of icodextrine.

* PD2 simply refers to Physioneal*


34

4.3 Elements of clinical activity – Summary (continued)

Table 4-1c: Summary Comparison of peritoneal dialysis solutions

Dianeal Extraneal Nutrineal Physioneal

Ph 5.5 5.5 6.7 7.4

Buffer Lac 35/40 Lac 40 Lac 40 Bicarb 25 Lactate 15

Osmotic Agent Glucose Icodextrine Amino acids Glucose

Osmolarity mOsm/L 295 / 340 / 390 / 480 284 365 340 / 390 / 480

Glucose Degradation Products (GDP) + Ø

4.3.1 PHYSIONEAL Physiological requirements

Goal: To develop a biocompatible PD solution that can replace Dianeal

Requirements:

1. physiological pH 7.4

2. physiological buffer (25 mM bicarbonate)

3. reduced lactate concentration (15nM)

4. reduced glucose degradation products (GDP)

5. improved biocompatibility

Glucose in low pH during heat sterilization maintains low level of GDP's. Calcium and Bicarbonate needs to be in different chambers during sterilisation to prevent precipitation.

Format : Physioneal 2.5 Litres

Dextrose (glucose)

Calcium chloride

Magnesium chloride

Sodium bicarbonate

Sodium lactate

Sodium chloride

725 mL

pH 4.0

1275 mL

pH 7.6

pH 7.4


35

4.3.1 PHYSIONEAl Physiological requirements (continued)

Goal: To develop a biocompatible PD solution that can replace Dianeal

Requirements:

1. physiological pH 7.4

2. physiological buffer (25 mM bicarbonate)

3. reduced lactate concentration (15nM)

4. reduced glucose degradation products (GDP)

5. improved biocompatibility

Glucose in low pH during heat sterilization maintains low level of GDP's. Calcium and Bicarbonate needs to be in different chambers during sterilisation to prevent precipitation.

Format : Physioneal 5 Litres


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4.3.2 Other solutions available: NUTRINEAL

Nutrineal is a PD solution is specially adapted for renal failure patients with abnormal protein metabolism. These patients are at higher risk for malnutrition.

Nutrineal contains 15 different amino acids of which 64% are essential amino acids by weight (1.1 % total amino acids equivalent to 11g/L).

Nutrineal does not contain any glucose, has a pH 6.4 and contains fundamental electrolytes.

The osmolarity of the solution is 365 mOsm/L providing equivalent ultrafiltration to that of a 1.5% dextrose solution.

Each 100 ml of Nutrineal contains :

i. Nutrineal is intended for intraperitoneal administration only, substituting for one or more exchanges.

ii. Nutrineal should be given as a daily exchange, preferably around meal time and dwell for 6 hours.

Table 4-2 :

Composition of Nutrineal PD solution

Adapted for patients with abnormal protein metabolism

Does not contain any glucose; Delivers equivalent UF to 1.5% dextrose

PD4 per 100ml Essential amino acids Nonessential amino acids

Total amino acids 1.1 g Valine 139.3 mg Arginine 107.1 mg

Total nitrogen (approx.) 170 mg Leucine 102 mg Alanine 95.1 mg

pH 6.4 Lysine 95.5 mg Proline 59.5 mg

Isoleucine 85 mg Glycine 51 mg

Electrolytes Methionine 85 mg Serine 51 mg

Sodium Chloride 538 mg Histidine 71.4 mg Tyrisine 30 mg

Sodium Lactate 448 mg Threonine 64.6 mg

Calcium Chloride Dihydrate 18.4 mg Phenylalanine 57 mg

Magnesium Chloride 5.1 mg Tryptophan 27 mg


37

4.3.3 Other solutions available: EXTRANEAL

Extraneal is a PD solution designed to increase ultrafiltration with an iso-osmotic solution

i. for PD patients with a decreased residual renal function or

ii. for PD patients with an episode of peritonitis to maintain ultrafiltration.

Extraneal is recommended as a once daily replacement for a single glucose exchange

Recommended for use in the longest dwell period in CAPD or APD regimens for one exchange only (CAPD overnight dwell, APD day time dwell).

Table 4-3 : Composition of Extraneal PD solution

Designed to INCREASE ultrafiltration

Use as a ONCE DAILY replacement for a SINGLE glucose exchange

Description of Extraneal Composition

Extraneal is a PD solution which contains an osmotic agent called icodextrin, a polydispersed glucose polymer.

Icodextrin 75 g/L

The predominant mechanism of action of icodextrin is believed to be colloid osmosis. This can account for the improvement in ultrafiltration and clearance in PD patients.

Sodium 133 mmol/L

Data on absorption of molecules from the peritoneal cavity indicate that the majority of molecules in icodextrin are too large for transfer across the peritoneum and that only small proportion will enter the blood stream via the lymphatic system.

Calcium 1.75 mmol/L

Slow absorption of icodextrin which occurs via the lymphatic system would be in keeping with its prolonged osmotic effect in PD.

Magnesium 0.25 mmol/L

A 7.5 % solution of icodextrin has been shown to be effective as an osmotic agent which results in improved ultrafiltration and clearance as compared to 1.36 % / 2.27 % glucose solutions.

Chloride 96 mmol/L

Icodextrin 7.5 % is iso-osmotic with human serum. Lactate 40 mmol/L


38

5 ROUTINE PD CARE, PRECAUTIONS & MISCELLANEOUS INFORMATION

5.1 Purpose

This protocol has been developed to prevent Infection.

5.2 Target audience



5.3.1 Shower & Bath

Table 5-1a: Shower Considerations and Precautions

Notes The first 6 weeks of PD After 6 weeks of PD

Objective: To prevent infection A shower is permitted only once a week but need to cover the entire exit site and dressing with 4x4 and Opsite or Tegaderm

It is preferred that the PD exit site be covered at all times. A shower is allowed with PD exit site exposed to air when the site is well healed, intact and after being assessed by PD nurse.

This technique is more applicable for the older children / patient

Dressing has to be covered with 4x4 and thenTegaderm or Opsite. Dressing needs to be changed after the shower

The minimum requirement for dressing change is 3 times per week but could be done every day after a shower or bath. Never immerse PD catheter.

Sponge bath is permitted every day When the PD exit site is not intact

(redness, trauma), the exit site should be covered again when showering or bathing with Tegaderm or Opsite

Table 5-1b: Shower Protocol with a PD catheter

Supplies Procedure

Clean face cloth Take a regular shower using the soap pump to wash the body. It is preferred that the PD exit site be covered at all times.

Soap pump. Do not refill the soap container.

At the end of the shower, wet a clean face cloth and clean the area with clear water.

Do not use bar soap Rub area around PD catheter close to the exit site and along the

catheter as well if the site is uncovered.

Rinse area with running water from the shower.

Pat dry with a dry clean face cloth or 4x4.


39

5.3.1 Shower & Bath (continued)

Table 5-1c: Bath Considerations & Precautions

Notes The first 6 weeks of PD After 6 weeks of PD

Objective: To prevent & minimize infection

Shower is preferred. A bath is permitted only once a week. PD exit site has to be covered with 4x4 and then Opsite or Tegaderm.

PD exit site has to be covered at all times with bath care. Water must be shallow and not cover the PD exit site.

i. Shower is preferred. A bath is allowed but PD exit site has to be covered with 4x4 and then Opsite or Tegaderm.

ii. PD exit site has to be covered at all times with bath care. Water must be shallow and not cover the PD exit site.

This technique is more applicable for younger children / patient

PD exit site has to be covered at all times with Bath care. Water must be shallow and not cover the PD exit site.

iii. PD exit site has to be covered at all times with Bath care. Water must be shallow and not cover the PD exit site.

A sponge bath is strongly suggested with younger children

Sponge bath is permitted every day iv. If showering is not possible for the older child and adolescent, a bath may be taken, but the water must be shallow and not cover the PD exit site

Never immerse the PD exit site (even for infant or young child) in the bath tub

The PD exit site dressing must be changed after the bath following the protocol

v. The PD exit site must be changed after the bath following the protocol

refer to the PD exit site care dressing change protocol

vi. refer to the PD exit site care dressing change protocol

5.3.2 Activities & Sports

Table 5-2: Activities & Sports - Special Considerations & Precautions

Notes Activities to avoid Activities considered acceptable

Objective: To minimize physical trauma to the PD catheter and peritoneal membrane

For the first 8 weeks after starting PD, strenuous activities or sports are not permitted

Amusement rides are permitted only when exit site is healed and this is approved by Nephrologist.

Avoid contact sports, weightlifting, gymnastics, parachuting, and bungee jumping

Objective: To minimize physical exposure to organic pathogens dangerous to the PD catheter and peritoneal membrane

Bathing in public pools, rivers and lakes carries a greater risk of inducing peritonitis, so it shouldn't be allowed

Swimming should also be avoided if exit site has been traumatized or infected

Swimming is permitted (after approved by nephrologist) in the ocean or a private swimming pool. The PD catheter and exit site must be covered with waterproof dressing (eg. colostomy bag, Tegaderm or Opsite).

Note: After swimming, refer to Exit Site Care – Dressing Change Protocol.


40

6 BASIC PREPARATION PROCEDURE

6.1 Purpose

To maintain an aseptic environment and minimize risk of infection during peritoneal dialysis procedures.

6.2 Target audience

Nursing and medical staff responsible for the care of the peritoneal dialysis patient. 6.3 Elements of clinical activity

6.3.1 Basic preparation procedure

Table 6-1: Basic Preparation Procedure: the 9 steps

Equipment Procedure

Chlorhexidine 4% (antiseptic solution) or foaming Chlorhexidine 2%

Masks

Alcohol handrub

Sanicloth or Alcohol

To prevent contamination, garbage can, toilet or sink should never be kept close to the area while sterile procedures are in progress.

To prevent contamination, garbage can, toilet or sink should never be kept close to the area while sterile procedures are in progress.

15 seconds hand washing

1. Restrict traffic in area. Close windows, doors, fans, air conditioners.

2. Clean 2 working surface areas with Sanicloth or alcohol

3. Let dry

4. Gather equipment

5. Put on mask

6. Remove jewelry

7. Wash hands with Chlorhexidine solution 4% for 2 minutes.

8. Dry hands well (close faucets with towel)

9. Close faucets with towel when necessary and Alcohol Hand rub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry (20-30 seconds). After handrub, touch only PD supplies. Proceed with desired procedure as per protocol.


41

6.3.1 Basic preparation procedure (continued)

Table 7-2: Quick Guide to Basic Aseptic Environment Preparation Procedure

To maintain an aseptic environment and,

To minimize risk of infection during the dialysis procedure

Equipment [4] Procedure


Chlorhexidine 4% or Foaming Chlorhexidine 2%

1. Close windows, doors and turn off any fans

Masks

2. Wash 2 working surface areas with Sanicloth or alcohol

3. Let dry

Alcohol handrub

4. Gather material

Alcohol

5. Put on mask

6. Remove jewelry

7. Wash hands with Chlorhexidine solution 4% for 2 mins

8. Dry hands well.

9. Close faucets with towel and Alcohol handrub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry (20-30seconds). After handrub, touch only PD supplies.

If hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.

To prevent contamination,

keep away from garbage cans, sinks and toilets.


42

6.3.1 Basic preparation procedure (continued)



2. Wash 2 working surface areas with Sanicloth or alcohol

3. Let the table dry

4. Gather material

5. Put on mask

6. Remove jewelry

7. 4% Chlorhexidine Wash hands for 2 minutes

8. Dry hands well

9. Close faucets with towel and Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry. (20-30 seconds) After handrub, touch only PD supplies


43

6.3.2 EXIT SITE CARE – DRESSING CHANGE

Table 6-3a : Catheter Exit Site Procedure

To maintain a clean catheter exit site and

To minimize risk of tunnel infection and/or peritonitis during the dressing change

Schedule Frequency Notes

Post-op 1. Change the dressing the day after the surgery by

the PD nurse.

First 6 weeks post-op 2. Change the dressing once a week or more frequently if the dressing is moist or soiled.

6 weeks gives the chance for healing

First 6 weeks post-op 3. Apply BIOPATCH at the exit site, grid side up (BIOPATCH: slow-release Chlorhexidine patch).

Do not use the BIOPATCH for babies:

premature 26 weeks or under, under 1000 grams, nor for newborns under 2 weeks of age.

After 6 weeks post-op 4. The dressing should be changed at least 3 times / week

i.e., Monday, Wednesday, Friday

minimum 3 times a week

could be done every day

After 6 weeks post-op 5. The dressing should be changed more frequently

if the dressing is moist, soiled, after showering, or if ordered by nephrologist.

Keep the dressing dry

Table 6-3b : Exit site scoring system

0 point 1 point 2 points

Swelling None Exit only (< 0.5 cm) Including part of or entire tunnel

Crust None < 0.5 cm > 0.5 cm

Redness None < 0.5 cm > 0.5 cm

Pain on pressure None Slight Severe

Secretion None Serous Purulent

If exit site score > 4, indicative of infection


44

6.3.2 EXIT SITE CARE – DRESSING CHANGE (continued)

Table 6-3c : Catheter Exit Site Care Protocol

Observation Required action

Redness, swelling or discharge at exit site Document in nursing notes

Visible discharge from exit site Swab exit site and send culture sample to Microbiology

Redness without discharge i. Inject sterile NS onto exit site

Culture with ALGINATE urethral culture swab

Send culture sample to Microbiology

Crust Irrigate with sterile NS to soften the crust.

Do not pull it off – this could worsen and / or damage the skin

Nasal Staphylococcus aureus carrier Use BACTROBAN (Mupirocin in the nose bid each first 5 days of every month until the exit site is healed

A small amount of BACTROBAN or GENTAMYCIN cream may be applied to the exit site at each dressing change when the exit site is healed.

Unless specified by nephrologist, do not use BACTROBAN or GENTAMYCIN cream on a fresh exit site for the

first few weeks.


and precautions.


45


Basic Procedure PD Dressing

Checklist

15 seconds hand washing.

Regular dressing Tray # 2333

Products for dressing: Chlorhexidine 2% aqueous swabsticks, no alcohol (green sticks)

Sterile gloves & mask

Covered dressing options : ( IV3000 / HYPAFIX / MEFIX / BLISTERFILM )

NS (normal saline) if crust is present

Chlorhexidine 4% / SteriGel+ 0.5%

BIOPATCH dressing for first 6 weeks post-op (grid side up)

Alcohol handrub sanitizer

SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area

Biopatch

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2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes

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3. Let dry

4. Gather material

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5. Put on mask

6. Remove jewelry

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8. Dry hands well. PD

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9. Close the faucets with a towel. Alcohol

handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-

30 secs). After handrub, touch only PD supplies.

