Peritoneal Dialysis Catheter Placement Strategies ~ Fulltext

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Mary Buffington*, Adrian Sequeira, Bharat Sachdeva , Kenneth Abreo

Nephrology Part, Division of Drugs, LSU Well being Sciences Middle, Shreveport Louisiana, USA

Summary

The success of catheter placement is critically vital for the power to remain on peritoneal dialysis over the long-term. Nephrologists have used percutaneous placement with or with out fluoroscopic steering and placement utilizing peritoneoscopic steering to put these catheters. Problems could be divided into early, inside 14 days, and late issues, these arising extra that 14 days after the process. The principle post-procedure issues are an infection, leakage, and obstruction. Outcomes of non-invasive placement have been similar to surgical placements. The non-invasive method is easy with minimal intra-operative morbidity, and a post-placement complication fee higher than surgical placements. Evaluating percutaneously positioned catheters to laparoscopically and peritoneoscopically positioned catheters exhibits that the laparoscopic method has a greater one yr survival fee. In deciding which method is finest for the affected person, you will need to determine benefits of percutaneous placement, reminiscent of use of native anesthesia, decrease charges of issues, the truth that it’s a bedside or workplace process, versus the constraints in that the percutaneous technique is just not suited to overweight sufferers or these sufferers prone to have peritoneal adhesions. Peritoneal catheters could be positioned in a well timed method with out delays related to surgical scheduling. This provides an added possibility, each to the neprhologist and the affected person and will keep away from beginning dialysis utilizing a central venous catheter. The position of peritoneal dialysis catheters by nephrologists has been proven to extend utilization of peritoneal dialysis as a dialysis modality, and this is a vital benefit of the process.

Key phrases: : Peritoneal, dialysis, catheter, insertion..


Article Info

Article Historical past:

Obtained Date: 1/2/2012
Revision Obtained Date: 12/4/2012
Acceptance Date: 20/4/2012
Digital publication date: 1 /6/2012

© Buffington et al. ; Licensee Bentham Open.

open-access license: That is an open entry article distributed below the phrases of the Inventive Commons Attribution License (http://creativecommons.org/licenses/by/2.5/), which allows unrestrictive use, distribution, and copy in any medium, offered the unique work is correctly cited.

* Handle correspondence to this writer on the Nephrology Part, LSU Well being Sciences Middle, Shreveport, LA 71130, USA; Tel: 318-675-7402; Fax: 318-675-5913; E-mail: [email protected]



INTRODUCTION

Offering peritoneal entry with a minimal of issues is the important thing to profitable peritoneal dialysis. This text evaluations the procedures regarding peritoneal dialysis (PD) entry positioned by interventional nephrologists. The assessment consists of catheter varieties, pre-procedure analysis, placement strategies, and customary issues encountered post-procedure. Peritoneal dialysis is an underutilized mode of dialysis. As of 2007, solely 7.2 p.c of the dialysis inhabitants in the USA was on peritoneal dialysis [1 US Renal Data System USRDS 2009 Annual Data Report: Atlas of chronic kidney disease and end-stage renal disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, The data reported here have been supplied by the United States Renal Data System (USRDS) The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government 2009.]. Placement of peritoneal dialysis catheters by nephrologists avoids delays related to surgical placement and dangers related to common anesthesia with comparable charges of issues. These components can improve the variety of sufferers on peritoneal dialysis. Research present that catheter placement by interventional nephrologists truly will increase utilization of peritoneal dialysis as a dialysis modality inside that group’s observe [2Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A. Does catheter insertion by nephrologists improve peritoneal dialysis utilization? A multicenter analysis Semin Dial 2005; 18: 157-60.4Asif A. Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program Semin Dial 2003; 16: 266-71.]. Nevertheless, information from Facilities for Medicare and Medicaid Providers signifies that solely 2.3% of PD catheters positioned in 2007 have been positioned by nephrologists [5Crabtree JH. Who should place peritoneal dialysis catheters? Perit Dialy Int 2010; 30: 142-50.].

TYPES OF PERITONEAL DIALYSIS CATHETERS

Most PD catheters are constructed out of silicone (majority of catheters); however the Cruz catheter is made from polyurethane. Silicone rubber is much less irritating to the peritoneum [6Aquila RD, Chiaramonte S, Rodighiero MP. Rational choice of peritoneal dialysis catheter Perit Dial Int 2007; 27: S119-25.]. Polyurethane catheters are stronger permitting catheters to be skinny walled with bigger lumens. Nevertheless, they generally tend to interrupt if alcohol or polyethylene glycol is utilized to the catheter [7Gokal R, Alexander S, Ash S. Peritoneal catheters and exit site practice: toward optimum peritoneal access Perit Dial Int 1998; 18: 11-33.]. The glue holding the cuff to the polyurethane catheter could fail inside 2 years leading to leaks and infections [8Ash SR. Chronic peritoneal dialysis catheters: overview of design, placement and removal procedures Semin Dial 2003; 16: 323-4.].

