Management of noninfectiousManagement of noninfectiouscomplicationscomplications

新光醫院 一般外科

鄭益和

Noninfectious complicaiton

• Catheter related

• Non-catheter related

Catheter related complication

• Pericatheter bleeding and hematoma

• Pericatheter and subcutaneous leaks

• Peritoneal catheter obstruction

• Catheter adapter disconnect or fracture of • Catheter adapter disconnect or fracture of peritoneal catheter

Pericatheter bleeding and hematoma

Pericatheter bleeding and hematoma

• Most bleeding source from subcutaneous tunnel

• Differentiate from internal bleeding

• Correct bleeding tendency

• Avoid heparin use during hemodialysis• Avoid heparin use during hemodialysis

• Sandbag compression to the tunnel

• A stitch of silk suture to the exit site

• Change dressing as needed to prevent infection

• Reopen is seldom required

Peritoneal and Subcutaneous leaks

• Patient at risk– Poor tissue healing (DM, elderly, malnourished, taking steroids)

– Increased intra-abdominal pressure

• Findings that require evaluation for leaks– External fluid at wound or exit site

– Reduced exchange outflow volume– Reduced exchange outflow volume

– Weight gain

– Abdominal swelling & edema/ increased girth

– Scrotal, penile or labial edema

– Peripheral edema

– Unilateral pleural effusion with or without volume overload

Peritoneal and Subcutaneous leaks

• External leaks– Verify that clear fluid at incision or exit site contains

glucose

– Document condition of exit site, subcutaneous tunnel or woundwound

– Alter dressing change procedure to accommodate increased fluid drainage

– Reduce leak by use of a dry or suspension of PD to be considered

– These leak increase the risk of peritonitis and consideration should be given to prophylactic antibiotic adminstration

Peritoneal and Subcutaneous leaks

• Subcutaneous leaks– Monitor abdominal girth

– Examine flank and back for subcutaneous fluid

– Examine for scrotal, penile or labial swelling– Examine for scrotal, penile or labial swelling

• Diagnostics– CT peritoneography

– Abdominal fluoroscopy with contrast

– Peritoneal scintigraphy

– Peritoneal MRI with dialysate as “contrast medium”

Pericatheter leak

Pericatheter leak

Pericatheter scintigraphy

Postdrain image demonstrating R’t inguino-scrotal collection

Therapeutics for peritoneal & subcutaneous leaks

• Dialysis therapy– Initiate PD or APD in supine position, using low volume

exchange (500-1500ml) until leak has sealed. Keep dry when not in supine

• Dialysis is not urgently required in new p’ts• Dialysis is not urgently required in new p’ts– Delay use of PD for 2 days to 3 weeks if necessary until

leakage stops

• Invasive steps– Persistent leak may require surgical repair

– Provide HD backup if needed during healing if low volume APD is not feasible or does not adequately control azotemia

Patient educaiton for peritoneal & subcutaneous leaks

• Monitor the S/S of exit site infection and peritonitis in presence of leaks

• Accommodate increased drainage• Report physical change indicating potential leak• Minimize intra-abdominal pressure following

surgical correction• Recurrent pericatheter leaks may require

catheter replacement

Peritoneal catheter obstruction

• Inflow and outflow obstruction occur more commonly as early complications but can also occur at any time, especially during or following episodes of peritonitisepisodes of peritonitis

• Ascertaining the cause of obstruction will assist in determining the appropriate intervention

Peritoneal catheter obstruction

• Inflow obstruction– Mechanical blockage such as clamps or kinks in

transfer set, tubing or catheter including segment under dressingsegment under dressing

– Postimplantation blood clots or fibrin

– Fibrin, particularly with peritonitis

Peritoneal catheter obstruction

• Outflow obstruction– Constipatioin

– Extrinsic bladder compression due to urinary retentionretention

– Catheter tip migration out of pelvis

– Catheter entrapment

•Omental wrap

•Epiploic appendices of colon

•Adhesions

Catheter migration after insertion

Catheter migration after insertion

Peritoneal catheter obstruction

• Conservation noninvasive steps– Eliminate kinks or remove clamps or transfer set, tubing

and catheter. Examine portion hidden by clothing and dressing

– Change body position– Change body position

– Dislodge blockage (by experienced PD personnel)

• Infuse dialysis or normal saline with a 50 ml syringe using moderate pressure (push and pull). Discontinue procedure if p’t notes pain or cramping

– Correct constipation

– Obtain KUB to visualize catheter position, a lateral view may be necessary to identify an internal catheter kink

Peritoneal catheter obstruction

• Invasive steps– Laparoscopy

– Open surgical reposition of catheter or replacementreplacement

– Partial omentectomy or omentopexy

– Fluoroscopically guided stiff wires or stylet manipulation

Therapeutics for peritoneal catheter obstruction

• In case of fibrin-related obstruction– Add heparin 500 to 2000 U/L to dialysate each

exchange

– Instill recombinant tissue plasminogen activator – Instill recombinant tissue plasminogen activator (tPA)

•tPA 1 mg/ml

•8-10 mg/dwell 1-2 hrs (with dialysis solution)

•If dialysate does not drain adequately, re-instill the tPA at the same dose / dwell 90 mins