If your hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.

PD

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To prevent contamination, Keep away from garbage cans, sinks and toilets.


46


PD Dressing Part 1

PD Dressing

Part 2

Step 1 of 16:


Follow Basic Procedure (9 steps).

Apply a palmful of alcohol based sanitizer and rub until dry (20-30 secs).

Open the dressing tray using sterile technique.

Step 5:

Remove old dressing and look for any signs of infection (redness, discharge, tenderness).

Notify nurse/MD

If there is any doubt, take a culture sample (culture swab or alginate).

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Step 2:

Using aseptic technique, open and drop 4 Chlorhexidine 2% green sticks into the sterile tray.

Open sterile 2x2 gauze and drop it into the sterile tray.

Step 6:

Do not pull any crust off – this could worsen and / or damage the skin!

Put on sterile gloves.

If there is crust at the site, use sterile NS to soak the crust in order to soften any crust.

Pulling any crust may increase the patient’s risk for infection.

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Step 3:

Add NS prn if there is presence of crust.

You may need a BIOPATCH for the first 6 weeks post-op (except NICU & PICU babies).

Step 7:

Using a gentle pressure, clean the area starting from the catheter site and working outward in a

circular motion.

Clean 2 times using a new Chlorhexidine swabstick each time.

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PD

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Disinfect your hands with Alcohol handrub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry. (20-30 seconds).

After handrub, touch only PD supplies.

Step 8 of 16: Example of circular motion

Never go back to the insertion site.

Use one Chlorhexidine stick at a time.

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47


PD Dressing Part 3

PD Dressing

Part 4

Step 9 of 16:

With 2 new swabsticks:

Clean over the

catheter and discard,

Let dry for 2 minutes.

Step 13:

Dressing IV 3000

Preferred for babies – it is impermeable to fluids but allows the skin to breathe

The site needs to be covered with IV 3000, HYPAFIX, MEFIX or BLISTERFILM.

Peel away the top protective film.

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Make sure area is dry. Dry area with 4x4

Apply a BIOPATCH

at the exit site, grid side up for the first 6 weeks only.

Fold one 2x2 gauze in half. Place the gauze under the catheter.

Step 14:

IV 3000

The dressing should cover 1 inch of the PD catheter.

Make sure the PD catheter is adequately immobilized.

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Step11:

This is what a biopatch looks like if you need one.

Do not use BIOPATCH for babies: premature 26 weeks or under, nor for infants under 1000 grams, nor for newborns under 2 weeks of age.

Step 15:

Hypafix

Proper healing will not occur if the catheter moves.

Example of hypafix covering dressing

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Cover the site with the 2

nd half of the 2 x 2

gauze

Step 16 of 16:

:

Immobilize the catheter with tape, hypafix or other immobilizers (GRIP LOCK).

Do not tape over connection joints.

Do not use alcohol on the catheter — it can damage the catheter.

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48

7 HOMECHOICE CYCLER PREPARATION PROCEDURE


7.1.1 BAG PREPARATION: Physioneal 5 liters


49

7.1.1 BAG PREPARATION: Physioneal 5 liters (continued)

Place the bags with the connector facing away from you

Check each bag for the following:

1. Expiry date

2. Solution name

3. Glucose concentration (as per prescription)

4. Volume

Open the over-pouch of all your bags

Put bag on a clean surface.

Press firmly on large chamber to check:

Long seal is intact

Short seal is intact

Check each bag to make sure:

Solution is clear

There are no leaks

Check the connector on each bag for:

Correct position of the wings

Presence of the pull-ring as shown on the picture (left)

If medication is required, it should be added now as prescribed by your doctor. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 seconds). After handrub, touch only PD supplies. Wipe injection port 15 sec. with alcohol chlorhexidine swab.

(see page 52 for procedure)

Step 1 Step 2

Step 3 Step 4

Step 5


50


To start opening the long-seal, grab each side of the large chamber firmly, turn your hands outwards and push the solution towards the middle of the long-seal or roll one of the side at a time.

Open the short-seal by lifting the large chamber, grabbing the material firmly in both hands and rolling the material towards the connector

Apply pressure, by leaning over the bag, and pushing the solution towards the short-seal to open it

Step 6

Step 7

Step 8

Check around the bag for any signs of a leak


51


Step 10

Step 11

Wash and disinfect your hands with Alcohol handrub. Remove the pull-ring Remove the protector cap from the HomeChoice cassette bagline

Connect the line to the bag until resistance is felt

Screw the line firmly Check the connection is secure

Close the wings of the bag connector with one hand Do Not hold the connector in this position (connector will click)

Make sure the wings are firmly closed

X


52

7.1.2 BAG PREPARATION: Procedure for adding medication with Physioneal 5 liters

Step 1

Step 3

Basic Procedure (9 steps). Position the bag with the blue medication port facing upwards

Disinfect the medication port 15 seconds With red alcohol chlorhexidine swab Let dry. Use 23 gauge needles only.

Disinfect your hands with Alcohol handrub and let dry Remove the blue pull-ring from the medication port

Step 2

Step 4

Inject medication directly through the medication port Do not inject anything other than prescribed medication


53

7.2 Purpose

To maintain an aseptic environment while preparing the Homechoice cycler

7.3 Target audience

Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.


7.4.1 CYCLER PREPARATION


54

7.4.1 CYCLER PREPARATION (continued)

1. Basic Procedure 9 Steps

2. Open Cycler

3. Open all solution bags Alcohol handrub – Add meds Break cones – Hang if needed

4. Open cassette package. Close all 6 clamps. Put on clean table

5. Open Drain Bag Open all other Bags Close all clamps

6. Press GO to Load the Set


55


7. Open Door 8. Install Cassette

9. Place Organizer 10. Alcohol handrub, Connect Specimen Bag if needed. Connect Drain Bag

11. Press GO to Self-Test 12. Alcohol handrub and let dry


56


13. Connect Bags 14. Open Clamps on Each Bag connected Close patient Line and Put 2x2

15. Press GO to Prime 16. When finished Priming, Close patient Line


57

7.4.2 CYCLER PREPARATION – The Basics

Basic Procedure

PD Dressing Checklist


Solution bag(s) prescribed (Physioneal, Dianeal & Extraneal)

HOMECHOICE Disposable set with cassette (pediatric or adult)

Drainage bag (15L)

Sterile gauze 2x2 PRN

(2) Fresenius medical clamps (Blue clamps)


Masks


For other items you may need, please refer to the

peritoneal dialysis item list :

5 prongs manifold if needs more bags

Effluent sample bag when needed

PD 3L drainage set-up II (empty heater bag) if needed

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2. Disinfect or Wash 2 working surface

areas with alcohol, SANICLOTH or disinfecting towelettes or alcohol.

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3. Let dry

4. Gather material

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5. Put on mask

6. Remove jewelry

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8. Dry hands well.

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30 secs). After handrub, touch only PD

supplies.


Check solution bags for strength, expiry date, amount, and leaks

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58

7.4.2 CYCLER PREPARATION – The Basics (continued)

Part 1 Material Preparation


Part 1 Material Preparation

Step 1 of 7:

Begin Set-up


Turn on the HOMECHOICE cycler (the ON/OFF button is on the back right side).

The display will show:

“PRESS GO TO START”

The HOMECHOICE system is ready.

Step 4:

Placing a solution bag or

empty heater bag on the heater cradle

When more than one concentration is used, Place the bag with the highest concentration

on the warming cradle unless using an empty heater bag (Please consult with the physician first).

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Remove all solution bags from their wrap

Put the bags on 2nd

clean surface area.

With the PHYSIONEAL solution bags, break the inner GREEN cones

between the 2 compartment bags.

Hang the bag(s) on a pole to allow the solutions to mix for 2.5 liters. (section 8.3.2liters)

Step 5:

Place an empty heater bag on the warming cradle

or solution bag

The empty heater bag will be needed if:

the patient needs a mixture of different concentration(s)

and

the patient is receiving small volume(s) of solution for each cycle.

Clamp the empty heater bag.

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Medication

Any medication that needs to be added to the bags must be done in this Step. Use Alcohol handrub and let dry. Wipe in injection port with alcohol chlorhexidine swab for 15 secs and let dry. Use a 23 gauze needle only).

Please refer to the protocol Addition of a Medication 5 liters bag

section 7.1.2 p 52.

Step 6:

Prepare disposable set

CLOSE all 6 clamps on the disposable set.

Open all other material needed. I.e. manifold & clamps, drainage bag, specimen bag…)

CLOSE all the clamps.

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Step 3:

Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of the hands. Rub until dry (20-30secs).


Open all packages, put on second table.

Step 7:

Prepare drainage & effluent sample bag

CLOSE the 2 clamps on the drainage bag.

Recommended: apply blue clamp on

the specimen port of the drainage bag.

Remember to CLOSE the clamp on effluent sample bag.

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59


Part 2 Installation

Part 2

Installation

Step 1 of 6: PRESS GO

When you are ready to begin,

PRESS GO TO START

Ou Vert pour démarrer.

Step 5: CLOSE DOOR

Make sure that the tubing is not kinked at the exit point of the machine.

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Step 2: LOAD THE SET

The display will show:

“LOAD THE SET”

ou

INSTALLER LES TUBULURES

Step 6 of 6: PLACE ORGANIZER

Place the organizer on

the front of the system.

Careful: Make sure to hold the specimen bag tubing in your hand, which is not attached to the organizer, and place it on the hanger on the side of the cycler‘s table.

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Step 3: OPEN DOOR

To unlock and open the door, pull the lever UP at the front of the cycler.

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Step 4: LOAD CASSETTE

Remember to orient the cassette with smooth side facing the machine.

The cassette will fit only one way

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6. Patient Line

5. Last Fill

2. Heater Line

Specimen Bag

1. Drainage Line

3,4 Supply Line


60


Part 3 Tubing & Bag connections


Step 1 of 8: Aseptic technique

Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands.

Rub hands until dry (20-30 seconds). After handrub, touch only PD supplies.

This is done before any connections.

Step 4: CONNECT BAGS

When the self-test is completed, the display will show:

“CONNECT BAGS”

ou

CONNECTEZ LES POCHES

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Step 2: CONNECT DRAIN BAG

Connect the drainage bag to the right line on the organizer. (line without clamp)

If you have a specimen sampling bag to add, do it before you attach the drainage bag.

Use aseptic technique without touching the exposed ends.

Put the drainage bag on the back of the cycler until all procedure completed or on a clean surface. Do not touch the floor.

Step 5: CONNECT BAGS

Alcohol handrub and let dry

Connect bags from right to left.

Remove line with RED clamp from

the organizer and connect to the bag on the heating cradle using aseptic technique without touching the exposed ends.

Break cone and open clamp.

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Step 3: PRESS GO

Display will show:

“SELF TESTING… TEST AUTOMATIQUE

Step 6 of 8:

Repeat for all solution bags needed

Remove line with WHITE clamp from

organizer and connect the bag that will be used during PD.

Install 5 prongs manifold if more lines are needed on other line with WHITE clamp.

Break all cones and open all clamps ONLY on lines connected to solution bags.

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Red clamp for Heater bag

White supply line


61




Step 7 of 8: BLUE CLAMPS

.

BLUE clamp is for

different dextrose or different solution for last fill (ex extraneal).

Remove line with BLUE clamp from organizer and

connect the bag that will be used for your last fill. (The BLUE line can become an

extra line only if you are using the same solutions (strength & concentration) as last fill – concentre same).

Break the cone and open the clamp.

You could put a blue clamp over unused 5 prong manifold lines

BLUE CLAMPS

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Step 8 of 8: Recheck all connections, open all clamps and break all cones.

Open clamps ONLY on lines connected to solution bags and drainage line.

If an effluent sample bag is connected to the system, keep its 2 clamps closed until the collection time.

After all connections are completed, you can hang bags on the side of the cycler table, leave on working surface area or leave hanging on a pole.

Now you can put drain bag from back of cycler to the dedicated space in the cycler table or on blue pad on the floor.

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Drain line

Patient line Blue clamp


62

7.4.3 CYCLER PREPARATION – Prime the lines

Part 4 Prime the lines

Part 4 Prime the lines

Step 1 of 6: Press GO

Put a 2x2 on patient line to protect connection

Remember to open clamp on patient line to prime line after set up is completed

Press GO

Step 4: Check fluid level

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Check that the fluid level (dialysate) of patient line is well primed.

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n

Ch

ecklis

t Step 2: Wait for prime

Display will show:

“PRIMING…”

This step will take about 10 minutes.

Step 5 : If the line is not well primed:

1. Unclamp the tubing that goes to the patient (line to the left).

2. Make sure the patient line is well positioned in the organizer.

3. Press “STOP”.

4. Press on the arrow down until you reach “REPRIMING”.

5. Press “ENTER”.

6. Repress “ENTER”.

(the cycler will ask if you really want to reprime)

Pa

rt 1

Ma

teria

l Pre

p

Step 3: Prime complete

PRIMING COMPLETE

When priming is complete the display will show:

“CONNECT YOURSELF”

alternating with

“CHECK PATIENT LINE”

Pa

rt 2

Insta

llatio

n

Repeat this step until your line is well primed.

Pa

rt 3

Tu

bin

g &

Ba

g

co

nne

ctio

ns

Sterigel and let dry. Clamp patient line.

Use sterile 2x2 gauze to cover the patient’s line if the system is not yet ready to connect to the patient.

Step 6 of 6:

You are now ready to connect the system to the patient & start the therapy.

Prim

e th

e lin

es

Patient line


63

7.4.4 CYCLER PREPARATION – Nurses Menu

HOW CAN I ENTER AND EXIT THE NURSE’S MENU?

There is a hidden button located to the left of the GO button.

To enter the Nurse’s Menu, Press and Hold the hidden button when turning on the Homechoice cycler until you hear a “BEEP”.

If the screen does not show: “NURSES MENU”, close the system & restart this step.

To exit the Nurse’s Menu, turn off the machine and then turn it back on.

You will be back to: “PRESS GO TO START”. OU VERT POUR DÉMARRER The options you changed in the Nurse’s Menu ou Menu Opérateur will be saved.