The intra-peritoneal phase is available in 4 fundamental designs: straight Tenckhoff, coiled Tenckhoff, straight Tenckhoff with silicone discs (Toronto Western Hospital, TWH) and T-fluted catheter (Ash benefit) [8Ash SR. Chronic peritoneal dialysis catheters: overview of design, placement and removal procedures Semin Dial 2003; 16: 323-4.]. The intra-peritoneal phase has been designed to decrease outflow obstruction both by stopping the peritoneal surfaces from occluding the facet holes (coiled Tenckhoff) or by stopping omental entrapment (TWH, Ash benefit), tip migration (coiled Tenckhoff) and outward migration of the catheter (Ash benefit). The coiled catheters trigger much less discomfort by minimizing the jet impact attributable to speedy influx of dialysate. Research appear to indicate that coiled catheters do higher than straight catheters when it comes to minimizing tip migration (drainage failure) and have higher catheter survival [9Ates k, Karatan O, Erturk S. Comparison between straight single cuff and curled double cuff catheters in patients on continuous ambulatory peritoneal dialysis Nephrol Dial Transplant 1996; 11: 914., 10Nielsen PK, Hemmingsen C, Friis SU, Ladefoged J, Olgaard K. Comparison of straight and curled Tenckhoff peritoneal dialysis catheters implanted by percutaneous technique: a prospective randomized study Perit Dial Int 1995; 15: 18-21.].

The extraperitoneal phase has both a Dacron cuff or a disc bead (TWH and Missouri catheters) with or and not using a Dacron cuff. The cuff induces a neighborhood inflammatory response with subsequent fibrosis that serves to anchor the catheter, stop leaks across the catheter in addition to stopping bacterial migration from the exit website or from the peritoneum into the subcutaneous tunnel. Double cuffed catheters decrease exit website, tunnel infections and peritonitis [6Aquila RD, Chiaramonte S, Rodighiero MP. Rational choice of peritoneal dialysis catheter Perit Dial Int 2007; 27: S119-25.8Ash SR. Chronic peritoneal dialysis catheters: overview of design, placement and removal procedures Semin Dial 2003; 16: 323-4., 11Thodis E, Passadakis P, Lyrantzopooulos N, Panagoutsos S, Vargemezis V, Oreopoulos D. Peritoneal catheters and related infections Int Urol Nephrol 2005; 37: 379- 93.]; nonetheless, the only cuff catheter can have good outcomes when that cuff is positioned in a deep reasonably than superficial place. In that case, the end result is similar to the 2 cuffed straight Tenckhoff catheters [12Flanigan M, Gokal R. Peritoneal catheters and exit site practices toward optimum peritoneal access: a review of current developments Perit Dial Int 2005; 25: 132-9., 13Eklund BH, Honkanen EO, Kyllonen LE, Salmela K, Kala AR. Peritoneal dialysis access: prospective randomized comparison of single cuff and double cuff straight Tenckhoff catheters Nephrol Dial Transplant 1997; 12: 2664-6.].

The subcutaneous half (between rectus muscle and exit website) of the extra-peritoneal phase has been usually designed to direct the catheter in a lateral or downward path towards the exit website thereby minimizing exit website an infection. There are three fundamental shapes: straight, swan neck with a 150 bend and pail deal with with two 90 bends (Cruz catheter) [8Ash SR. Chronic peritoneal dialysis catheters: overview of design, placement and removal procedures Semin Dial 2003; 16: 323-4.]. Research counsel that there is no such thing as a distinction in exit website infections between the swan neck and straight catheters [14Eklund BH, Honkanen EO, Kyllonen LE. Peritoneal dialysis access: prospective randomized comparison of the Swan Neck and Tenckhoff Catheters Perit Dial Int 1995; 15: 353-6.]; nonetheless, the swan neck catheter has a decrease incidence of cuff extrusion and pericatheter leakage [15Hwang T-L, Huang CC. Comparison of Swan Neck catheter with Tenckhoff catheter for CAPD Adv Perit Dial 1994; 10: 203-5.]. The swan-neck catheter could be prolonged utilizing a titanium connector to exit on the chest wall in overweight sufferers, these with belly stoma, youngsters with recurrent exit website infections and people in diapers.

