st. paul’s hospital
TRANSCRIPT
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St. Paul’s Hospital
Peritoneal Dialysis CatheterBedside Insertion
G. Nussbaumer
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SPH – Bedside PD Catheters
• Thanks to Dr. Abeed Jamal
• Data obtained from PROMIS Access Module
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SPH – Bedside PD Catheters
• Pt. Selection• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheters
• Pt. Selection• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheters
• Almost everyone is a candidate for bedside insertion
• Exceptions – Pt. Needing other surgical intervention such as
hernia repair– Pt. With previous hernia repair with mesh (that
is in the way)– Pt. With multiple previous abdominal surgeries
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SPH – Bedside PD Catheters
• Admit over night• Procedure takes 30 to 45 minutes
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SPH – Bedside PD Catheters
• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheters
• Peritoneoscope• Procedure Room on Renal Ward
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SPH – Bedside PD Catheters
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SPH – Bedside PD Catheters
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SPH – Bedside PD Catheters
• Pt. Supine, in trendelenberg• Abdomen Exposed• Prepped and draped (2% chlorhexidine
gluconate• No premedication (no prophylactic
antibiotics, no analgesic, usually no anxiolytic)
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SPH – Bedside PD Catheters
• 1 % xylocaine with epinephrine• 1 cm incision approx. 2 cm below umbilicus• Quill inserted into peritoneum, abdomen
insufflated with 1 liter air• Quill directed to LLQ with peritoneoscope• Scope removed, quill dilated• PD cath advanced through quill as quill is
removed
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SPH – Bedside PD Catheters
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SPH – Bedside PD Catheters
• PD catheter connected to flush• If good inflow and outflow, tunnel is
measured and frozen• PD tube pulled through tunnel, fitted with
titanium adapter, transfer set, capped of with 7cc 1000 u/ml heparin
• Midline incision sutured with 2 2-0 silk sutures
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SPH – Bedside PD Catheters
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SPH – Bedside PD Catheters
• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheters Pt. #
Bedside Surgical Total # Pts
2005- Aug
41 (85%)
7 48 46 2,2
2006 50 (89%)
6 56 52 4,2
2007 72 (95%)
4 76 71 1,3 3,2
2008 29 (94%)
2 31 27 4,2
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SPH – Bedside PD Catheters
• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheters Advantages
• No wait for PD tube insertions• No mistakes with insertion/tube assembly• Smaller incision, faster recovery, less
bleeding• Significantly less cost to healthcare system• Easier to initiate changes to
procedure/equipment etc.
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SPH – Bedside PD Catheters Disadvantages
• Visualization not as good as in OR• No lysis of adhesions etc.• Loss of surgical expertise• Pt. awake• Pt. discomfort from intraperitoneal air
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SPH – Bedside PD Catheters
• Technique Used• Patient Numbers• Advantages/Disadvantages• Outcomes
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SPH – Bedside PD Catheter Outcomes
• Inability to place PD catheter (6/217 = 2.8%)
• Perforation of Viscus (1/212 = 0.47%)• Early infection (< 30 days post insert 0%)• Nonfunctioning catheter (14/211 6.6%)
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SPH – Bedside PD Catheter Outcomes
• Various reports of catheter obstruction 5 – 35 %• Usually secondary to wrapping of omentum
– Tenckhoff recommended a caudally placed intraperitoneal catheter segment so the tip enters the pelvis because the omentum does not extend into the pelvis
– Skin exit site also needs to be directed down– Cuff acts as a fulcrum and catheter memory causes
cephalad displacement of catheter
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SPH – Bedside PD Catheter Outcomes
• Factors implicated in Obstruction– Adhesions– Body Habitus– Omentum– Catheter migration
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SPH – Bedside PD Catheter Catheter Migration
• Reversible versus Permanent – Left side
• Thought to be reversible, due to peristalsis of descending colon
– Right side• Peristalsis of ascending colon displaces the catheter
further cephalad
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SPH – Bedside PD Catheter Catheter Migration
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SPH – Bedside PD Catheter Catheter Migration
• Prevention– Catheter Design
• Multiple different designs– Cuffs– Coiled versus straight– Weighted– Swan neck versus straight
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SPH – Bedside PD Catheter Catheter Migration
• How to avoid?– Catheter design
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SPH – Bedside PD Catheters Migration Prevention
• Gadallah et al, 2000 Adv in PD– Six Year study comparing straight versus swan
neck catheters in 2 centers• Only examined laparscopically placed catheters• All catheters were coiled and identical other than the
swan neck
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SPH – Bedside PD Catheters Migration Prevention
• Swan Neck– N= 243– Age 49– 58 % Caucasian– 82% Diabetic– Body weight 81.2kg– Prior Abd Surgery
46%
• Straight– N= 219– Age 46– 66% Caucasian– 74 % Diabetic– Body weight 77.5kg– Prior Abd Surgery
48%
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SPH – Bedside PD Catheters Migration Prevention
• Non functioning catheters– Documented x-ray evidence of migration– 48 hour trial of laxatives
• Soap suds enema• PO Sorbitol• If patency restored these patients were not counted
as migration, but if still non-functioning after catharsis, then included
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SPH – Bedside PD Catheters Migration Prevention
• Results– Migration rates
• 2/243 Swan neck = <1%• 33/219 Straight = 15%
• P value <0.002
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SPH – Bedside PD CathetersPt. #
Bedside Surgical Total # Pts
2005- Aug
41 (85%)
7 48 46 2,2
2006 50 (89%)
6 56 52 4,2
2007 72 (95%)
4 76 71 1,3 3,2
2008 29 (94%)
2 31 27 4,2
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SPH – Bedside PD Catheters Summary
• Bedside PD catheter insertions are successful
• Result in more timely intervention• Low complication Rates