64

7.4.4 CYCLER PREPARATION – Nurses Menu (continued)

Options & Definitions MODE : STANDARD MODE : LOW FILL VOLUME

MODE For patients with

Fill volume > 1000mL

For patients with

Fill volumes from 60mL – 1000mL

Note: You absolutely need to put a value in the option “Minimum drain time” in order for the low-fill volume mode to be saved.

Minim

um

drain volum

e

Minim

um

drain time

MINIMUM DRAIN VOLUME

The minimum volume that the patient needs to drain before the cycler moves on to the next cycle. It is marked in %.

The cycler will alarm if the minimum drain volume % has not been reached.

Setting range: 60–125% of the patient’s fill volume

Default setting: 85% of the

patient’s fill volume

(Unless otherwise specified by the physician)

Setting range: 50% –125% of the patient’s fill volume

Default setting: 85% of the

patient’s fill volume

(Unless otherwise specified by the physician)

Note: for low-fill mode, this option is used in conjunction with the “Minimum Drain Time”

Negative

UF

limit

Positive

UF

limit

Sm

art

dwells

Heater bag

empty

MINIMUM DRAIN TIME

The minimum amount of time a cycle must drain in order for the cycler not to alarm.

When a “low flow” or a “no flow” condition occurs during a drain, the cycler will either alarm or move on to the next fill depending on the settings of the “Minimum Drain Time” and the “Minimum Drain Volume”.

If the «Minimum Drain Volume” percentage is set too low, an incomplete drain could result. This could result in anoverfill. An overfill volume may result in a feeling of abdominal discomfort, and in some circumstances may cause injury to the patient.

+

MINIMUM DRAIN TIME is NOT available in Standard Mode

Setting range: 1 minute [0:01] –1 hour [1:00]

Set at: at least 1 minute [0:01]

** WARNING **

When a patient is in low fill mode, it is MANDATORY to put the minimum drain time. If not, the system will go back to standard.

Tidal full

drains

Language F

lush P

rogram

locked

Therapy

log

Alarm


65



NEGATIVE UF LIMIT

(Overfill alarm)

A negative ultrafiltration indicates that the cumulative amount drained from the patient is less than the cumulative amount filled in the patient’s peritoneum.

The patient is in a state of positive fluid balance.

This limit is set in percentage of the fill volume.

The cycler will alarm when the patient drains less than the set limit.

NEGATIVE UF LIMIT is NOT available in Standard Mode

Setting range: 20% – 60% of the patient’s fill volume

Default setting: 50% of the patient’s fill volume

The negative UF limit can be set higher for patients who absorb fluid so that the therapy can run without generating nuisance alarms.

Minim

um

drain volum

e

Minim

um

drain time

Negative

UF

limit

Positive

UF

limit

Sm

art

dwells

Heater bag

empty

POSITIVE UF LIMIT

(Dehydration alarm)

A positive ultrafiltration indicates that the cumulative amount drained from the patient is more than the cumulative amount filled in the patient’s peritoneum.

The patient is in a state of negative fluid balance.

The cycler will alarm when the patient drains more than the set limit.

POSITIVE UF LIMIT is NOT available in Standard Mode

Setting range: 0mL – 5000mL

Default Setting: OFF

Note: The system alarms whenever the cumulative drain volumes have exceeded the cumulative fill volumes set the positive UF limit setting. The alarm is informational in nature and will not prevent the therapy from completing.

Tidal full

drains

Language F

lush P

rogram

locked

Therapy

log

Alarm


66

7.4.4 CYCLER PREPARATION – Nurses Menu (continued


SMART DWELLS PROGRAMMED

If set on “YES”, dwell times can be automatically adjusted Up or Down based on the therapy time programmed and the patient’s actual fill and drain times for each cycle. The therapy will finish on time.

If set on “NO”, the cycler will provide controlled dwell times. Each dwell will last the same time.

Setting range: YES or NO

Default Setting: YES



(IDEM to Standard Mode)

Minim

um

drain volum

e

Minim

um

drain time

Negative

UF

limit

HEATER BAG EMPTY

Presence of a heater bag on the heating cradle or not.

If set on “YES”, the cycler will allow therapy to begin with an empty heater bag. System will begin by filling the heater bag with solution connected to the supply lines.

If set on “NO”, the cycler will assume there is solution on the heating cradle at the beginning of therapy. An alarm will be posted if fluid cannot be obtained from the heater bag.

When to use an empty heater bag:

When a patient needs:

a mix of different concentrations of a solution, AND

Have small volumes/cycles.


Default Setting: YES, if using an empty heater bag,

NO, if not using an

empty heater bag.


Default Setting: YES, if using a empty heater bag,

NO, if not using a empty heater bag. (IDEM to Standard Mode)

Positive

UF

limit

Sm

art

dwells

Heater bag

empty

Tidal full

drains

Language F

lush

TIDAL FULL DRAINS

If set on “YES“, the cycler will ensure that each drain is a full, complete drain.

Always keep “YES“.



Setting range: YES


Program

locked

Therapy

log

Alarm


67



LANGUAGES

Selection of 14 different languages.

Setting range: Various languages

Note: If you are using English US,

HIGH DOSE will show under therapy when you set your program.

If you are using English UK,

OCPD will show.

IDEM to Standard Mode.

Minim

um drain

volume

Minim

um

drain time

Negative

UF

limit

FLUSH

If set on “YES”, during priming, the cycler will automatically flush 100 ml of solution from each bag to the drainage bag. The heater line, supply lines, and final line (if used), are each flushed. This is a preventive measure against infection.

If set on “NO”, the cycler will not flush the lines during the priming.




Positive

UF

limit

Sm

art

dwells

Heater bag

empty

RESET WEIGHT Setting range: YES or NO

PROGRAM LOCKED

To allow user to change or not the therapy settings.


Default Setting: NO


Tidal full

drains

Language

THERAPY LOG

Allows user to review information about the 6 most recently performed therapies, not including therapy in progress. Information also available on the data card.

Flush

Program

locked

ALARM LOG

Allows user to review up to 20 of the most recent user-recoverable alarms. Includes date and time of each alarm.

Therapy

log

Alarm


68

7.4.5 CYCLER PREPARATION – Connection with a PEDIATRIC Cycler Tubing with Cassette

Basic Procedure Equipment


Gather material:

Sterile gauze 4X4

Alcohol chlorhexidine swabs (red swabs)


Masks

Homechoice cycler tubing with cassette


** If the patient is wearing diapers or if the patient has a GT tube, roll a blue pad around the patient extension catheter to protect the connection from body fluids.

Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry

4. Gather material/ Con

ne

ctin

g

Pe

dia

tric tu

bin

g

5. Put on mask

6. Remove jewelry

Dis

con

nectin

g

Pe

dia

tric tu

bin

g

7. Wash hands with Chlorhexidine solution

4% for 2 mins

8. Dry hands well.







69

7.4.5 CYCLER PREPARATION –Connection with a PEDIATRIC Cycler Tubing

Connecting Pediatric tubing


Connecting Pediatric tubing

Step 1 of 8:

Follow Basic Procedure (9steps)

Disinfect hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands.


Step 5:

Get ready to make the connection,

Hold each piece behind the protective rings in order not to contaminate.

Ba

sic

P

roce

du

re

Eq

uip

me

nt Step 2:

Make sure the patient extension is closed.

To ensure closure hold white part closest to patient with one hand and twist LIGHT BLUE clockwise.

Step 6:

Connect to patient by removing the cap of the system first and then the patient’s MINICAP with an aseptic technique.

While connecting, do not touch the DARK BLUE end on the

patient extension.

Con

ne

ctin

g

Pe

dia

tric tu

bin

g

Step 3:

Open a 4x4

With an alcohol chlorhexidine swab clean the exterior part of the patient extension piece for 15 sec at the junction with the MINICAP.

Let it dry

Do NOT open to wipe the inside of the connection.

Step 7:

This is what the patient’s catheter looks like when connected.

Roll a blue pad around the patient’s extension catheter to protect the connection if patient wear diapers or have gastrostomy.

Dis

con

nectin

g

Pe

dia

tric tu

bin

g

Step 4:

Place the patient’s extension catheter on 4x4 or keep in your hands.

Step 8 of 8:

Open the system by holding white piece closest to patient and turning the LIGHT BLUE counter-

clockwise.

CAUTION: Do not open the system, until you are ready to start your PD dialysis.


70

7.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing



Gather material:

Sterile gauze 4X4


MINICAP with Povione-Iodine Solution


Masks



Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry

4. Gather material Con

ne

ctin

g

Pe

dia

tric tu

bin

g

5. Put on mask

6. Remove jewelry

Dis

con

nectin

g

Pe

dia

tric tu

bin

g


4% for 2 mins

8. Dry hands well.







71

7.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing with Cassette (continued)

Disconnecting Pediatric tubing


Disconnecting Pediatric tubing

Step 1 of 9:

Follow Basic Procedure (9 steps)


Rub hands until dry (20-30 seconds). After handrub, touch only pd supplies.

Step 5:

Disinfect hands with Alcohol handrub.

Let your hands dry.

Ba

sic

P

roce

du

re

Eq

uip

me

nt

Step 2:


To ensure closure hold white part closest to patient with one hand and twist LIGHT BLUE

clockwise.

Close clamp on the patient line.

Step 6:

Clean the exterior part of the extension piece at the junction of the connection site with an alcohol chlorhexidine swab for 15 seconds. Let it dry.

Place the patient’s extension catheter on the 4x4 gauze or keep it in your hands.

Con

ne

ctin

g

Pe

dia

tric tu

bin

g

Step 3:

This is what the patient extension catheter looks like closed. The half-moons should be aligned.

Step 7:

CAREFULLY disconnect the patient’s line from the patient’s extension.

IMMEDIATELY apply the MINICAP to the patient extension piece.

Tighten the MINICAP.

Dis

con

nectin

g

Pe

dia

tric tu

bin

g

Step 4:

Open a 4x4

Open the MINICAP package, keeping the MINICAP inside the package.

Caution: When opening the package, do NOT contaminate the MINICAP.

Step 8 of 8:

This is what the patient extension set looks like closed with the MINICAP on securely.

Roll a blue pad around the patient extension catheter to protect the connection if patient wear diapers or have gastrostomy.


72

7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System



Gather material:

Sterile gauze 4X4


Connection shield sysll with poviodine-iodine solution (white protective shield)

Twin bag manual PD set or Homechoice adult disposable set with cassette (according to prescription)


Masks



Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry


ne

ctin

g

Ad

ult s

yste

m 5. Put on mask

6. Remove jewelry

Dis

con

nectin

g

Ad

ult s

yste

m


8. Dry hands well.







73

7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System (continued)

Connecting Adult system



Step 1 of 11:




Step 5:

Open a CONNECTION SHIELD SYSLL with proviodine.

Keep the connection shield in its envelope

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 2:


To ensure closure hold white part closest to patient with one hand and twist LIGHT BLUE

clockwise.

Open a 4x4

Step 6:

Alcohol handrub and let dry.

Get ready to make the connection,

Hold each piece behind the protective rings in order not to contaminate any of the pieces.

Con

ne

ctin

g

Ad

ult s

yste

m

Step 3:

Take an alcohol chlorhexidine swab, clean the exterior part of the patient extension piece for 15 sec at the junction with the MINICAP.

Let it dry.


Step 7:

Connect to patient by removing the cap of the system first and then the patient’s MINICAP with an aseptic technique.

While connecting, do not touch the DARK BLUE end on the

patient extension piece.

Dis

con

nectin

g

Ad

ult s

yste

m

Step 4:

Place the patient extension catheter on 4x4 or hold it in your hands.

Step 8 of 11:

This is what it looks like connected.

NOTE: the open area is susceptible to infection.


74

7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System (continued)


Notes:

Step 9 of 11:

Using aseptic technique, cover the open area with the CONNECTION SHIELD SYSLL.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 10:

Make sure the clamp is well sealed.

For extra protection, you can roll sterile 4 x 4 gauze around the connection shield.

Con

ne

ctin

g

Ad

ult s

yste

m

Step 11 of 11:

Open the system set by holding white piece closest to patient and turning the LIGHT BLUE

clockwise.

Caution: Do not open the patient extension set until you are ready to start your PD dialysis.

Dis

con

nectin

g

Ad

ult s

yste

m


75

7.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system or CAPD Twin Bag Manual System



Gather material:

Sterile gauze 4X4

Minicap with Povione-Iodine Solution


Masks


Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry


ne

ctin

g

Ad

ult s

yste

m 5. Put on mask

6. Remove jewelry

Dis

con

nectin

g

Ad

ult s

yste

m


8. Dry hands well.







76

7.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system (continued)




Step 1 of 10:




Step 5:

Open the MINICAP package, keeping the MINICAP inside the package.

**USE CAUTION when opening the package.

Do not contaminate the MINICAP.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 2:

Open a 4x4

Optional: place the patient extension catheter over it.

Step 6:


Let your hands dry.

Con

ne

ctin

g

Ad

ult tu

bin

g

Step 3:

Make sure the patient’s extension catheter is closed.

To ensure closure hold white part closest to patient with one hand and twist LIGHT BLUE part

clockwise.

Close clamp on patient line.

Step 7:

Remove the connection shield.

**Caution: DO NOT TOUCH THE EXPOSED AREA!!!!!

Do NOT clean the connection shield with an alcohol swab.

Dis

con

nectin

g

Ad

ult tu

bin

g

Step 4:

This is what the patient extension catheter looks like closed. The half-moons should be aligned.

**Note: There is no longer an open space.

Step 8 of 10:

CAREFULLY disconnect the patient’s line from the patient’s extension.

Do NOT touch the DARK BLUE exposed

area on the patient extension set.


77

7.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system (continued)

Disconnecting Adult system

Notes

Step 9 of 10:

Immediately apply the MINICAP to the patient’s extension.

Ba

sic

P

roce

du

re

Eq

uip

me

nt

Step 10 of 10:

Tighten the MINICAP making sure the extension piece is well closed.

This is what the patient’s extension set looks like closed with the MINICAP on securely.

Con

ne

ctin

g

Ad

ult tu

bin

g

Roll a blue pad around

the patient extension catheter to protect the connection if patient wear diapers or have gastrostomy.

