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Placing PD Catheters - a Placing PD Catheters - a nephrologist's perspectivenephrologist'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
IntroductionPD catheter placement techniques
Laparotomy / open surgicalLaparoscopyPeritoneoscopyFluoroscopyBlind
Percutaneous
Introduction Percutaneous Blind PD catheter placement - 1984
[Nakanishi T et al. Nephron 1984;37:128–132]
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 /interventionWhat 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
2% Bleeding in a case series (6/292)
Messana JM Injury to the Inferior Epigastric Artery Complicating Percutaneous Peritoneal Dialysis Catheter Insertion.Perit Dial Int. 2001;21: 313-15.
Mital S, Bleeding complications associated with peritoneal dialysis catheter insertion.Perit Dial Int 2004;24:478–80.
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
Blunt tip
Cutting edge
Challenges Constant attempts to refine / simplify technique
Using the Veress needle to fill peritoneal cavity
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
Challenges
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
In those with past abdominal surgeries??? CONTRAINDICATED in those with previous abdominal surgery
Laparoscopy preferred – direct vision / adhesiolysis if needed
One patient with laparoscopic cholecystectomy + tubectomy
Opportunities
Peppelenbosch A Peritoneal dialysis catheter placement technique and complications. NDT Plus 2008;1 [Suppl 4]: iv23–8.
Successful percutaneous CAPD catheter insertion in a patient with past abdominal surgeries. Varughese S et al Saudi J Kidney Dis Transpl. 2012
Four patients - laparoscopic cholecystectomyOne patient - past intra-abdominal abscess in right lower quadrant of abdomen for which
laparotomy & surgically drainage had been doneOne patient – appendicectomyOne patient - lower segment caesarian sectionOne 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
Opportunities
Our initial insertion experience
From November 2007 to 2011 Feb Number of patients: 119 Age: 50.5 yrs (range 23–74 yrs) 64 males
Technique: Trocar and cannula or peel-away sheath using Seldinger technique
PD Catheter Insertion Procedure
Secret ingredient = Grace of God!
s
End result!
Our learning curve!
119 patients
Poor flow (14) Surgical repositioning (9)
Cath Removal (2)
Percutaneous repositioning (3)Current number = 295
Complications encountered Intra-abdominal bleed - 2
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 - 1 Suspected perforation - 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
Challengeso Willingness to learn and do
o Surgical team co-operation
o Aseptic / universal precautions
o Skill of PD catheter placement
o Knowledge of complications
o Refine / simplify technique
o Training of colleagues
o Attempt to decrease time
o Smaller incision sizes
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