Intervention

Intra-aortic balloon pumps

Plasmapheresis & therapeutic plasma exchange
Bair Hugger warming system

Intra-aortic balloon
pumps
 IABP
subclavian‫ سم من ال‬٢ ‫ قبل ب‬arch‫في نهاية ال‬
IABP‫منحط ال‬

‫البالون بنتفخ في الدياستول يعني‬

‫ملا بسكر االورطة منحجز الدم والدم‬
‫هاد بزيد الضعط جوا االورطة‬
‫وبالتالي الدم بروح‬
Coronaries‫على‬

IABP Uses
The indications for the insertion of an IABP include:
 Cardiac failure, cardiogenic shock or unstable angina due
to severe ischaemia while awaiting a revascularization
procedure (either angioplasty or CABG)
 Development of arrhythmias caused by ischaemia

 Difficulty weaning from cardiopulmonary bypass during

cardiac surgery
 Any cause of reversible myocardial impairment

 Support of cardiac function while awaiting cardiac

transplantation.
 IABP
How it works
 An 8–10F coaxial double lumen catheter is inserted into the
femoral artery.
 The inner lumen opens at the tip of the catheter and is used to
measure the aortic pressure in the same way as other invasive
blood pressure monitors.
 The outer lumen opens into the balloon just proximal to the
catheter tip, and has a volume of between 30 and 50 ml depending
on the size of the patient.
 Ideally the balloon should occupy 80–90% of the diameter of the
aorta when inflated, and should be positioned just distal to the
origin of the left subclavian artery.

IABP
How it works

 A balloon that is too large may damage the aortic

wall, whereas one that is too small may not cause
sufficient haemodynamic effect.
 The catheter is connected to the pump machine,
which has a computer and carries a gas cylinder.
 The machine monitors the cardiac cycle using the
aortic pressure waveform and a standard three-
lead ECG, and these are both displayed on its user
interface.
 IABP
How it works
 Modern IABP machines use helium for balloon inflation,
although air and CO2 were used previously .
 The balloon is inflated in early diastole, just after
aortic valve closure – at the peak of the T-wave on the
ECG or at the dicrotic notch on the aortic pressure
waveform.
 It remains inflated until just before the aortic valve re-
opens, and deflates as late as possible in diastole.

Effects
The displacement of blood by the balloon has two main
effects:

I. Inflation during diastole leads to a higher early

diastolic blood pressure because the volume of the aorta
has effectively been reduced by the balloon. This results in
improved end-organ perfusion, especially to the heart
because coronary perfusion occurs principally during
diastole. This effect is known as diastolic augmentation.
 Effects
II. Deflation of the balloon as late as possible
results in a reduced end-diastolic pressure in the
aorta. This results in a reduced afterload (and
therefore lower systolic pressure) and
consequently reduced myocardial oxygen demand
and consumption.

IABP
Set
 The machine can be set to inflate the balloon
every time the heart beats (a 1:1 ratio), or
every other beat (1:2) or every third beat
(1:3), etc.
 This is therefore a method of weaning a patient
off the pump as their condition improves by
slowly reducing the number of beats that are
supported.
 IABP
Set
 The machine can also be set to trigger balloon
inflation and deflation using either the ECG or the
aortic pressure trace.
 Therefore, should one system fail there is always a
back-up.
 In the event that the patient suffers a cardiac
arrest, the IABP should be set to trigger based
on the aortic pressure so that it will inflate and
deflate during cardiopulmonary resuscitation.
 Disadvantages
 Insertion needs to be performed with image
intensifier guidance and fluoroscopy.

I. Limb ischaemia. This is caused by either

thromboembolism or mechanical obstruction of
an artery by the balloon. Prophylactic heparin is
often given to reduce the risk of the former. The
latter should be prevented by correct positioning of
the balloon when it is inserted.

Disadvantages
II. Haemorrhage. This can be at the insertion
site in the femoral artery or elsewhere due to
thrombocytopenia caused by the balloon. Heparin
may also contribute to this.