Dis

con

nectin

g

Ad

ult tu

bin

g


78

8 PERITONEAL DIALYSIS BAG PREPARATION

8.1 Purpose

To maintain an aseptic environment while adding or changing a bag during dialysis

8.2 Target audience




79

8.3.1 How to ADD a Bag During Dialysis



Gather material:

New bag of PD solution



Masks


Yellow clamp (not shown on picture)

Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry

4. Gather material Ad

din

g a

New

Ba

g

5. Put on mask

6. Remove jewelry Cha

ng

ing

a B

ag


4% for 2 mins

8. Dry hands well.



30 secs. After handrub, touch only PD supplies.




80

8.3.1 How to ADD a Bag During Dialysis (continued)

Connecting a New Bag



Step 1 of 13:




Step 5:

Press STOP to stop the cycler.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 2:

Open the solution bag by removing from the wrap and put on 2

nd clean

surface area.

If Physioneal 2.5 L, hang the bag and break inner GREEN cone to mix the solution.

For 5 liters bag section 7.1.1

Step 6: (CLAMP)

You can use the tubing that is not attached to a solution bag.

Make sure the tubing is CLAMPED.

Ad

din

g a

New

Ba

g

Step 3: (CLAMP)

CLAMP the patient extension piece.

To ensure closure hold the white part closest to patient with one hand and twist LIGHT BLUE part clockwise.

Step 7:


Let your hands dry.

Wipe the outside connection with alcohol chlorhexidine swab and let dry.

Do not remove or open the protective cap.

Cha

ng

ing

a B

ag

Step 4: (CLAMP)

CLAMP the patient line on the set up.

Step 8 of 13:

Remove the pulling color coded ring of the bag you want to add.


81

8.3.1 How to ADD a Bag During Dialysis (continued)



Step 9 of 13:

Remove protective cap from line

Attach the new bag to the tubing.

Step 12 of 13:

Press GO to continue the treatment.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 10: (UNCLAMP)

UNCLAMP the tubing on the new bag.

Ad

din

g a

New

Ba

g

Step 11

Open the patient extension piece.

Cha

ng

ing

a B

ag

Step 12: : (UNCLAMP)

UNCLAMP the patient line.


82

8.3.2 How to CHANGE a Bag During Dialysis



Gather material:

New bag of PD solution

(according to the doctor’s order)

Alcohol chlorhexidine swab (red swabs)

Alcohol handrub hand sanitizer

Masks


Dravon yellow clamp (not shown on picture)

Ba

sic

Pro

ce

du

re




Eq

uip

me

nt 3. Let dry

4. Gather material Ad

din

g a

New

Ba

g

5. Put on mask

6. Remove jewelry Cha

ng

ing

a B

ag


4% for 2 mins

8. Dry hands well.


handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30

secs). After handrub, touch only PD supplies.

handrub




83

8.3.2 How to CHANGE a Bag During Dialysis (continued)

Changing a Bag


Changing a Bag

Step 1 of 15:




Step 5:

Press STOP to stop the cycler.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 2:

Open the solution bag by removing from the wrap and put on 2

nd clean

surface area.

If Physioneal 2.5 L, hang the bag and break inner GREEN cone to mix the solution.

For 5 liters p.48

Step 6: (CLAMP)

CLAMP the tubing of

the line where the solution bag you want to change is connected.

You need to apply a yellow clamp to the bag to prevent leaking.

Ad

din

g a

New

Ba

g

Step 3: (CLAMP)

CLAMP the patient extension piece.

To ensure closure, hold white part closest to patient with one hand and twist LIGHT BLUE part clockwise.

Step 7:

Clean the outer connection site with an alcohol chlorhexidine swab (red swabs) for 15 seconds.

Let it dry.

Cha

ng

ing

a B

ag

Step 4: (CLAMP)

CLAMP the patient’s line on the set up.

Step 8 of 15:

Put the new bag and the bag to change side by side

Remove the pulling color coded ring of the bag you want to add.


84

8.3.2 How to CHANGE a Bag During Dialysis (continued)

Changing a Bag

Changing a Bag

Step 9 of 15:

Disconnect the old bag from the system.

Keep the tip of the line sterile.

Step 13: (UNCLAMP)

Open the patient extension piece.

Ba

sic

Pro

ce

du

re

Eq

uip

me

nt

Step 10:

Be ready to attach the new solution bag to the system.

Step 14:

UNCLAMP the patient line. A

dd

ing a

New

Ba

g

Step 11: (UNCLAMP)

Using aseptic technique, connect the new solution bag to the system.

Step 15 of 15:

Press GO to continue the treatment.

Cha

ng

ing

a B

ag

Step 12:

UNCLAMP the tubing

on the new bag.


85

9 MANUAL CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)

9.1 Purpose

To maintain an aseptic environment while preparing for dialysis

9.2 Target audience




86

9.3.1 CAPD manual set-up with TWIN BAGS

CAPD manual set-up with TWIN BAGS (Quick reference)

Connect – Drain – Prime – Fill – Disconnect


1. 9 Steps Basic Procedure

2. Alcohol handrub and let dry

3. Connection

4.Put white protective shield

5. Remove yellow clamp on Drain line

6. Close patient extension Break Green cone and PRIME

7. Scale Weight the PD bag

8. Fill Remove yellow clamp on Fill line

9. Disconnect Remove shield and put MiniCap


87

9.3.1 CAPD manual set-up with TWIN BAGS (continued)

Basic Procedure 15 seconds hand

washing. Equipement

1. Close windows, doors and turn off any

fans

Gather material:

2 x Clamps Hemostat DRAVON Dialysis (YELLOW)

WHITE CONNECTION SHIELD SYSLL with Povione-Iodine Solution (protective shield)

MINI CAP with Povione-Iodine solution

Alcohol chlorhexidine swabs (red swab)

TWINBAG® manual PD set

Sterile 4 x 4 gauze

Masks




Ba

sic

Pro

ced

ure

Eq

uip

men

t

2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes P

art 1

Pre

pa

ratio

n

3. Let dry

4. Gather material

Pa

rt 2

Con

ne

ctio

n

5. Put on mask

Pa

rt 3

Dra

in

6. Remove jewelry


4% for 2 mins

Pa

rt 4

Prim

ing

8. Dry hands well.

Pa

rt 5

Fill



seconds). After handrub, touch only PD supplies.


Pa

rt 6

Deco

nne

ctio

n


Pa

rt 7

Fin

al C

he

ck


88


Part 1 Preparation


Part 1 Preparation

Step 1 of 6:

Follow Basic Procedure

(9 steps).



Step 5:

This is what a FISH scale looks like.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 2:

Remove TWINBAG® solution from its wrap.

Put on 2nd

clean surface

Inspect the bag for expiratory date, etc…

Step 6 of 6:

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 3:

Disinfect your hands with Alcohol handrub.

Let your hands dry.


Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 4:

Break the inner GREEN

cone.

Hang the bag on a pole to allow the solutions to mix.

** If a medication is needed, add it now using #23 gauze needle. Please refer p52 to the protocol: Addition Of a Prescribed Medication in PD Solution section 7.1.2

Pa

rt 6

Dis

co

nne

ctio

n

Hang the FILL bag on a pole equiped with a FISH scale and place the empty bag in the drain position (lower than the patient) on a clean surface.

Pa

rt 7

Fin

al C

he

ck

Need to add Fish Scale


89


Connect – Drain – Prime – Fill –Disconnect

Part 2 Connection

Part 2 Connection

Step 1 of 12:





Step 5:

Place the patient extension on 4x4 or keep in your hands.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 2:

Make sure the patient extension piece is closed.

To ensure closure, hold WHITE piece closest to the patient and twist the middle LIGHT BLUE part in a clockwise manner.

Step 6: (CLAMP x 2)

Place a YELLOW clamp on the BLUE solution bag line. (Fill Bag)

Place a YELLOW clamp on the clear drainage bag line.

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 3:

This is the WHITE protective shield you will need in order to clamp over the connection site.

Open the package and leave the protective shield inside it to keep it sterile.

Open a sterile 4x4.

Step 7:

Alcohol handrub and let dry.

Remove pulling color coded ring from the TWINBAG® solution connector.

Keep the exposed area sterile and do not drop it.

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 4:

With a alcohol chlorhexidine swab clean the exterior part of the patient extension piece for 15 seconds at the junction with the minicap.

Let it dry.

Step 8 of 12:

Remove the MINICAP from patient extension piece by unscrewing WHITE part.

DO NOT TOUCH the exposed DARK BLUE area!!!!!

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck


90



Part 2 Connection

Notes

Step 9 of 12:

Immediately attach the TWINBAG® solution connector to the patient extension piece.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 10:

This is what the setup looks when connected.

Note: The exposed area is susceptible to infection.

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 11: (CLAMP )

Take the WHITE protective shield and clamp it over the exposed DARK BLUE area and cover the disk.

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 12 of 12:

Make sure the WHITE protective shield is closed properly.

For extra protection, you may wrap a sterile 4x4 gauze around the protective shield.

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck


91

9.3.1 CAPD manual set-up with Twin bags (continued)


Part 3 Drain

Part 3 Drain

Step 1 of 5: (UNCLAMP)

Remove the YELLOW clamp (not visible) from the drain line (clear line) to drain the patient.

Step 5 of 5:

Close patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE part clockwise.

If many exchanges are done with the same TWIN BAG set-up, weigh the drainage bag after each drain to determine how much the patient drained after each drainage.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 2:

Open the patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE

part counter clockwise.

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 3:

Please note: the GREEN cone near the connection site remains unbroken; this allows the patient’s peritoneum to drain by gravity into the drainage bag.

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 4: (CLAMP)

After draining, place a YELLOW clamp on drain line.

You will notice that the drain phase is finished when the drainage bag stops filling up with effluent.

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck


92



Part 4 Priming

Part 4 Priming

Step 1 of 7:

Close Patient line.

Break GREEN seal nearest to patient’s connection site.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 2: (UNCLAMP)

Remove the YELLOW clamp from the fill line.

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 3: (UNCLAMP)

Remove the YELLOW clamp from the drain line for 5 seconds. This will allow priming of the fill line and of the drain line.

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 4: (CLAMP)

Replace the YELLOW clamp on the drain line and the fill line.

Pa

rt 6

Dis

co

nne

ctio

n

NOTE: The dialysate does not go into the patient’s peritoneum as the patient extension piece is closed. It only flushes the lines exterior to the patient and flushes any potential bacteria from the tubing into the drainage bag.

Pa

rt 7

Fin

al C

he

ck

Need to add Fish Scale


93



Part 5 Fill

Notes

Step 1 of 3:

Weigh bag on scale.

Open the patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE

part counter clockwise.

Remove the yellow clamp on the blue line to allow filling.

The peritoneum is now filling.

Watch the scale’s numbers ↓ to infuse the right amount. See Note.

NOTE: Ensure that it is filling with the right amount of

fluid according to the prescription. The FISH scale displays the total amount of dialysate remaining in the fill bag. Weight of the bag minus fill volume = infused volume

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Pa

rt 2

Co

nn

ectio

n

Step 2: (CLAMP )

After filling, replace the YELLOW clamp on the

fill line or blue line.

NOTE: Ensure that the

prescribed dwell time is respected

Pa

rt 3

Dra

in

Pa

rt 4

Prim

ing

Pa

rt 5

Fill Step 3 of 3:

Close patient’s extension.

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck

Patient line

Drain lineline


94



Part 6 Disconnection

Part 6 Disconnection

Step 1 of 8:

Follow Basic Procedure (9steps).



Step 5:

Do NOT clean the protective shield with an alcohol swab.

Remove the connection shield.

DO NOT TOUCH the exposed DARK BLUE area!!!!!

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Step 2:

Open the MINICAP package and leave the MINICAP inside it to keep it sterile.

Open sterile 4x4 gauze and place the connection site over it if you want.

Step 6:

CAREFULLY disconnect the TWINBAG® connector from the patient’s extension.

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Step 3:

Make sure the patient extension piece is closed.

Step 7:

Immediately apply the MINICAP to the patient extension.

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Step 4:

Disinfect your hands with Alcohol handrub

Let your hands dry.

Step 8 of 8:

Tighten the MINICAP making sure the extension is closed properly.

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck


95


Part 7 Final Check

Notes

Step 1 of 1:

Check the drainage fluid bag for clarity.

If only one exchange is needed with the same TWIN BAG® set- up, weigh the drainage bag to know how much fluid was drained from this manual PD exchange.

Ba

sic

Pro

ced

ure

Eq

uip

men

t

Pa

rt 1

Pre

pa

ratio

n

Pa

rt 2

Co

nn

ectio

n

Pa

rt 3

Dra

in

Pa

rt 4

Prim

ing

Pa

rt 5

Fill

Pa

rt 6

Dis

co

nne

ctio

n

Pa

rt 7

Fin

al C

he

ck


96

10 PROCEDURE FOR ATTACHMENT OF EXTENSION TUBING

10.1 Purpose

To maintain an aseptic environment while managing an accidental PD tubing separation or contaminated Baxter STAYSAFE catheter.

10.2 Target audience



97


10.3.1 How to attach TITANIUM adaptor to Pd catheter

Change Titanium 15 seconds hand

washing Change Titanium

Step 1:

**Procedure is done by PD nurse with sterile technique or by surgeon in the OR

This is the titanium adaptor.

Step 5:

Attach the catheter to the titanium adapter, pushing the catheter firmly to the end of the titanium.

Basic

P

rocedure

E

quip

me

nt

Step 2:

This is the titanium adaptor and the Baxter extension

transfer set.

Step 6:

The line shows how far you need to go.

Change B

axte

r exte

nsio

n

Dam

aged

Tra

nsfe

r Set

Step 3:

Attach the Baxter extension transfer set to the titanium with aseptic technic in the dressing tray as per protocol.

Step 7:

Screw on the titanium threaded Ring into the end of titanium catheter adapter, making sure the catheter is kept in place.

Step 4:

Pass the threaded ring through the end of the catheter.

Step 9:

Screw the new extension well.


98

10.4 Accidental Disconnection

An accidental disconnection is not something to be ignored. When the catheter is accidentally opened, a

leak occurs and bacteria can enter. Any type of contamination can lead to a major infection.

If the liquid can leak …bacteria can enter!

Prevent the bacteria from reaching the peritoneum by adding a clamp on the catheter with 2x2

underneath.