Patient education for peritoneal catheter obstruction

• Tape catheter and transfer set to avoid kinking• Position tubing to prevent kinking while asleep if

using APD• Prevent constipation with diet, exercise and • Prevent constipation with diet, exercise and

stool softeners• Patient to report reduced drain volume

Catheter adapter disconnect or fracture of peritoneal catheter

• Observe for dialysis fluid leak from peritoneal catheter or transfer set

• Obtain culture to rule out peritonitis

Catheter adapter disconnect or fracture of peritoneal catheter

• Initial prophylactic antibiotics• For adapter disconnect or catheter fracture

– Stop dialysis

– Clamp catheter proximal to damage

– If catheter length is adequate, use sterile technique to change

• If catheter portion is marginal length– Repair with appropriate manufacture’s repair kit or

catheter extension

PD catheter repair kit

Patient education for adapter disconnect or fracture of peritoneal catheter

• Instruct patient to– Stop dialysis– Clamp catheter proximal to damage spot– Cover area with sterile dressing– Go to clinic or emergency room as soon as possible– Go to clinic or emergency room as soon as possible

• Teach patient to– Secure catheter and transfer set under clothing,

avoiding sharp bands in catheter– Keep sharp objects and tools away from catheter– Avoid using unsuitable disinfectants and soaps on

catheter– Use only clamps provided on catheter

Noninfectious complicationsNonNon--catheter relatedcatheter relatedNonNon--catheter relatedcatheter related

Non-catheter related complications

• Hernia• Abdominal discomfort during infusion and

drain• Pneumoperitoneum• Hemoperitoneum• Hydrothorax

Hernia

• Significant abdominal wall hernias should be surgically repaired prior to the initiation of peritoneal dialysis

• The most common seen hernias• The most common seen hernias– Incisional, umbilical, inguinal

• Hernia left untreated– Increased the risk of further enlargement

– Pain, bowel incarceration

– Subsequent discontinuation of peritoneal dialysis

Therapeutics for hernia

• Umbilical hernia may be asymptomatic and can be managed by avoiding large fill volume

• Significant hernia requires surgical repair with prosthetic mesh and watertight closure to minimize the high risk of recurrencethe high risk of recurrence

• Use of supine, low-volume intermittent PD permitsimmediate resumption of therapy after hernia repair and avoids the need for temporary hemodialysis

• Provided HD backup if needed if small volume frequent exchange are insufficient to control azotemia

Patient education for hernia

• Minimize intraabdominal pressure, avoid heavy loading

• Treat underlying medical illness such as COPD, constipation

• Instruct patient to maintain separation of exit site • Instruct patient to maintain separation of exit site and operative wound dressings to prevent cross-contamination

• Use Velcro abdominal binder during ambulatory period following repair of umbilical and midline hernia

Patient education for hernia

• Use alternative perioperative dialysis regimen– Supine position during dialysis therapy

– Initial low-volume intermittent dialysis– Initial low-volume intermittent dialysis

– Dry abdomen during ambulatory periods during first 2 weeks

– Volume graduated incrementally over 2 week to usual regimen

Abdominal discomfort during infusion and drain

• Rule out peritonitis

• Evaluate presence, frequency and degree of discomfort or pain and relation to inflow discomfort or pain and relation to inflow and outflow

• Monitor dialysis outflow drainage for timing, completeness of drain, color and clarity, solution temperature

Abdominal discomfort during infusion and drain

• Inflow pain– Mechanical causes– Solution temperature or pH– Inflow pain usually subsided gradually after filling is

completecomplete

• Management– Change position during infusion– Reduce dialysis infusion rate– Ensure proper warming of solution– Investigate PD catheter position– Add sodium bicarbonate (2-5 meq/L) or 2% Lidocaine (3-5

ml) to the dialysate soultion may offer some relief– Reposition catheter if unresolved

Abdominal discomfort during infusion and drain

• Outflow pain– Leave small amount of dialysis fluid in the

peritoneal cavity

– In APD patients, program cycler to deliver – In APD patients, program cycler to deliver modified tidal PD (85~90%)

Pneumoperitoneum (shoulder pain)

• Rule out pain of cardiac origin

• Evaluate degree and duration of shoulder pain

• Interview patient regarding recent infusion • Interview patient regarding recent infusion of air during exachange procedure

• Assess for bowel perforation

Pneumoperitoneum (shoulder pain)

• Observe patient/caregiver’s exchange procedure to verify adherence to adequate tubing priming

• Culture peritoneal fluid for potential • Culture peritoneal fluid for potential contamination

• Identify PD catheter position and free air in the peritoneal cavity or under the diaphragm

Hemoperitoneum

• Cloudy / blood effluent

• The most common cause in women includes retrograde menstruation and ovulation

• Mild bleeding can be caused by catheter-• Mild bleeding can be caused by catheter-induced trauma, strenuous exercise and the formation of abdominal adhesions

• Any bleeding needs to be carefully monitored for severity and potentially serious causation

Therapeutics for postcatheter insertion blood-tinged effluent

• 200-1500 ml volume flush with heparinized dialysis fluid or saline until drain is clear

• Add heparin 500-1000 U/L as long as the effluent has visible sign of blood or fibrin to maintain catheter patency

• IP heparin is contrainducated in p’t with heparin-induced • IP heparin is contrainducated in p’t with heparin-induced thrombocytopenia

• Check Hct as needed

• Consider investigating for peritonitis or other acute abdominal issue is prolonged

• Perform rapid exchange with dialysis at room temperature until effluent clears

• Obtain imaging and surgical consultation as required

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