III. Infection.

VI. Balloon rupture. This may lead to ischaemia

in many places due to occlusion of small vessels
by helium bubbles.
 contraindicated
 If there is severe aortic regurgitation, aortic
dissection, severe peripheral vascular disease
(particularly if femoral artery surgery has
been performed), severe coagulopathy, and
sepsis.

Plasmapheresis
& therapeutic plasma exchange
 Plasmapheresis
centrifuge
Overview
 In an autoimmune disease, the immune system
attacks the body's own tissues.
 In many autoimmune diseases, the chief weapons
of attack are antibodies, proteins that circulate in
the bloodstream until they meet and bind with the
target tissue.
 Once bound, they impair the functions of the
target.

Plasmapheresis
Overview
 Plasmapheresis is a treatment process that
involves separating the liquid part of the
blood, or plasma, from the blood cells. The
plasma is then usually replaced with another
solution such as saline or albumin,
 Therapeutic plasma exchange refers to discarding
the plasma completely and substituting a
replacement fluid (usually donor plasma or albumin
solution).
 Plasmapheresis
Overview
 Blood is initially taken out of the body through a
needle or previously implanted catheter.

 The catheter (Temp cath) is two way, one is used

to withdraw blood from the body and other is
used to introduce plasma substitute in patient,s
body.

 Anticoagulant is also given during the procedure.

Plasmapheresis
Overview

 First blood passes through the air filter,if air is

present in blood it is filtered here.

 Then blood enters into ball(centrifuge). Plasma is

then removed from the blood by a cell separator.

 When the blood is entering in the ball,at the same

time some air of ball is collected in air bag.
 Plasmapheresis
Overview
 After some time, when ball becomes full of cells the machine takes a
break and blood cells are returned back to the body, and air is
returned back from the airbag to the the ball. Now 1 cycle is
completed.
 Same process is repeated again and again and mostly 8 to 10 cycles
are required.
 Extracted plasma is discarded.

 In females less no. of cycles are required.

 The whole procedure is repeated 5 times but on alternate days

Plasma volume is calculated as follows: TBV × (1 - hematocrit)

Plasmapheresis
Indications
 Guillain-Barré syndrome

 Myasthenia gravis

 Chronic inflammatory demyelinating polyneuropathy

 Thrombotic thrombocytopenic purpura/TTP

 Idiopathic thrombocytopenic purpura/ITP

 Dermatomyositis

 Good pasteur’s syndrome

 Multiple sclerosis
Bair Hugger warming
system

Bair Hugger warming system

 To keep patients warm before, during, and after

surgery.
 The Bair Hugger warming system draws in the filtered
air of the operating room, passes it through an
internal filter and warms that air to the selected
temperature.
  Intravenous access (central, perephral)

 Arterial access

 Intraosseous access

 Infusion pump/Target controlled infusions

 Volumetric pumps/Dropper machine

 Patient control analgesia (PCA)

 ECMO

Intravenous cannula
 Uses: They are inserted into a peripheral vein and can be
used to deliver fluid therapy or IV drugs to the patient.
 Intravenous cannula
 Cannulas are sized according to standard wire gauge
(SWG).
 This is an old-fashioned method of measuring the cross-
sectional area.
 It refers to the number of wires of the same size as the
cannula that could pass through a hole of a standard size
in parallel.
 The bigger the wires, the fewer could fit through the hole,
and therefore larger cannula have a smaller gauge
number.

Intravenous cannula
 The maximum flows quoted by manufacturers are
determined by running distilled water through the
cannula under standardized conditions
 Eg. Flow was measured using deionized water at 22°C
with a pressure gradient of 10 kPa through 110 cm of
tubing with an internal diameter of 4 mm.
 24G cannulae (yellow) also exist with flows of 13–22 ml/min
depending on manufacturer.
 Safety cannulae are available which have a clip at the end of the
needle that activates as it is withdrawn. The clip covers the tip of the
needle and is therefore said to reduce the risk of sharps injury.
 Intravenous cannula
 The Luer taper is a standardized system of small-scale
fluid fittings used for making leak-free connections between
medical or laboratory instruments
 luer fitting is defined as a small, friction based, leak-proof
connector
 The luer slip syringe requires the medical staff to push the
hypodermic needle onto the syringe end, creating a secure
strong connection. Luer lock syringes requires the hypodermic
needle to be screwed on, rotating the needle clockwise can
achieve a very tight fit bond between the needle and the
syringe.
Central venous catheters
 Central venous catheters are inserted into the internal
jugular, subclavian or femoral veins.
 Lines with up to five lumens are available in typical adult
lengths of 16 or 20 cm.
 The lines are available in a variety of diameters
(measured in French).
 The lumens within them are measured in standard wire
gauge