Call the Nephrologist STAT

If the tubing disconnects from the catheter, remain calm and react quickly in order to minimize the risks

for contamination. Never infuse the abdomen when contamination occurs. Dialysis samples need to

be acquired, extension will need to be changed and antibiotics started.

Always be prepared and keep the necessary tools handy for a quick connection (clamp).

If an accidental disconnection occurs:

Pinch the catheter;

Firmly attach the clamp on the catheter with 2x2 underneath.

Securely re-tighten the connection with the tubing or use a new cap or tubing.

If the catheter is damaged (detached, split or punctured), follow the previous steps and wrap the catheter

with a sterile gauze sponge; firmly attach this to the abdomen with adhesive tape.

This is a serious situation that needs to be corrected immediately.

Immediately inform the nurse at the dialysis clinic from Monday to Friday, from 8:00am to 16:00 or call the

on-call nephrologist. Call the nephrologist at (514) 412-4400, press “53333” and ask the operator for the

on-call nephrologist at the Montreal Children’s Hospital (evenings, nights and week-ends).


99

10.5 ACCIDENTAL CONTAMINATION

An accidental contamination is not something to be ignored. When the catheter is accidentally opened, a leak occurs and bacteria can enter and it can lead to a major infection

10.5.1 Basic Rules

1. Clamp the catheter with the Dravon hemostat yellow clamp by using the 2x2 underneath if disconnection is between PD catheter and extension.

2. Close roller clamp of the extension if disconnection is between catheter and tubing.

3. You can close system with cycler tubing or by putting a mini cap.

4. Call nephrologist and PD nurse.

5. Never infuse the abdomen when there is contamination.

6. Need to assess what type of contamination and get history.

7. Need to take a specimen and send for cell count & culture.

8. Need to change the extension. Usually done by PD nurse in hospital.

9. Need to cover with antibiotics with either cefepime 250 mg per liter or cefazolin 250 mg /liter for 3 days depending of contamination history.

10. Need to reassess therapy after results from cell count & culture.

11. If PD is not started yet, no infusion. Drain abdomen and take samples for cell count & culture /

change extension/ start antibiotics with cefepime or cefazolin 250mg/liter. If patient did not start PD yet and can do without a night of dialysis or has some night off, family or nurse can take the samples, disconnect from the cycler using Basic Procedure. The PD nurse will change the extension the following morning depending on the type of contamination.

12. If started PD, Stop dialysis /no more infusion/ take samples cell count & culture / change

extension/ start antibiotics cefepime or cefazolin 250 mg per liter x 3 days and reassess.


100

10.5.2 Accidental Contamination prior to PD Treatment

1. Make sure the system is closed with either mini cap, or Dravon hemostat yellow clamp with 2x2 underneath. Make sure roller clamp on Baxter PD extension is closed.

2. Never infuse the abdomen when there is a contamination.

3. Assess the situation and type of contamination.

4. Connect to Dialysis cycler if not already done.

5. Make sure specimen bag is connected using basic procedure. If on the cycler, you need to add a specimen bag using the basic procedures (the 9 steps). Wipe the outside specimen connection with alcohol swab 15seconds and let dry. Connect the specimen bag.

6. Drain the abdomen to collect sample for cell count & culture. You need to let drain 20 ml before

taking the samples if pediatric set up or 50 ml if adult set up.

7. Disconnect and apply a mini cap following the Basic Procedures (9steps).

8. Need to change the extension. This is usually done in hospital by the PD nurse.

9. If family can wait without dialysis until the next morning, give them the night off until next morning where PD nurse will change the extension and start antibiotics IP.

10. Cover with antibiotics for 3 days depending on cell count and culture results.

11. Cefepime 250 mg/liter or cefazolin 250 mg/ liter.


101

10.5.3 Accidental Contamination at the start of PD Treatment

1. Need to stop the dialysis. Make sure roller clamp on Baxter PD extension is closed

2. Make sure the system is closed and add a Dravon hemostat yellow clamp with 2x2 underneath.

3. Never re-infuse the abdomen when there is a contamination.

4. Assess the situation and type of contamination

5. Need to get samples for cell count & culture.

Make sure specimen bag is connected using basic procedure. If on the cycler,you need to add a specimen bag using the basic procedures (the 9 steps). Wipe the outside specimen connection with alcohol swab 15 seconds and let dry. Connect the specimen bag.

6. Drain the abdomen to collect sample for cell count & culture. You need to let drain 20 ml before collecting the samples if pediatric set up or 50 ml if adult set up.

7. Disconnect and apply a mini cap following the Basic Procedures (9steps).

8. Need to change the extension. This is usually done in hospital by the PD nurse.

9. Cover with antibiotics for 3 days depending on cell count and culture results.

10. Cefepime 250 mg/liter or cefazolin 250 mg/ liter.


102

10.5.4 Accidental Disconnection Between the Extension and Tubing

Goals:

Prevent the contamination of the catheter and reduce the risk for peritonitis.

If the white blood cell count < 100, a 3-day treatment is required.

If the white blood cell count > 100, the medical prescription will continue for a longer period and antibiotics will change according to culture results. The extension should be changed by the dialysis nurse once the white blood cells drop < 100.

Equipment:

Dressing Tray

Mask

Sterile gloves x2

Dravon hemostat yellow clamps

2x2 gauze sponge

4% Chlorhexidine soap, 0.6% Steri-gel

70% Alcohol / 2% chlorhexidine solution

Alcohol swabs

1 or 2 manual dialysis systems twinbag or you can use the cycle

PD solutions

Minicap

Extension

Procedure:

1. Clamp roller clamp on Baxter extension. Clamp the catheter with the Dravon hemostat yellow clamp by using the 2x2 under the clamp; Call the hospital or nephrologist on call.

2. Never infuse if contamination occurs, need specimen, change extension and start antibiotics.

3. Basic procedure;

4. Prepare the dialysis system; cycler or manual CAPD set up. If you are using the cycler, prime the tubing according to protocol; If you are using the twin bag, apply the yellow clamps on fill & drain line, connect the child and drain the abdomen.

5. Connect the dialysis system to the child following the protocol using cycler or CAPD manual system; Apply a white protective connecting shield and wrap around the exposed dark blue area of the extension tubing if using the twin bag CAPD system;

6. Release the yellow clamp and drain the abdomen;


103

10.5.4 Accidental Disconnection Between the Extension and Tubing (continued)

a. If the abdomen drains:

1. Let the abdomen drain to allow for a complete drainage of the abdominal cavity. After the drainage, take a dialysate sample for cultures and cell count;

2. Change the extension according to protocol (see Changing extension); usually done by PD nurse

3. Connect the child to a new dialysis system with antibiotic as prescribed by nephrologist; (usually

cefepime 250 mg/liter or cefazolin 250 mg/Liter for 3 days depending of contamination history)

4. Refill the child with the daily or night dwell volume depending of nephrologist.

b. If the abdomen does not drain:

1. Change the extension according to protocol (see Changing the extension); usually done by PD nurse.

2. Connect the child to a new dialysis system; use cycler or put protective shield if you use the manual CAPD twin bag.

3. Make 3 rapid exchanges (in & out) with the prescribed volume using PD solution. Take a sample on the first exchange for culture and cell count: Nephrologist will advise you for the duration of dwell time before taking the samples (30 to 90 min).

4. Connect the child to a new dialysis system with antibiotics as prescribed; use cycler or put protective shield if you use the twin bag manual CAPD system (usually cefepime 250mg/liter or cefazolin 250mg/liter for 3 days depending of the contamination history).

5. Refill the child with the daily or night dwell volume depending of situation and nephrologist.


104

10.6 Elements of clinical activity ACCIDENTAL DISCONNECTION

10.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET

Basic Procedure


Equipment

1.Close windows, doors and turn off any fan

fans

Gather material:

Chlorhexidine 2% with 70% alcohol 225 mL unidose


Dressing tray

Sterile gloves (x 2)

Masks

MINI CAP extended life PD transfer set

(Baxter PD patient extension piece x 2)

Clamp Hemostat DRAVON Dialysis (YELLOW)

2x2 & 4x4 gauzes

MINI CAP

Alcohol handrub

Basic

Pro

cedure

2 [Disinfect] Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes and let dry

Equip

me

nt

3.Let dry

4.Gather material

Change

Sta

yS

afe

C

ath

ete

r

5.Put on mask

Dam

aged

Tra

nsfe

r Set

6. Remove jewelry

7. Wash hands with Chlorhexidine solution 4% for 2 mins and dry hands well. (Close the faucets with a towel)

8. Dry hands well.





To prevent contamination, Close the faucets with a towel, keep away from garbage cans, sinks and toilets.


105

10.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET (continued)

Change Baxter extension 15 seconds hand

washing Change Baxter extension

Step 1 of 15:


(9 steps)



Step 5:

Open your PD Baxter extension set in your sterile field.

Add extra 4x4 compresses with aseptic technic.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Clamp the PD catheter with a YELLOW clamp (Hemostat Dravon) and 2x2 gauze.

Step 6:

Don your sterile gloves.

Take a 4x4 to hold patient’s catheter and put the sterile sheet under the PD catheter and use it to make a sterile surface.

Change B

axte

r exte

nsio

n

Dam

aged

Tra

nsfe

r Set

Step 3:

Open your dressing tray with an aseptic technique.

Step 7:

Put Chlorhexidine 2% with 70% alcohol on a sterile 4 x 4 gauze.

Clean the junction of the catheter with Chlorhexidine 2% with 70% alcohol for 2 minutes.

Step 4:

Add Chlorhexidine 2% with 70% alcohol in one container of your dressing tray (unidose bottle 225 mL).

Step 8 of 15:

Let the catheter dry.


106

10.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET (continued)

Change Baxter extension Change Baxter extension

Step 9 of 15:

Change and don new sterile gloves.

Step 13:

Install the new Baxter patient catheter

extension (MINI CAP

extended life PD transfer set).

Make sure the

extension is tight (MINI

CAP extended life PD

transfer set).

Basic

P

rocedure

E

quip

me

nt

Step 10:

You can close the clamp on the extension.

Step 14:

Get ready to connect the patient to drain the abdomen with the appropriate dialysis set up or with a syringe.

Do Culture and cell count.

Change B

axte

r exte

nsio

n

Dam

aged

Tra

nsfe

r Set

Step 11:

This is what a MINI CAP

extended life PD transfer set looks like.

Step15 of15:


CAREFULLY disconnect the PD set up from the patient extension as protocol.

Tighten the MINICAP

Step 12:

Remove the old MINI CAP

extended life PD transfer set or Baxter patient catheter extension.

.

.


107

10.6.2 How to change the Transfer Set and a titanium connector of the PD catheter when it is damaged


washing. Equipment


fans

Gather material:


Titanium (x 1)

Chlorhexidine 2% with Alcohol 70% (225 mL unidose bottle)

Sterile scissors

Dressing tray

Sterile gloves (x 2)

Masks

MINI CAP extended life PD transfer set (Baxter PD

patient extension piece x 1)

2x2 & 4x4 gauzes

MINI CAP

Red alcohol swab

Alcohol handrub

Basic

P

rocedure

Equip

me

nt

2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes

Equip

me

nt

3. Let dry

4. Gather material

Change B

axte

r

exte

nsio

n

5. Put on mask

Dam

aged

Tra

nsfe

r Set

6. Remove jewelry


8. Dry hands well.







108

10.6.2 How to change the Transfer Set with a titanium connector when the PD catheter is damaged (continued)

Change Baxter extension transfer set and titanium


Damaged PD catheter

Step 1 of 18:




Step 5:

Add Chlorhexidine 2% with 70% alcohol in one container of your dressing tray.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Clamp the PD catheter with a YELLOW clamp (Hemostat Dravon) and a 2x2 gauze.

Step 6:

Using aseptic technique, open and drop your sterile materiel in sterile field: sterile scissors, titanium connector, PD Baxter extension set, extra 4x4.

Change B

axte

r

exte

nsio

n tra

nsfe

r set a

nd tita

niu

m

Dam

aged P

D

Cath

ete

r

Step 3:

This is a titanium connector.

Step 7:


Take a 4x4 to hold catheter and put the sterile sheet under the PD catheter and use it to make a sterile surface.

Step 4:


.

Step 8 of 18:

Put Chlorhexidine 2% with 70% alcohol on a sterile 4 x 4 gauze.

Clean the catheter with Chlorhexidine 2% with 70% alcohol for 2 minutes where you will cut the PD catheter.

Let the catheter dry.


109



Damaged PD catheter

Step 9 of 18:

Make sure the catheter is dry.

Step 13:

Pass the titanium threaded Ring through the end of the catheter.

Basic

P

rocedure

E

quip

me

nt

Step 10:

Change and don new sterile gloves.

Step 14:

Attach the catheter to the titanium adapter, pushing the catheter firmly to the end of the titanium.

Change B

axte

r

exte

nsio

n tra

nsfe

r set a

nd tita

niu

m

Dam

aged

PD

cath

ete

r

Step 11:

In the sterile tray, you can close the clamp on the extension and

Attach the Baxter extension transfer set to the titanium with aseptic technic.

Step 15:

Screw on the titanium threaded Ring into the end of titanium catheter adapter, making sure the catheter is kept in place.

Step 12:

Cut the damaged catheter as close as possible to the titanium.

Step 16 of 18:

Screw the new Baxter extension transfer set and the titanium well.


110



Damaged PD catheter

Step 17 of 18:

To test the installation: Pull on the catheter away from the titanium.

The catheter should not be moving and is not removable once it is screwed to the maximum.

Basic

P

rocedure

E

quip

me

nt

Step 18 of 18:

Remove yellow clamp

Drain the patient with the appropriate system to push the bacteria away (manual CAPD set up or with syringe or cycler).

Do a culture & cell count.

Follow Nephrologist‘s orders for administration of antibiotics.

Change S

tayS

afe

C

ath

ete

r D

am

aged

PD

cath

ete

r


111

11 PROCEDURE TO COLLECT A DIALYSATE EFFLUENT SAMPLE

11.1 Purpose To maintain an aseptic environment while collecting a dialysate effluent sample

11.2 Target audience Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.


Table 11-1 :

Chart of prescribed tests on dialysate and characteristics (Sterile specimens taken from effluent sample bag)

Dialysis specimen:

Always use the 2 sterile containers for cell count and culture (routine and peritonitis). You have to add the blood culture bottles (aerobic, anaerobic and fungus) if suspected peritonitis only. Do not use blood culture bottle for routine cell count and culture.

