Placing PD Catheters - a nephrologist's perspective

Nephrology Dept 1971 > 25000 HD sessions annually > 75 transplants annually

Overview

Introduction

What does it involve?

Challenges Opportunities PD catheter insertion procedure Our learning curve

Introduction
incidence of CKD in developing countries Pts - inadequate access to HD & Tx - CAPD - obvious preferred modality for renal replacement therapy

Laparotomy / direct visualization - conventional mainstay of access placement Necessitates availability of surgeon / anaesthetist cost / duration of hospital stay

Introduction
PD

catheter placement techniques Laparotomy / open surgical Laparoscopy Peritoneoscopy Percutaneous Fluoroscopy Blind

Introduction

Percutaneous Blind PD catheter placement - 1984

[Nakanishi T et al. Nephron 1984;37:128132]

popularity in the past decade

What does we need?

Reasonably spacious area

minor operating room in dialysis area Clean room with enough elbow space

Instruments / implements most easily obtained

Willing nephrologist usually the toughest part !!!

Challenges

Obsession with aseptic / universal precautions

Skill of PD catheter placement very easily acquired!

Knowledge of complications of technique
Blind procedure Complications - laceration of viscera, bleeding, perforation Prompt recognition urgent surgical consultation /intervention What the mind does not know the eye does not see!

Challenges

Co-operation / support of surgical colleagues

imperative

Immediate consultation & intervention where needed

Challenges
One of our earliest patients - Jejunal mesenteric artery laceration severe bleeding shock Multiple transfusions Urgent laparotomy & ligation of bleeder save life

Challenges

Paramedian approach Inf epigastric A injury reported

Messana JM Injury to the Inferior Epigastric Artery Complicating Percutaneous Peritoneal Dialysis Catheter Insertion. Perit Dial Int. 2001;21: 313-15.

2% Bleeding in a case series (6/292)

Mital S, Bleeding complications associated with peritoneal dialysis catheter insertion. Perit Dial Int 2004;24:47880.

Challenges

Clues to bleeding

Blood tinged PD effluent fluid Drop in blood pressures tachycardia

[BRADYcardia likely to be vagal response to pain]

Check Hematocrit

If hematocrit up to 2% Conservative Rx sufficient Heparinization of PD fluid is necessary to prevent cath clotting

Farooq MM Peritoneal dialysis: An increasingly popular option. Semin Vasc Surg 1997;10:144-50.

Challenges

One patient upper abdominal distension & obliteration of liver dullness bowel perforation Laparotomy self-sealed no repair needed

Bladder injury pre-procedure bladder emptying or catherization

Challenges

Constant attempts to refine / simplify technique

Using the Veress needle to fill peritoneal cavity

Blunt tip

Cutting edge

Challenges

Attempt to decrease time taken for procedure

Initially about 2 hours for uncomplicated cases Now less than 45 minutes (fastest 20 minutes)

Smaller incision sizes

Initially 2-3 cm now < 1 cm in length more cosmetic

Training of colleagues all become adept

Opportunities

No break-in period needed

51 consecutive pts - straight double-cuffed Tenckhoff cath Only 1 pericatheter leakage (1.9%)

Opportunities

Time taken Cost of procedure saving of Rs. 15000 (~$ 300) Hospital stay reducing costs further Non-requirement of surgical suite

No Anaesthetist / Surgeon required Use for uremic CKD 5 patients as acute PD

16 patients in our initial cohort

In the Intensive care for renal replacement therapy

Opportunities

Ideal procedure for HIV / HBV / HCV infected pts

Resource-constrained settings Already overstretched OR facilities Lack of personnel for one-to-one therapy 11 patients in our initial cohort

Opportunities

In those with past abdominal surgeries???

CONTRAINDICATED in those with previous abdominal surgery
Peppelenbosch A Peritoneal dialysis catheter placement technique and complications. NDT Plus 2008;1 [Suppl 4]: iv238.

Laparoscopy preferred direct vision / adhesiolysis if needed

One patient with laparoscopic cholecystectomy + tubectomy

Successful percutaneous CAPD catheter insertion in a patient with past abdominal surgeries.
Varughese S et al Saudi J Kidney Dis Transpl. 2012

Opportunities

Four patients - laparoscopic cholecystectomy One patient - past intra-abdominal abscess in right lower quadrant of abdomen for which laparotomy & surgically drainage had been done One patient appendicectomy One patient - lower segment caesarian section One patient - right femoro-femoral arterio-venous graft was constructed due to thrombosis in all vessels; very large perigraft collection occupying entire right lower quadrant left CAPD cath Four patients tubectomies (including 2 with past laparoscopic cholecystectomies)

Opportunities

Percutaneous PD catheter placement can be attempted in

patients with previous abdominal surgeries where risk of

peritoneal adhesions is minimal

Our initial insertion experience

From November 2007 to 2011 Feb Number of patients: 119 Age: 50.5 yrs (range 2374 yrs) 64 males

Technique: Trocar and cannula or peel-away sheath using Seldinger technique

PD Catheter Insertion Procedure

Secret ingredient = Grace of God!

End result!

Our learning curve!

119 patients

Cath Removal (2)

Poor flow (14)

Surgical repositioning (9)

Current number = 295

Percutaneous repositioning (3)

Complications encountered

Intra-abdominal bleed

Laparotomy required - 1
[Varughese S et al. Jejunal Mesenteric Artery Laceration Following Blind Peritoneal Catheter Insertion Using the Trocar Method Perit. Dial. Int. 2010 30: 573-574.]

Conservative Rx

-1

Leak Suspected perforation

1 1

Conclusions

Percutaneous PD catheterization is a simple & safe procedure done by nephrologists Easy training and practice makes one adept at it Several challenges and opportunities for the nephrologist

Challenges
o Willingness to learn and do o Training of colleagues

o Surgical team co-operation

o Aseptic / universal precautions

o Attempt to decrease time

o Smaller incision sizes

o Skill of PD catheter placement

o Knowledge of complications

o Refine / simplify technique

Opportunities
No break-in period costs, time taken, hospital stay No surgical suite, anesthestist, surgeon needed Procedure of choice in pts with HIV, HBV, HCV Use for uremic CKD 5 patients as acute PD Use in Intensive care for renal replacement therapy In pts with past abdominal surgeries with minimal risk of peritoneal injury