Central venous catheters

 Central lines are inserted using the Seldinger technique
under strict aseptic conditions.
 The target vein is cannulated (live ultrasound guidance),
and a guide wire is passed through the cannula.
 The cannula is then removed leaving the wire in situ.
After dilation, the central line is passed over the wire and
into the vein.
 The guide wire is then removed before the line is sutured
into place and covered with a transparent sterile
dressing.
Central venous catheters
Uses:
 Administration of drugs that cause phlebitis in smaller
peripheral veins
 TPN and many types of chemotherapy
 Infusion of potent vasoactive drugs that require
guaranteed uniform mixing throughout the blood volume
 Measurement of central venous pressure
 Where peripheral venous access is difficult
 Occasionally for regular sampling of blood in a patient
who is difficult to take blood from peripherally.
Interventions to prevent central line
associated blood stream infections
(CLABSIs)
 The use of full aseptic technique during insertion
 Skin preparation using 2% chlorhexidine rather than 10%
povidone–iodine and allowed to dry.
 lines inserted into the femoral vein have a higher
incidence of infection, and (DVT).
 The use of a line with the minimum number of lumens
necessary.
 The use of a line made of Teflon or polyurethane

Interventions to prevent central line

associated blood stream infections
(CLABSIs)
 The use of a line impregnated with an antimicrobial
agent such as silver sulphadiazine or chlorhexidine
prolonge the antimicrobial activity of the catheter
 line impregnated with antibiotics such as rifampicin and
minocycline
 Using a dressing that is transparent, so that changes in
skin colour or signs of local infection can easily be seen.
 At least daily review of the on-going need for the line.
Long-term general vascular
access lines
 Broviac
 Hickman
 Groshong
 Peripherally inserted central catheters(PICC)
 Non-dominant arm between the axilla and the antecubital
fossa, its length between 38 – 52cm long.

Peripherally inserted central

catheters(PICC)
 Implantable ports
 Port-A-Cath, SmartPort or Bardport
 These systems consist of a tunnelled silicone catheter with
one end positioned in the superior vena cava And other side
connected to disc-shaped reservoir(beneath the skin), often
made of titanium and typically 2.5–4 cm in diameter, covered
by a soft silicone membrane.
 When access is required the skin over the port is cleaned and
local anaesthetic cream is applied. A Huber needle is then
inserted through the skin and the silicone membrane into the
reservoir and can be used to take a blood sample or infuse a
drug.

Huber needle
 Renal replacement therapy lines
 VAS cath/temp-cath/ Temporary Dialysis Catheters
 Permcath
 Tesio
 Ash Split
 Opti-flow
 Renal replacement therapy lines
 Catheter heparinization:
- Heparin is commonly used after using along term catheter
like hemodialysis treatments catheters as a locking solution
to prevent catheter thrombosis ranged from 1000 to 5000
units per mL, (volume written on catheter).

 Antibiotic lock therapy (ALT):

- instillation of high concentrations of anti-microbial agent
with or without anti-coagulant into the lumen of central
venous catheters is considered a valid conservative treatment
for central line associated blood stream infections (CLABSIs) in
patients highly dependent on maintaining the catheter.
 Intra- arterial lines

 An arterial line (A-line) is used if frequent blood pressure

and arterial blood gas determinations are needed.
 Common sites of arterial cannulation are the radial artery
in the wrist and the dorsalis pedis artery in the foot.
 The femoral artery can be cannulated using the Seldinger
technique when routine sites cannot be accessed

Vygon
 Intra-osseous needles

Intraosseous devices provide reliable access to the

circulation. They are of particular use where intravenous
access is difficult to obtain rapidly, such as in:
 peri-arrest and cardiac arrest situations
 trauma
 pediatrics
 obstetrics.