Test Minimum amount of

effluent needed Type of requisition

Type of specimen container

Other specifications

C & S and gram smear

Take both specimens if suspected peritonitis

9 mL*+3ml for fungus

50ml

(always for routine and suspicion of

peritonitis)

Microbiology requisition

specify “PD effluent” on the requisition

Aerobic blood culture bottle (4 mL) YELLOW]

Anaerobic blood culture (5 mL) ORANGE]

50 ml in a sterile container with

orange lid

Do not store in the refrigerator (only orange container could go in the fridge)

Send to the lab STAT if suspect

peritonitis.

Fungus

To do only when peritonitis suspected 1 to 3 mL**

50 mL from above (same specimen but

add fungus on requisition)

Microbiology requisition

specify “PD effluent” on the requisition

send only if peritonitis

Fungus bottle (1-3ml)

Sterile specimen container same as

above (ORANGE LID 50 ML)

If amount of dialysate is less than 50 ml, send as much as possible with one cycle.

2 requisitions and 1 specimen for 50 ml. Use a separate microbiology requisition from the C & S test.

Send STAT. Store

in the refrigerator.

Cell count (including cytospin)

5–10 mL

(always for routine and if suspicion of

peritonitis)

Biochemistry requisition

In Hematology, under “CSF/Other”:

Specify “PD effluent” on the requisition

Check “cell count & differential” test,

Add “cytospin” in “Other”.

Sterile specimen container (ORANGE LID)

Do not store in the refrigerator.

Send to the lab STAT if peritonitis is

suspected.


112

11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag with cycler


washing. Equipment


fans

Gather material:

Effluent sample bag

Alcohol swabs (red) with chlorhexidine

60 mL syringe depending on kind of test

23 Gauge needle (18 if patient not connected to the dialysis system).

Sterile specimen container(s) x 2

Blood culture bottles (only if suspect peritonitis)

Appropriate laboratory requisition

Gloves and Masks


Refer to the Home Choice Quick Reference Guide protocol to know when to connect the effluent sample bag to the PD cassette tubing during the set-up (section8.3.4 and section12.3.1).

Basic

Pro

cedure

2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes E

quip

me

nt

3. Let dry

4. Gather material

Part 1

: Connect

Sam

ple

bag

5. Put on mask Part 2

: Positio

n

& F

ill Sam

ple

Bag

6. Remove jewelry

7. Wash hands with Chlorhexidine

solution 4% for 2 mins

Part 3

: Colle

ct

Sam

ple

8. Dry hands well.

Part 4

: Dis

card

Efflu

ent


handrub. Apply a palmful of alcohol based sanitizer and rub until dry

(20-30 secs). After handrub, touch only PD supplies.


Connect the effluent sample bag just before the drainage bag is connected to the drain line of the PD cassette when setting up see Part 1 (section 8.3.1 8.3.4 and 12.3.1)



113

11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag (continued)

Part 1: Connect Sample bag


Part 1: Connect Sample bag

Step 1 of 6:


Desinfect your hands with Alcohol based sanitizer and let dry.

Remove the effluent sample bag from the package and close the clamp.

Step 5: Protective rings

Hold effluent sample bag tubing near the connecting end by placing fingers behind the protective ring, and remove safety cap from the effluent bag.

Hold the shorter line on the “Y” tubing near the end by placing your fingers behind the protective ring, and

remove safety cap.

Basic

P

rocedure

E

quip

me

nt

Step 2: Drain line

The drain line is the last line to the right on the organizer. It has no clamp.

Part 1

: Connect

Sam

ple

bag

Step 6 of 6:

Without touching the exposed ends, connect the effluent sample bag to the shorter line on the “Y” tubing of the drain line.

Part 2

: Positio

n

& F

ill Sam

ple

Bag

Step 3: Drain line to drainage bag

Y-line effluent clamp sampling site

The effluent sampling site is situated at the Y junction of the drain line. This is where you will attach the effluent sample bag.

Make sure the clamp on the Y- line is clamped.

Part 3

: Colle

ct

Sam

ple

This is what the set up looks like with the effluent sampling bag.

Part 4

: Dis

card

E

ffluent

Step 4:

Disinfect hands with Steristat 0,5%. Apply a palmful and cover all surfaces of hands.

Rub hands until dry. (20-30 seconds)

Connecting a Sample Bag to the PD Cassette Set


114


Part 2: Position & Fill Sample Bag

Part 2: Position & Fill Sample Bag

Part 2:

All sterile samples are collected from the effluent sample bag at the beginning of the last drain of a PD

therapy (routine culture) unless otherwise specified by the physician or if peritonitis. The effluent sample bag is then detached from the PD set-up at the end of therapy, after the patient is disconnected from the PD set-up.

If you need a sterile specimen STAT during the course of the therapy:

i. Follow step 1 at the beginning of the drain of any cycle.

ii. KEEP THE EFFLUENT SAMPLE BAG ATTACHED

to the PD set- up (skip step 2).

iii. Follow Basic Procedures.

iv. Go to step 3.

v. Call the porter to take the specimen STAT to the lab

Step 3:

Once the effluent sample bag is full, close the 2 clamps.

Reopen the drain bag to complete the dialysis.

Basic

P

rocedure

E

quip

me

nt

Step 4:

Make sure the patient is disconnected from the PD set-up. Use # 23 needle if patient still connected to set-up

Disinfect hands with Steristat 0,5%.

Let them dry.

Part 1

: Connect

Sam

ple

bag

Step 1 of 6:

When the drain phase start, the effluent sampling bag must be closed at the beginning. You need to first drain the dead space before collecting the sample.

This is to prevent collecting fluid fro-m the previous fill (dead space).

Part 2

: Positio

n

& F

ill Sam

ple

Bag

Step 5:

Don clean gloves (the effluent sample is a biological waste).

Part 3

: Colle

ct

Sam

ple

Step 2:

If using a PEDIATRIC set, let drain a minimum of 20 mL of the last

drain into the drainage bag and then open the clamps on the effluent sampling site and effluent sample bag.

If using an ADULT set, let drain a minimum of 40 mL of the last drain

into the drainage bag and then open the clamps on the effluent sampling site and effluent sample bag

Part 4

: Dis

card

E

ffluent

Step 6 of 6:

Disconnect the effluent sample bag from the Y-junction line.

Collecting an Effluent Sample via the PD Baxter Cycler System

Effluent Sample


115


Part 3: Collect Sample


Step 1 of 9:

Assemble syringe and needle.

Use 23 gauge needle if patient is still connected otherwise use #18 gauge needle.

Step 5:

Always use 2 sterile orange containers. Use Blood culture bottle also if peritonitis suspected.

Remove the caps from the blood culture bottles, rub the injection ports with an alcohol swab and allow to dry.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Rub the injection port of the effluent sample bag with an alcohol chlorhexidine swab for 15 seconds and allow to dry.

Step 6:

Fill the sterile specimen container(s) with the appropriate amount of PD effluent from the syringe.

Close specimen container tightly.

Part 1

: Connect

Sam

ple

bag

Part 2

: Fill S

am

ple

B

ag

Step 3:

Withdraw the appropriate amount of dialysate from the effluent sample bag through the injection port.

Step 7 of 7:

Fill the blood culture bottles with the appropriate amount of PD effluent from the syringe (See chart on p.1).

Part 3

: Colle

ct

Sam

ple

P

art 4

: Dis

card

E

ffluent

Step 4:

Open the sterile specimen container(s) and place the lid with the inside facing “up” on a clean surface.

10 ml for cell count and 50 ml for culture.

Step 8 of 9:

Label container and/or blood culture bottles as “PD effluent”. Clearly mark the patient’s name and hospital number on the label.

Collecting the Sample from the

Effluent Sample Bag


116



Part 4: Discard Effluent

Step 9 of 9:

Send to lab STAT if

peritonitis suspected.

Do not store in fridge

unless it is a fungus test or orange containers.

Step 1 of 1:

Discard remaining effluent from sample bag into the unit’s toilet (dirty utility room).

Note: Remember this is a body fluid and routine precautions should be applied.

Basic

P

rocedure

E

quip

me

nt

Part 1

: Connect

Sam

ple

bag

Part 2

: Fill S

am

ple

B

ag

Part 3

: Colle

ct

Sam

ple

P

art 4

: Dis

card

E

ffluent


117

11.3.2 How to collect a sterile effluent sample via a seringe attached to the extension


Part 4: Collect sample

Step 1 of 6:

Follow Basic procedure (9 steps)



Step 4:

Open the extension by holding white piece closest to patient and turning the LIGHT BLUE part in a counter-clockwise manner.

Pull on the syringe to obtain your specimen for cell count and culture.

Basic

P

rocedure

E

quip

me

nt

Step 2:


To ensure closure hold white part closest to patient with one hand and twist LIGHT BLUE part in a clockwise manner

Step 5:

Close patient’s line.

CAREFULLY disconnect the syringe from patient’s extension.

IMMEDIATELY apply the MINICAP to the patient’s extension.

Tighten the MINICAP.

Part 1

: Colle

ct

Sam

ple

with

syrin

ge

Part 1

: Colle

ct

Sam

ple

with

syrin

ge

Step 3:

Open a 4x4 and minicap.

With an alcohol chlorhexidine swab clean the exterior part of the patient’s extension for 15 sec at the junction of the MINICAP and let it dry.


Step 6:

Put the effluent in 2 orange sterile containers for cell count and culture.

Send to lab STAT if

peritonitis suspected.

Do not store in fridge

unless it is a fungus test or orange containers.

Part 1

: Colle

ct

Sam

ple

with

syrin

ge

Step 4 :

Open new minicap.

Remove old minicap from patient and connect the syringe on the extension.

Do not touch the dark blue area.

Use Blood culture bottle as well only if peritonitis or requested. Always use sterile orange containers.


118

11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE

Table 12-2 : Chart of prescribed test on dialysate and characteristics

Test & Purpose Minimum amount of

effluent needed Type of requisition

Type of specimen container

Other specifications

Creatinine clearance and urea

(24-hour collection)

Purpose:

To monitor patient’s status and the efficiency of the PD treatment.

50 mL Yellow biochemistry requisition

1. In Oasis or the requisition Biochemistry section, under “URINE”, cross-out “URINE” and write “PD EFFLUENT”.

2. Write the total amount of dialysate

contained in the drainage bag on requisition:

*Add up the drains from the “OUT” column on your

IN/OUT sheet, including the 1st drain

OR

*Calculate: Volume/Cycle x # of Cycles + Initial Drain + cumulative UF written on the cycler.

3. Write duration, time of start and end of collection.

4. Check “CREATININE”, “CREATININE

CLEARANCE”, “PROTEIN TOTAL”,

lytes and write UREA beside

“OTHER”.

5. Write the patient’s dry weight and height.

Non sterile specimen container (yellow lid)

In the program, put dextrose to same. Do not use extraneal or the blue line for that evening only.

**You should empty the drainage bag before the therapy starts to remove the accumulated fluid from the flushing of the tubing (this fluid may alter the results of the test).

If 2 drainage bags are attached to the system, place them at the same level from the start of the therapy so that the effluent dialysate can equally spread in the 2 drainage bags for the duration of the PD. You may take a sampling from each bag in equal amount in same container.

Mix the drainage bag contents before taking the sample. Take the

sample at the end of therapy when patient is disconnected.

Draw a BLOOD

specimen at the same time for urea and creatinine.


119

11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE (continued)

Collect effluent sample from drainage bag


Step 1 of 10:

Gather material:

Clean gloves

Non sterile specimen container

Biochemistry requisition

Step 5:

Mix the drainage bag.

Place open specimen container under the specimen port of the drainage as to be ready to collect the sample

Co

llect e

ffluen

t sa

mp

le fro

m

dra

inag

e b

ag

Step 2:

This is what the sampling port of the drainage bag looks like with the white and blue clamps closed.

Step 6:

Colle

ct e

ffluen

t sa

mp

le fro

m th

e

Pe

dia

tric S

etu

p

Step 3: Drain line to drainage bag

Don clean gloves (the effluent sample is a biological waste).

Step 7:

Remove the safety cap on the specimen port.

Step 4:

Open non sterile specimen container and place the lid with the inside facing “up” on a clean surface.

Step 8 of 11:

Open white and blue clamps and collect specimen.

Make sure the patient is disconnected from the PD system


120

11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE (continued)



Step 9 of 11:

Close white and blue clamps.

Co

llect e

ffluen

t sa

mp

le fro

m

dra

inag

e b

ag

Step 10:

Close specimen container tightly.

Co

llect e

ffluen

t sa

mp

le fro

m th

e

Pe

dia

tric S

etu

p

Step 11 of 11:

Use printed label from Oasis

or Label container as “PD effluent”. Clearly mark the patient’s name, hospital number and total drained volume for the night on the label.

Complete appropriate requisition

Note: Remember to draw a BLOOD sample at the same time (urea and creatinine) and send PD effluent for urea, creatinine, protein and write the total amount of effluent drained.


121

11.3.4 How to collect an effluent sample via the PEDIATRIC SETUP

Collect effluent sample from the Pediatric Setup


Collect effluent sample from the Pediatric Setup

Step 1 of 4:

Effluent procurement with the Pediatric set up use the sampling port below the drainage soluset.



Let your hands dry.

Step 3:

Drain some effluent from the patient into the drainage soluset.

Do not overfill the soluset to prevent the vent from getting wet and causing a system malfunction.

Co

llect e

ffluen

t sa

mp

le fro

m

dra

inag

e b

ag

Step 2: (old version)

Clean sampling port with alcohol swab with chlorhexidine (red swab) for 15 secs. and let dry.

Step 4 of 4:

Clean sampling port with alcohol chlorhexidine swab (red swab) for 15 secs. and let dry.

Use a 60 ml syringe and 23 gauge needle.

Puncture the sampling port with the needle and draw approximately 60 mL or as much as you can if small volume: 5 mL for cell count and 50 mL for culture (as much

as you can) and put in 2 orange sterile containers.

Send orange containers and blood culture bottle (if enough PD fluid) as well if peritonitis is suspected otherwise use the orange containers for routine culture and cell count

50ml or less in a sterile container (orange lid)

5ml cell count

4 mL in paediatric aerobic blood culture and

5 mL anaerobic blood culture

1-3 ml fungus

For small babies, just take as much as you can

Colle

ct e

ffluen

t sa

mp

le fro

m th

e

Pe

dia

tric S

etu

p

Volume of pediatric set up lines:

Fill line 24 ml

Drain line 20 ml

Patient extension 2 ml

Total prime line 46 ml

24 mL

20 mL

2 mL


122

12 SET-UP PROCEDURE FOR A PEDIATRIC MANUAL CAPD SYSTEM

12.1 Purpose

To maintain an aseptic environment while setting-up the pediatric manual CAPD system with ASTOFLO PLUS warmer


Nursing and medical staff responsible for the care of the patient on peritoneal dialysis


12.3.1 FRESENIUS STAYSAFE SETUP

24 mL

20 mL

2 mL


123

12.3.2 How to set-up the pediatric manual CAPD system

24 mL

20 mL 2 mL

Fill volume : 24 mL

Drain line : 20 mL

Patient line : 2 mL

Total priming volume: 46 mL


124

12.4 How to set-up the pediatric manual CAPD system: Quick reference


1. 9 Steps Basic Procedure

2. Steri-Gel+ and rub hands until dry

3. Open Solution Bag. Steri-Gel+ & add Medications Hang bag and Break Cones

4. Open all packages and put on clean table

5. SteriGel 0.5% and let dry. Close all 7 clamps on the Paed set (6 clamps and 1 roller clamp)

6. SteriGel 0.5% and let dry. Connection to Drainage Bag. Yellow to Yellow

7. Connect the 4 inch Safe-Lock adaptor to the Bag connector line

8. Sterigel and let dry. Connection to bag to the 4 inch Safe Lock adaptor

9. Prime the system Prime Fill and Drain line first and Prime Patient line last.


125

12.4.1 How to set-up the pediatric manual CAPD system

Basic Procedure


Equipment


fans

Gather material:

PD-Paed system (# 5895) (including 4 liters drainage bag)

Solution bags: Physioneal : 1.36% (72099),

2.27% (72098)

3.86 % (72094) Dianeal : 0.5% 7110

SAFE LOCK APD LUER-LOCK CONNECTOR 4 inch 72092

STAY SAFE CAP 72101

DRAVON hemostats (YELLOW clamps) # 5876

Chlorhexidine with 70% Alcohol swabs (red swab)

Syringe for heparin / Needle 23 gauge

Alcohol handrub hand sanitizer

Masks


Basic

Pro

cedure

2. [Disinfect] Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes and let dry

Equip

me

nt

3. Let dry

4. Gather material

Part 1

:

PD

PA

ED

S

ET

5. Put on mask

Part 2

:

PD

PA

ED

SE

T

6. Remove jewelry

Part 3

:

PD

PA

ED

S

ET


8. Dry hands well

9. Close the faucets with a towel. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 seconds). After handrub, touch only PD supplies.

If your hands become contaminated, remember to use SteriGel+ 0.5% or Chlorhexidine 4% solution for 15 seconds.



126

12.4.1 How to set-up the pediatric manual CAPD system (continued)

Part 1: PD PAED SET


Part 1: PD PAED SET

Step 1 of 7:




Step 5:

Put all tubing on the second clean surface.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Open solution bags and inspect bag for expiratory date. Put on 2

nd clean

surface.

After disinfecting your hands, you can add any medication to the solution bag via the injection port. Wipe with alcohol swabs 15 sec.

*See ADDITION OF MEDICATION PROTOCOL

Step 6:

Open safe lock APD luer-lock connector 4 inch package and drop on the 2

nd clean surface

or into open paed set packaging.


Let your hands dry.

Part 1

: P

D P

AE

D S

ET

P

art 2

: P

D P

AE

D S

ET

Step 3:

Break the inner cone (GREEN cone) by

bending it back and forth.

Hang the bag to allow the solution to mix together.

Step 7:

SYSTEM SETUP


Close all 7 clamps on the Paed set (6 clamps and 1 roller clamp)

Part 3

: P

D P

AE

D S

ET

Step 4:

Open Paed set package and all others packages.

Alcohol handrub before each connection.

Apply a palmful and cover all surfaces of hands. Rub hands until dry ( 20-30 seconds). After handrub, touch only PD supplies.


127


Part 2: PD PAED SET

Part 2: PD PAED SET

Step 1 of 7:

CONNECTION TO DRAINAGE BAG

Hold connections only on the square part of the connector.

Join the two YELLOW

connectors together using aseptic technique.

Step 5

Join the BLUE square

safe lock connector to the BLUE square end of safe lock 4-inch adaptor.

While connecting: remember to hold square to square to prevent contamination.

Basic

P

rocedure

E

quip

me

nt

Step 2:

The connection from the solution bags to the paed set is not compatible. They are not airtight and are a risk for infection.

The safe lock APD luer lock connector MUST be

used.

This is what it looks like.

Step 6:

Remove the pulling color coded ring from the solution bag and the white cap from safe lock 4-inch adaptor.

Use sterile technique and take extra precaution not to contaminate either end.

Part 1

: P

D P

AE

D S

ET

P

art 2

: P

D P

AE

D S

ET

Step 3:


Apply a palmful and cover all surfaces of hands.

Rub your hands until dry.


Step 7 of 7:

Connect the Safelock APD luer lock 4 inch adapter (blue & WHITE) to the solution bag.

Part 3

: P

D P

AE

D S

ET

Step 4:

Using aseptic technique, remove the 2 WHITE

caps completely (there are 2 detachable pieces) from one BLUE square

connector.

Attach the safelock APD luer lock connector.


128


Part 3: PD PAED SET

Part 3: PD PAED SET

Step 1 of 10 :

Install solution bag and 2 solusets on an IV pole.

A= Soluset receives solution for dialysis.

B= Soluset receives

drainage from dialysis.

Step 2:

Step 4 :

Open blue clamp below solution bag to partially fill soluset “A” then close when done.

**Do not overfill soluset “A”. This is to prevent the vent from getting wet. Should the vent get wet it can cause a system malfunction**

Basic

P

rocedure

E

quip

me

nt

Step 5 :

Fill the soluset with the amount prescribed.

Fill the drip chamber partially by squeezing it. (The drip chamber contains exactly 10 ml if fully filled) • Ensure that the ball of the safety valve is floating.

Part 1

: P

D P

AE

D S

ET

P

art 2

: P

D P

AE

D S

ET

Step 2 :

Use the holder if available

Step 6 :

PRIMING:

Need to put a YELLOW

clamp on the patient end after the Y (fill and drain line join).

Prime tubing from soluset “A” (fill soluset) to the soluset “B” (drain soluset).

Part 3

: P

D P

AE

D S

ET

Step 3 :

This is a clamped system.

Open clamp and break the cone

Step 7 :

When finished priming fill and drain line, close the clamps.

Make sure not to fill soluset “B” with any dialysis solution or empty the drain soluset each time for accurate reading.

A

B


129


Part 3: PD PAED SET

Part 3: PD PAED SET

Step 8 :

Priming patient line:

Raise end of patient line above soluset “A” to prevent overfill.

Remove yellow clamp to finish priming and fill end of patient line to tip without overflowing.

Volume of paed set lines:

Infusion line 24 ml

Drain line 20 ml

Patient extension 2 ml

Total prime line 46 ml

Basic

P

rocedure

E

quip

me

nt

Step 9 :

Place heater line over patient’s line from drip chamber to patient line.

Temperature to be set at 37.5°C Do not exceed

Part 1

: P

D P

AE

D S

ET

Part 2

: P

D P

AE

D S

ET

Step 10 :

Temperature to be set at 37.5°C Do not exceed

Part 3

: P

D P

AE

D S

ET

37.5


130

12.5 Procedure for Connection/Disconnection with Pediatric Setup - STAYSAFE Connection Procedure

12.5.1 Purpose

To maintain an aseptic environment while connecting and disconnecting the Baxter STAYSAFE with pediatric setup

12.5.2 Target audience

Nursing and medical staff responsible for the care for the patient on peritoneal dialysis

12.5.3 Elements of clinical activity


131

12.5.4 FRESENIUS STAYSAFE CONNECTION procedure

Basic Procedure


Equipment


fans

Red alcohol swabs

Gather the materials:

STAY SAFE CAP 72101


Alcohol Chlorhexidine swabs (red swab)

Alcohol handrub / Chlorhexidine solution 4%

4x4 & 2x2 Gauzes


Masks

Basic

Pro

cedure


Equip

me

nt

3. Let dry

Change S

tayS

afe

Cath

ete

r

4. Gather material

5. Put on mask

Dam

aged

Tra

nsfe

r Set

6. Remove jewelry


8. Dry hands well

9. Close the faucets with a towel. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 secs). After handrub, touch only PD supplies.




132

12.5.4 FRESENIUS STAYSAFE CONNECTION procedure (continued)

Part 1 Connection Procedure



Step 1 of 4:



Rub hands until dry. (20-30 seconds). After handrub, touch only PD supplies.

Step 1 of 3:

Remove cap from the end of the tubing set and cap from patient extension and connect.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Make sure set up is well primed.

Step 2:

Use aseptic technique

Part 1

Connectio

n

Pro

cedure

Part 2

Connectio

n

Pro

cedure

Step 3:

Clamp patient PD catheter with a YELLOW clamp using a

2 X 2 underneath to protect the catheter.

Step 3 of 3:

:

Remove the YELLOW

clamp (dravon). You can start your dialysis treatment.

Part 3

Connectio

n

Pro

cedure

Part 4

Connectio

n

Pro

cedure

Step 4 of 4:

Open 4x4.

Wipe outside Stay safe patient connection with alcohol chlorhexidine swab (red) for 15 secs. and let dry.

Put the PD catheter on the 4x4.

Connection to the child


133

12.5.5 FRESENIUS STAYSAFE DISCONNECTION procedure

Part 3 Disconnection Procedure


Part 4 Disconnection Procedure

Step 1 of 3:

Basic Procedure (9steps)

Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands. Rub hands until dry (20-30 secs). After handrub, touch only PD supplies.

This is the STAY SAFE CAP

Step 5 of 7:

Put a YELLOW clamp

on the PD catheter with a 2x2 underneath to protect and close catheter

Basic

P

rocedure

E

quip

me

nt

Step 2:

Wipe outside Stay safe patient connection with alcohol chlorhexidine swab for 15 secs. Let dry

Put a 2x2 underneath the catheter

Step 6 of 7:

Open the stay safe cap.

You will see the blue pin that closed the catheter

Put the stay safe cap. The pin will perforate the stay safe cap to release proviodine.

Part 1

Connectio

n

Pro

cedure

Part 2

Connectio

n

Pro

cedure

Step 3 of 7:

Turn and push.

Turn clockwise the blue push button situated closest to the catheter connection tubing

Step 7 of 7:

You can remove the yellow clamp

Part 3

Dis

connectio

n

Pro

cedure

Part 4

Dis

connectio

n

Pro

cedure

Step 4 of 7:

Push to the end the blue pushbutton to introduce the pin in the extension of the patient.

Make sure the clamp is not on when you push the pin because it will create a pressure that could make the pin fall


134

13 PROCEDURE FOR STAYSAFE CATHETER ADAPTER INSTALLATION


13.1.1 FRESENIUS STAYSAFE CATHETER ADAPTER INSTALLATION procedure

StaySafe Adapter Installation Procedure

Notes

This is the stay safe catheter adapter.

Basic

P

rocedure

E

quip

me

nt

1. Pass the Threaded Ring through the end of the catheter.

2. Place the end of the catheter into the end of the STAY SAFE catheter adapter, pushing the catheter firmly to the end.

Part 1

Connectio

n

Pro

cedure

Part 2

Connectio

n

Pro

cedure

3. Screw on the Threaded Ring into the end of the STAY SAFE catheter Adapter, making sure the catheter is kept in place.

4. At the end, use the wrench to tighten the screw.

Part 3

Dis

connectio

n

Pro

cedure

Part 4

Dis

connectio

n P

rocedure

5. Remove the wrench.

6. To test the installation: Pull on the catheter away from the Safe Lock Adapter.

Ad

ap

ter

Insta

llatio

n


135

13.1.1 FRESENIUS STAYSAFE CATHETER ADAPTER INSTALLATION procedure (continued)

StaySafe Adapter Installation Procedure


Basic procedure (9 steps).

Disinfect your hands with handrub.

Apply a palmful and cover all surfaces of hands. Rub hands until dry (20-30 seconds).

This is the stay safe catheter adapter.


Take a 4x4 to hold catheter and put the sterile sheet under the PD catheter and use it to make a sterile surface.

Clean the catheter for 2 minutes with chlorhexidine 2% and let dry.

Basic

P

rocedure

E

quip

me

nt

Clamp the PD catheter with a YELLOW clamp

(Hemostat Dravon) and a 2x2 gauze underneath to protect catheter.

Change sterile gloves

Pass the Threaded Ring through the end of the catheter.

Place the end of the catheter into the end of the stay safe catheter adapter, pushing the catheter firmly to the end

Part 1

Connectio

n

Pro

cedure

Part 2

Connectio

n

Pro

cedure


Screw on the Threaded Ring into the end of the Stay safe catheter Adapter, making sure the catheter is kept in place.

At the end, use the wrench to tighten the screw

Part 3

Connectio

n

Pro

cedure

Part 4

Connectio

n

Pro

cedure

Add Chlorhexidine 2% with 70% alcohol in one container of your dressing tray (unidose bottle 225 mL).

Add the stay safe catheter adapter and extra 4x4.

Remove the wrench.

To test the installation: Pull on the catheter away from the Safe Lock Adapter


136

14 PROCEDURE FOR HEPARINIZATION WITH PEDIATRIC SETUP


14.1.1 FRESENIUS STAYSAFE SAMPLE PORT CONNECTION PROCEDURE

Basic Procedure


Equipment


Gather material:

SAMPLE PORT


Alcohol Chlorhexidine swabs (red swab)

Alcohol handrub / Chlorhexidine solution 4%

4x4 & 2x2 Gauzes

Masks


Basic

Pro

cedure


Equip

me

nt

3. Let dry

Change S

tayS

afe

Cath

ete

r

4. Gather material

5. Put on mask

Dam

aged

Tra

nsfe

r Set

6. Remove jewelry


4% for 2 mins and dry hands well. (Close the faucets with a towel)

8. Dry hands well


handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 seconds). After handrub, touch only PD supplies.




137

14.1.1 FRESENIUS STAYSAFE SAMPLE PORT CONNECTION PROCEDURE (continued)




Step 1 of 3:




Step 2 of 5:

Flush the stay safe sample port with syringe.