Intra-osseous needles
Advantages
 Insertion is usually straight forward.
 All resuscitation fluids (infused under pressure), emergency
drugs and blood products may be administered.
 Marrow aspirate may be used for a group and save.
Disadvantages Intraosseous
point to the
needles
bone
provide
marrow,
a direct
allowing for
access
the

 Insertion may be painful.

 extravasation
 injury to the growth plate
 fracture
 infection
 Ensuring this distance
from the tibial
tuberosity means that
the needle avoids the
growth plate in
children

Infusion pump/Target
controlled infusions
 How it works: In order to achieve a particular target
concentration of a drug, TCI pumps are factory
programmed with an algorithm based on a
pharmacokinetic model for a particular drug. The
anaesthetist enters simple data about the patient, such as
the age, sex, weight and/or height, and sets the desired
concentration. The pump then uses the model to adjust
the rate of infusion.
 Volumetric pumps/Dropper machine

 Volumetric pumps are commonly used to control fluid

infusions via drips. The drip tubing passes from the fluid bag,
through the pump and then connects to the patient’s venous
access device. The pumps run on mains or battery power and
the volumes delivered are accurate to within 5–10%.

 Volumetric pumps incorporate pressure transducers and

alarms to detect upstream or downstream occlusions. These
pumps also stop and sound an alarm should air be detected in
the tubing.
Patient-controlled analgesia
 PCA pumps vary in design. Some are volumetric pumps
and others use a syringe driver, but all have a control
button that the patient can press when they require
analgesia.
 The pumps allow programming of a bolus dose (given
when the patient presses the request button), and a
lockout period. The bolus dose cannot be repeated until
the time specified in the lockout period has expired.
Extracorporeal membrane
oxygenation
 (ECMO) is used to support or replace cardiac and
pulmonary function in intensive care cases.
 it may be considered if a patient is being treated with
maximal conventional treatment, and still has one of the
following:
 PaO2 to FiO2 ratio of less than (100 mmHg) despite
intubation and an optimal ventilator strategy
 respiratory acidosis with pH less than 7.20
 cardiogenic shock despite maximal inotropic therapy and
use of an intra-aortic balloon pump.
 If respiratory support alone is required, then a
venovenous arrangement is usually used. This means that
blood is taken from a vein, oxygenated and pumped at
low pressure back into a different vein.
 Should haemodynamic support be required in addition to
this, the return cannula is placed in an artery (often iliac)
and blood is pumped back to the patient at arterial
pressure, retrograde fl ow permitting systemic perfusion.
This is a venoarterial arrangement.

PaO2/FiO2 ratio
 PaO2/FiO2 ratio is the ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen
(FiO2 expressed as a fraction, not a percentage)
 At sea level, the normal PaO2/FiO2 ratio is = 400-500
mmHg (55-65 kPa)
 PaO2 should = FiO2 x 500 (e.g. 0.21 x 500 = 105 mmHg)
ARDS Severity PaO2/FiO2 Mortality

Mild 200 – 300 mmHg 27%

100 – 200 mmHg

Moderate 32%

< 100 mmHg

Severe 45%
36
 The oxygenator in extracorporeal
membrane oxygenation (ECMO)
 Gas exchange in ECMO is
accomplished by pumping blood
through an oxygenator, consisting of 2
chambers divided by a
semipermeable membrane.
 Venous blood passes along one side
of the membrane and fresh gas,
referred to as sweep gas, passes along
the other side.
 Oxygen uptake and carbon dioxide
elimination occur across the
membrane.
 The fraction of oxy gen delivered
through the gas chamber is
determined by a blender, which
typically mixes oxygen with room air.
 1

Dialysis Machine

Introduction:
 Hemodialysis removes wastes and water by circulating
blood outside the body through an external filter, called a
dialyzer, that contains a semi permeable membrane.