Stay safe sample port volume 2.2ml.

Basic

P

rocedure

E

quip

me

nt

Step 2:

Clamp patient PD catheter with a YELLOW

clamp using a 2 X 2 underneath to protect the catheter.

Step 3 :

Connect the sample port to the PD catheter

Remove the YELLOW

clamp (dravon).

Infuse the prescribed amount of heparin.

Part 1

Heparin

izatio

n

Pro

cedure

Part 2

Heparin

izatio

n

Pro

cedure

Step 1 of 3:

Wipe outside Stay safe patient connection with alcohol chlorhexidine swab for 15 secs. and let dry.

Put the PD catheter on the 4x4.

Step 4:

Turn the blue push button clockwise situated closest to the catheter connection tubing.

Part 3

Dis

connectio

n

Pro

cedure

Part 4

Dis

connectio

n

Pro

cedure

Step 1 of 5:

Connect syringe of heparin (concentration determine by nephrologist) to stay safe sample port with aseptic technic.

Flush the syringe.

Step 5 of 5:

Clamp patient PD catheter with a YELLOW clamp

You see the blue pin that closed the catheter

Put the stay safe cap. The pin will perforate the stay safe cap to release proviodine.

Heparinization of PD catheter


138

15 PROCEDURE TO SAFELY DISPOSE OF BIOLOGICAL DIALYSATE EFFLUENT

15.1 Purpose

To properly dispose of anatomical biological dialysate effluent using universal precautions.




Dialysis effluent is a non-anatomical biological waste.

It is a body fluid for which universal precautions apply.

The effluent measured from the drainage bag must be discarded into the toilet or in the unit’s drain in utility room (or where bed pans are emptied on your unit).

DO NOT DISPOSE EFFLUENT IN THE SINK.


139

16 PROCEDURE TO CHART DIALYSIS EXCHANGES

16.1 Purpose

To monitor and keep a record of the patient’s fluid balance.




Table 16.1 Guidelines for charting dialysis exchanges

1. Write the name of the patient and his / her unit number or stamp with a card on Peritoneal Dialysis Record flowsheet

2. Enter patient`s weight before starting PD and post dialysis ( with last fill volume ).

3. To detect any signs of dehydration: every morning post-dialysis,

Take a postural BP and heart rate ( lying and standing ) 60 seconds apart.

If the patient has already gotten up in the morning, make him/her lie down for 10 minutes first.

If there is a decrease of 20 mmHg for BP and/or increase beats/min for HR( between lying and standing ), advise the physician.

4. Use time or time intervals when recording exchange, e.g.: write 15:00 – 15:50 for Infusion / Dwell, 15:50 – 16:00 Drain, mainly for CAPD, time CCPD.

5. Number of cycles according to infusion, e.g. first infusion write « 1 ». The number of cycles does not become « 0 » at midnight. They add up for the length of the overnight treatment. For 6S and 6N: if 24 hours dialysis restarts at midnight.

6. Write volume infused (in mL).

7. Write type of solution, e.g. Dianeal 2.5% or Physioneal 2.27% .

8. Write any added medications, e.g. : Heparin 500u /L

9. Use a different line to record drainage / output using time intervals.

10. Record volume drained (in mL).

11. Calculate balance for the cycle, indicate clearly if balance is positive (+) or negative (-). i.e. Balance is ( + ) if volume infused > drained Balance is negative ( - ) if volume infused < drained.

12. Enter cumulative balance.

13. Describe quality of the effluent, e.g.: clear, cloudy, presence of fibrin, blood, clots, sediment.

14. The daily PD record is kept at the bedside. Use a new sheet daily.


140

16.4 PROCEDURE TO CHART DIALYSIS EXCHANGES

PERITONEAL DIALYSIS RECORD

Date

Weight Before After:

Time Cycle Volume Solution

IN OUT Balance UF Cumulative UF Balance

Type and Added Medications

Remarks

0 200 Physioneal 1.36%

1 500

With Heparin 1000 units/L

600 – 100 – 100 Extraneal

2 500

525 – 25 – 125

3 500

490 + 10 – 115

4 500

550 – 50 – 165


141

17 PROCEDURE TO MANAGE A BLOCKED PD CATHETER WITH TPA (rt-PA) PROTOCOL (ALTEPLASE)

17.1 Purpose To use TPA (rt-PA, tissue plasminogen activator) for blocked PD catheters.

17.2 Target audience Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.


Consult Nephrologist for final decision. TPA: Original concentration 1.0 mg/mL

The Pharmacist can dilute TPA to a concentration of 0.5mg/mL or more.

Do not further dilute TPA, it could precipitate.

Table 17.1 Guidelines for TPA adminisitration and catheter dwell

1. Prepare solution to obtain concentration of 1 mg /ml. Could be 0.5 mg /ml for neonatal depending nephrologist.

2. Instill an amount equal to 110% of the internal volume of the catheter.

3. Allow to dwell and leave medication for 90 min to 2 hours in the PD catheter and then withdraw the medication from the catheter.

4. Dosage children’s catheter:

PD catheter 60cm : Catheter length 3.0 ml+ Baxter transfert set 1.4 ml with titanium= 4.6 ml

Need to cover 110%, would need to inject 5 ml. To verify with nephrologist

PD catheter 39cm: Catheter length 2.2 ml+ Baxter transfert set 1.4 ml with titanium = 3.8 ml

Need to cover 110%, would need to inject 4.2ml. To verify with nephrologist

PD catheter 44.25cm: Catheter length 2.4 ml+ Baxter transfert set 1.4 ml with titanium = 4.0 ml

Need to cover 110%, would need to inject 4.4ml. To verify with nephrologist

4. Dosage neonatal catheter:

Neonatal PD Catheter length 2.3ml + stay safe catheter adapter + staysafe sample port 2.6 ml =4.6ml

Need to cover 110 %, would need to inject 5 ml. To verify with nephrologist. Nephrologist might want a concentration 0.5 mg /ml for neonate.

If neonatal baby on cycler with Baxter extensionCatheter length 2.3ml + Baxter extension 1.4ml with titanium = 3.9ml 110%=4.3ml

5. Nephrologist and / or Fellow need to be present and PD nurse will give this medication

6. Add antibiotics ( first generation cephalosporin preferred, e.g. cefazolin) to dialysate in following exchange. Always try to withdraw alteplase.

7. Due to risk of abdominal pain and allergic reactions, TPA infusion should only be done in hospital with medical supervision.

8. The prescription needs to be sent to pharmacy with:

the name of patient stamped on the prescription,

weight of patient,

dosage in milligrams and

the total volume in millilitres to be injected into the lumen.

The Pharmacist will send a vial to dilute. Should be given to PD nurse or experienced staff.



142

18 PROCEDURE TO PERFORM A PERITONEAL EQUILIBRATION TEST (PET PROTOCOL)

18.1 Purpose

Helps define the permeability and efficiency of a patient’s peritoneal membrane by measuring dialysate to plasma ratios of certain solutes.

Enables the clinician to diagnose and assess which dialysis regimen will best meet the individual requirements of each specific patient.





143

18.3.1 How to perform a PET test

Basic Procedure


Equipment


fans

Gather material:

Physioneal 2.27% or

Dianeal 2.5% (1100 cc x SAM2) or patient’s fill volume prescription.

SAM2 ( surface area ) = Ht (cm) x wt ( Kg ) ÷ 3600

Manual dialysis system x 2 (TWIN BAG) – ask PD nurse.

Dravon clamp with 2x2 (YELLOW) x 3

White connective shield x 2

MINI CAP.

Alcohol swabs with chlorhexidine red swabs)

Chlorhexidine 4% soap or foamy soap/ Alcohol handrub.

Masks.

4 x 10 mL syringe 1 x 60 mL syringe and needles #23 x 5.

7x sterile urine containers.

Blood procurement equipment and microtainers.

Lab requisitions : 5 Biochemistry requisitions

2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes and let dry

3. Let dry

4. Gather material

5. Put on mask

6. Remove jewelry


8. Dry hands well







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18.3.1 How to perform a PET test (continued)

Table 19.1 How to perform a PET test 15 seconds hand washing

1. Basic Procedure (9 steps). Apply a palmful of Acohol handrub and cover all surfaces of hands. Rub hands until dry (20-30 seconds).

2. Prepare 2 dialysis set ups (one to drain the patient and the other to fill and do PET test).

3. Infuse approximatively 1100 cc / SAM2 of 2.5 % dialysis solution on the evening prior to the PET and allow to dwell for 8 to 12 hours or the patient’s prescription fill volume. Note time of last infusion at home.

4. The following day, go to your scheduled appointment for the PET.

5. Connect a dialysis system and drain abdomen over 20 minutes. Record volume and send samples for cell

count and culture ( hematology and culture ) and for urea, creatinine, glucose , sodium ( write total volume drained ).

6. Prime and connect a new dialysis system with connective shield following the basic procedure and re-infuse 1100 cc /SAM2 or usual home cycling fill volume of a new 2.5% or 2.27% dialysis solution over exactly 10 minutes. Ask the patient to roll intermittently from side to side. Zero dwell time is the time the infusion is completed.

7. At 0, 1, 2 and 4 hours, obtain dialysate samples and blood sample at 2 hours as follows :

a. Basic procedure (mask, wash hands and dry them well…) before each sampling.

b. Drain dialysate samples (approx. 5 mL / Kg) into drainage bag.

c. Mix sample in the drainage bag.

d. Rub injection port with red alcohol swab x15 seconds and let dry. This cleaning is to be done before and after each sample is taken.

e. Obtain 5 mL sample through injection port of drainage bag with needle # 23 and syringe.

f. After each sample is taken, re-infuse remaining dialysate from drainage bag to the patient.

8. Send the dialysate samples to the biochemistry lab for sodium, glucose, creatinine, urea and protein to the nephrology lab. Write the total volume on first overnight sampling and on the last drain.

9. Draw a single serum for sodium, glucose, creatinine and urea at 2 hours dwell time. Send to biochemistry lab.

10. After 4 hours, drain the patient completely over 20 minutes. Record the volume drained. Mix sample in the drainage bag. Obtain a 5 ml dialysate sample and send to biochemistry lab for sodium, glucose, creatinine and urea to the nephrology lab.

11. Infuse his regular day volume with the appropriate solution.


145


Pediatric PET curve

PET Corrected Creatinine

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3 4

Time (Hr)

D/P

0.77

0.88

0.64

0.51

0.37

High Avg

Low Avg

Low

High

PET Corrected Glucose

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3 4

Time (H r)

D/D

O

0.22

0.43

0.12

0.55

0.33

High Avg

Low Avg

Low

High


146


Table 18.2 PET worksheet

Name:

Date:

Overnight IN:

Overnight OUT:

UF

Total dwell time:

Time morning infusion is completed:

Volume out at 4 hours:

Dialysate samples:

Dwell Time Creatinine Urea Glucose Sodium Protein

Overnight

0 hours

1 hour

2 hours

4 hours

Serum sample:

Dwell Time Creatinine Urea Glucose Sodium Albumin

2 hours

Ratios:

0 hours 1 hour 2 hours 4 hours

Dialysate plasma

Creatinine ratio

Urea ratio

Dialysate / Dialysate at 0 time ( D/DO )

Glucose ratio


147

19 PROCEDURE TO PERFORM AN INTRAABDOMINAL PRESSURE MESUREMENTS (IPP)

19.1 Purpose

IPP should be measured in all PD patients in an effort to optimize clearance and ultrafiltration.

Pressures above 18 cm H2O are associated with discomfort and must be avoided.

Increase volume slowly accommodating 1 to 3 weeks.

Maximum tolerable IPV that results in an IPP of 15 to 18 cm H2O. Aim for 14.

IPPs in children need to be done in recumbent position. IPP should be performed in patients when: we need to increase the intraabdominal volume faster than protocol, or when the volume is reaching 1100 mL/m

2 or for clinical assessment of the patient.




Table 19.1 Guidelines for preparation for a IPP test

1. Make sure the bladder is empty.

2. Heat the dialysis bag for comfort.

3. Zero level of the column (on graduated scale) is set at the center of the abdominal cavity i.e. Medial axillary line.

4. You could use the Pain Scale to assess comfort and volume tolerance.

5. Patient needs to be in a supine position

6. Recommended to use a neutral Ph solution: reduces IPP (physioneal)

7. Never go higher than 18 cmH2O. Aim for 14 cmH2O.


148


Make sure patient uses the bathroom prior to the test

Table 19.2 Procedure for preparation for a IPP test 15 seconds hand washing

1. Basic procedure (9 steps).

2. Patient is at rest, lying completely flat.

3. Set up 2 manual systems (twinbag CAPD manual set up is preferred) physioneal 1.36%.

4. Connect patient and drain the abdominal cavity completely.

5. Connect to the 2nd set up and fill the abdomen with regular volume – minus 50 mL.

6. Put the drain line on manometer and hang the drain bag on the pole.

7. Open the drain line assess the PD fluid

8. With a manometer, measure the level of PD solution with the zero at mid-abdomen. Take the level of pressure on inspiration and expiration, calculate the mean pressure generated.

9. Level of the column of dialysis fluid in the PD line is read with the scale graduated in cm after the height of the column stabilises, firstly after inspiration, secondly after expiration.

10. Mean IPP = IPP insp + IPP exp 2

11. Zero level of the column, on the graduated scale, is set at the center of the abdominal cavity, on the medial axillary line.

12. Repeat the same procedure by adding 50 mL at each cycle up to maximum of 1400 mL/m2

(usually 1200ml/m2)


149


Table 19.3 Summary for IPP test

Patient Goal volume

mL/m2

Maximum volume mL/m

2

Maximum IPP cm H2O

Last Fill mL/m

2

Neonates 600 – 800 800

unless low IPP permits increase

8 – 10 600 – 800

Infants <2 y.o. 1000 – 1400 1400 ?10 – 14 800 – 1200

Children>2 y.o. 1000 – 1400 1400 18 800 – 1200

IPP cm H2O IPV mL/m2 BSA

in adults 13.4 + 3.1 1585 + 235

in children >2 y.o. 5.2 + 2.6 600 + 50

in children >2 y.o. 8.2 + 3.8 990 + 160

in children >2 y.o. 14.1 + 3.6 1400 + 50

peritoneal dialysis (pd) protocols...

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