 The blood flows in one direction and the dialysate flows

in the opposite. The counter-current flow of the blood
and dialysate maximizes the concentration gradient of
solutes between the blood and dialysate, which helps to
remove more urea and creatinine from the blood.
2
 Dialysis Machine
Introduction:

 The concentrations of solutes (for example potassium,

phosphorus, and urea) are undesirably high in the blood,
but low or absent in the dialysis solution, Dialysis is an
increasingly common type of treatment.

 The dialysis solution has levels of minerals like potassium

and calcium that are similar to their natural concentration
in healthy blood.
3

Definitions
 The Hemodialysis name it self contains hemo means blood and
dialysis means the diffusion of solute molecules through a semi
permeable membrane, normally passing from the side of higher
concentration to that of lower.

 Semi permeable membrane is one that allows the passage of

certain smaller molecules of such crystalloids as GLUCOSE and
UREA, but prevents passage of larger molecules such as the
colloidal plasma PROTEINS and PROTOPLASM.

 Hemodialysis, It is a method that is used to achieve the

extracorporeal removal of waste products such as creatinine and
urea and free water from the blood when the kidneys are in a
state of renal failure. Hemodialysis is one of three renal
replacement therapies (the other two being renal transplant and
peritoneal dialysis).
4
 Definitions
Dialysate:
 Also called dialysis fluid, dialysis solution or bath, is a
solution of pure water, electrolytes and salts. The purpose
of dialysate is to pull toxins from the blood into the
dialysate.
 Dialysate solution commonly contains six (6) electrolytes:
sodium (Na+), potassium (K+), calcium (Ca2+),
magnesium (Mg2+), chloride (Cl–), and bicarbonate ( ). A
seventh component, the nonelectrolyte glucose or
dextrose, is invariably present in the dialysate

Principle

 Hemodialysis utilizes counter current flow, where the

dialysate is flowing in the opposite direction to blood flow
in the extracorporeal circuit.

 Counter-current flow maintains the concentration

gradient across the membrane at a maximum and
increases the efficiency of the dialysis.

 It involves diffusion, osmosis and ultra filtration

6
 7

Description
 Hemodialysis is diffusion across a semi permeable membrane (one that allows
only certain molecules to pass through it). the semi permeable membrane is
used to remove the wastes from the blood and at the same time correct the level
of electrolytes in the blood. before hemodialysis can be performed, a surgeon
must make a way for the blood to be pumped out of the body and then be
returned after it has been cleansed.

 To do this, the surgeon uses an artery and a vein in the forearm.

 Arteries (which have muscles in their walls) bring oxygenated blood to the body
from the heart, and veins return blood to the heart, which needs to have oxygen.

 The surgeon connects the radial artery in the forearm to a large vein called the
cephalic vein. This connection is called an arterio venous shunt.

 A shunt carries something from one place to another. In this case it carries blood
from an artery to a vein. After this shunt is made, the veins in the forearm get big
and eventually form muscles in their walls like arteries. They are now strong and
can be punctured many times for dialysis.
8
 Description Con’t
Dialysis:
 There are two different kinds of dialysis used in medicine:
Hemodialysis and peritoneal dialysis. The methods for
performing dialysis may be different, but the goal of the
treatment is the same, that is, to remove waste products.
These wastes are composed mainly of nitrogen in the form of
urea, uric acid, and creatinine.

Front View
1. Monitor
2. Blood Pressure Cuff
3. Extracorporeal blood
circuit module
4. Concentrate connectors
5. Brake
6. Shunt interlock for the
dialyzer connecting lines
7. IV pole
8. Status indicator

10
Back View
1. Monitor
2. Sampling value
3.Bracket for the dialyzer connection lines
4. Dialysate outlet tube
5. Dialysate inlet tube
6. Disinfection connector
7. Filter
8. CDS (red) option
9. Drain
10. Water connector (permeate)
11. DIASAFE plus
12. Vent tubing
13. Power supply unit
11

Parts And Functions

12
Parts And Functions

13

14
 Step By Step Procedure

1. After the dialysis procedure has been done to a patient, the

machine should get ready for another new patient, we should
clean the disposable tubing's and filter with sterilizing fluid and
should checked with a type of litmus test.

2. When the patient arrives, the parameters like weight, blood

pressure and temperature are measured.

3. For fistula procedure we have to connect to veins of arms or

legs. For catheter procedure we have to connect to large veins
at chest.
15

Step By Step Procedure

4. Then the patient is connected to the machine with complete
loop, then the timer and pump are started.

5. Hemodialysis is under process.

6. Periodically for every half hour, the blood pressure is taken.

If, low blood pressure can cause cramping, nausea, shakes,
dizziness, lightheadedness, and unconsciousness.

7. The amount of fluid to be removed is set by the dialysis

nurse according to the patient's "estimated dry weight."

16
 Step By Step Procedure
8. At the end of the procedure time, the patient is disconnected
from the plumbing. needle wounds are bandaged with gauze,
held for up to 1 hour with direct pressure to stop bleeding, and
then taped in place.

9. Temperature, standing and sitting blood pressure, and weight

are all measured again. Temperature changes may indicate
infection. BP discussed above. Weighing is to confirm the
removal of the desired amount of fluid.

10.Care staff verifies that the patient is in condition suitable for

leaving. The patient must be able to stand, to maintain a
reasonable blood pressure, and be coherent.
17

Complications
1. anemia: due to the procedure associated blood losses and mild
effect on oxygen transporting function.

2. Hematocrit (Hct): It levels, a measure of red blood cells, are

typically low in ESRD patients. This deficiency is caused by a lack of
the hormone erythropoietin.

3. Cramps, nausea, vomiting, and headaches: Some patients

experience cramps and flu-like symptoms during treatment. These
can be caused by a number of factors, including the type of
dialysate used, composition of the dialyzer membrane, water
quality in the dialysis unit, and the ultra filtration rate of the
treatment.

18
 Complications
4. Hypotension: Because of the stress placed on the cardiovascular
system with regular Hemodialysis treatments, patients are at risk for
hypotension, a sudden drop in blood pressure. This can often be
controlled by medication and adjustment of the patient's dialysis
prescription.

5. Infection: Patients can also get infections through surroundings.

The room and area used for patients must be kept clean.

6. Infectious diseases: There is a great deal of blood exposure

involved in dialysis treatment, a slight risk of contracting hepatitis B
and hepatitis C exists. The hepatitis B vaccination is recommended
for most patients.

19

Dialysis Machine
Advantages Disadvantages
 Low mortality rate  Restricts independence, as people
undergoing this procedure cannot
 Better control of blood pressure and
travel around because of supplies'
abdominal cramps availability

 Requires more supplies such as high

 Less diet restriction
water quality and electricity
 Better solute clearance effect for the
 Requires reliable technology like
daily hemo dialysis: better tolerance dialysis machines
and fewer complications with more
frequent dialysis
 The procedure is complicated and
requires that care givers have more
knowledge

 Requires time to set up and clean

dialysis machines, and expense with
machines and associated staff

20
 Peritoneal Dialysis

Introduction:
 Peritoneal dialysis is the process during which the peritoneal cavity
acts as reservoir for the dialysate and peritoneum serves as semi-
permeable membrane, across which excess body fluids and
solutes, including uremic toxins are removed .Peritoneal
membrane is in contact with rich blood supply to the abdominal
organs and dialysate is infused into peritoneal cavity via catheter.
 peritoneal dialysis is a process or procedure which allows exchange
of wastes, fluids and electrolytes in the peritoneal cavity.
 Peritoneal dialysis involves repeated cycling of instilling dialysate
into peritoneal cavity, allowing the time for substance exchange
and then removing the dialysate.

21

Peritoneal Dialysis

22
 Principles

23

Peritoneal Dialysis
Indications:
• Patient's with chronic kidney disease.
• Unstable patients who cannot tolerate anticoagulation.
• Patients with chronic infections, vascular access problems
• Peritoneal dialysis is often the treatment of choice for older adults,
because it offers more flexibility, if his or her status changes
frequently.
Contraindications:
• Peritoneal adhesions.
-Extensive intra-abdominal surgery.
- Obesity
• Recurrent episodes of peritonitis
• Abdominal malignancies.
• Respiratory diseases, ruptured diverticulum.

24
 Peritoneal Dialysis
Advantages Disadvantages
 Easy to learn  Time consuming
 Can be done at home  Sterile technique is required
 Ambulatory - no machines  Presence of permentant
are needed, when machines catheter
are used, they are small  Risk for peritonitis and
 Better BP Control peritoneal injury
 Less dietary and fluid  Contraindicated in abdominal
restriction surgeries, chronic back pain
 Greater freedom in or development of hernias.
scheduling and travelling

25

Peritoneal Dialysis- Procedure

 Each peritoneal exchange consists of 3 phases:

 Fill, dwell and drain.

 A siliconized rubber catheter is surgically placed into the abdominal cavity for
infusion of dialysate. Usually 1 to 2 of dialysate is infused by gravity (Fill phase)

 Fluid stays (dwells) in the cavity for a specified time, prescribed by the
nephrologist.
 Fluid then flows out of the body (drains) by the gravity into drainage bag.

 Peritoneal outflow generally called as "peritoneal effluent " contains the

dialysate and excess waste, electrolytes and nitrogen -based waste products.)

 The 3 phases of the process (infusion or fill, dwell and outflow or drain) makes
up one peritoneal dialysis exchange.

26
Peritoneal Dialysis- Procedure

Complications:
 Peritonitis
 Bleeding
 Dialysate
 leakage
 Bladder perforation
 Pain
 Bowel Perforation.

27

Peritoneal Dialysis
Types:
 Continuous ambulatory peritoneal dialysis
 Automated peritoneal dialysis
 Intermittent peritoneal dialysis
 Continuous cycling peritoneal dialysis.

Factors affecting peritoneal dialysis efficiency:

 Decreased peritoneal membrane permeability caused by
infection or scarring.
 Reduced capillary blood flow resulting from blood vessel
constriction.
 Vascular disease
 Decreased perfusion of peritoneum.
28
 ICP

Overview
 There are three main tissues that make up the intracranial
volume: blood, brain and cerebrospinal fluid (CSF).
 Intracranial pressure (ICP) is normally 8–12 mmHg, but
can rise rapidly if there is an increase in the volume of
one of the intracranial tissues because the skull is a bony
vault and cannot allow expansion of one component
without reduction in another.
 This concept is known as the Monro–Kellie doctrine.
 Monro–Kellie doctrine

 The Monro-Kellie doctrine was first described over two-

hundred years ago by Dr. Alexander Monro and Dr.
George Kellie.
 It describes the direct relationship between the contents
of the cranium and intracranial pressure
 Hypothesis, is that the sum of volumes of brain, CSF, and
intracranial blood is constant. An increase in one should
cause a decrease in one or both of the remaining two.

Uses
 In cases where there has been intracranial haemorrhage,
brain tumor or obstruction of CSF drainage, monitoring of
ICP may be indicated.
 A raised ICP may prompt the initiation of a particular
treatment or investigation (especially CT scanning), and a
knowledge of its value also allows calculation of the
cerebral perfusion pressure CPP=MAP-CVP or CPP=MAP-
ICP, if ICP suspected to be >CVP → CPP= MAP- ICP
External ventricular drains
 The EVD is considered to be the gold standard technique for
ICP monitoring and CSF drainage.
 A fine plastic catheter is inserted by a surgeon through a burr
hole, and passes through the meninges and brain into the
lateral ventricle.
 The CSF in the catheter forms a continuous fluid column that
is connected to a strain gauge transducer that works in the
same way as an invasive blood pressure monitor.
 The ICP may also be read using a simple manometer using the
vertical height of the CSF column above a zero calibration
point.
 This zero point is taken to be the patient’s mastoid process,
external auditory canal, tragus of the ear or other fixed point.

External ventricular drains

 As well as monitoring ICP, CSF can be drained via the catheter
if necessary, and the equipment can be set up so that CSF will
automatically drain if the ICP rises above a set pressure.
 Surgeons will often instruct that the drain should be ‘kept at
15 cm’.
 This means that the CSF column is allowed to be 15 cm higher
than the zero point before it starts to drain, and in theory this
should prevent the CSF pressure rising above 15 cmH2O.
 A modern EVD system is can also be sampled from the EVD for
microbiological or biochemical analysis.