PRE-OPERATIVE EVALUATION

The preoperative evaluation features a historical past, bodily examination and blood work (CBC, blood group, PT/PTT, INR). Earlier belly surgical procedures or makes an attempt at catheter placement ought to elevate the query of whether or not the affected person has anatomic limitations to percutaneous placement. These sufferers must be referred for laparoscopic placement of the catheter. The bodily examination ought to concentrate on the presence of belly hernias or belly wall weak spot. Cautious consideration must be paid to hepato-splenomegaly, enlarged bladder, or pelvic plenty attributable to fibroids.

The exit website must be chosen and marked (Fig. 1). That is achieved with the affected person supine and carrying clothes in order to determine the belt line. The exit website must be above or under the belt line and away from scars. The affected person must be noticed standing to determine folds of the belly wall or websites the place strain perhaps utilized throughout each day exercise. The exit website must be directed laterally and downward when utilizing a swan-neck catheter or laterally when the catheter doesn’t have a pre-formed bend. It ought to by no means be directed in an upward path as a result of this may improve the chance for exit website an infection. The exit website must be simply visualized by the affected person. Overweight sufferers or these with stomas or extreme belly folds could favor a pre-sternal catheter with the exit website on the chest.

Holding low molecular weight heparin and warfarin for twenty-four hours previous to an open surgical strategy of catheter placement leads to a bleeding fee of solely 2% [16Mital S, Fried LF, Piraino B. Bleeding complications associated with peritoneal catheter insertion Perit Dial Int 2004; 24: 478-80.]. PD catheter placement could be safely carried out below low dose aspirin remedy [17Shpitz B, Plotkin E, Spindel Z. Should aspirin therapy be withheld before insertion and/or removal of a permanent peritoneal dialysis catheter Am Surg 2002; 68: 762-4., 18O’Connor SD, Taylor AJ, Williams EC, Winter TC. Coagulation concepts update Am J Roentgenol 2009; 193: 1656-64.]. Screening for nasal carriers of MRSA permits remedy so as to scale back the speed of exit website and tunnel infections [19 Mupirocin study group Nasal mupirocin prevents Staphylococcus aureaus exit site infection during peritoneal dialysis J Am Soc Nephrol 1996; 7: 2403-8., 20Bonifati C, Pansini F, Torres DD, Navaneethan SD, Craig JC, Strippoli GF. Antimicrobial agents and catheter-related interventions to prevent peritonitis in peritoneal dialysis: using evidence in the context of clinical practice Int J Artif Organs 2006; 29: 41-9.]. A Foley catheter must be positioned the morning of the process to forestall retention from incomplete voiding and help with early detection of inadvertent placement of the PD catheter within the bladder. Bowel evacuation has been really useful [12Flanigan M, Gokal R. Peritoneal catheters and exit site practices toward optimum peritoneal access: a review of current developments Perit Dial Int 2005; 25: 132-9.]. Using prophylactic antibiotics with a primary or second era cephalosporin reduces the chance of peritonitis and exit website infections [12Flanigan M, Gokal R. Peritoneal catheters and exit site practices toward optimum peritoneal access: a review of current developments Perit Dial Int 2005; 25: 132-9., 20Bonifati C, Pansini F, Torres DD, Navaneethan SD, Craig JC, Strippoli GF. Antimicrobial agents and catheter-related interventions to prevent peritonitis in peritoneal dialysis: using evidence in the context of clinical practice Int J Artif Organs 2006; 29: 41-9., 21Wikdahl AM, Engman U, Stegmayr BG, Sorenssen JG. One dose cefuroxime i and ip reduces microbial growth in PD patients after catheter insertion Nephrol Dial Transplant 1997; 12: 157-60.]. Routine use of vancomycin must be averted to forestall the event of vancomycin resistant enterococcus (VRE) [12Flanigan M, Gokal R. Peritoneal catheters and exit site practices toward optimum peritoneal access: a review of current developments Perit Dial Int 2005; 25: 132-9.]. The affected person also needs to bathe on the morning of the process. Belly hair must be clipped if required.

PLACEMENT OF THE CATHETER

Location of Insertion

Paramedian insertion of the deep cuff and making certain that the deep cuff is tunneled into the rectus muscle prevents catheter leaks. The left facet is normally chosen for comfort as a result of most operators are proper handed. Peristaltic actions trigger migration of the catheter into the proper higher quadrant, a complication seen in 15-30% of insertions. Migration is extra prone to occur when the catheter tip is positioned in the proper iliac fossa [3Goh BL, Ganeshadeva YM, Chew SE, Dalimi MS. Does peritoneal dialysis catheter insertion by interventional nephrologists enhance peritoneal dialysis penetration? Semin Dial 2008; 21: 561-6., 22Twardowski ZJ, Nolph KD, Khanna R, Prowant BF, Ryan LP, Nichols K. The need for a “swan neck” permanently bent arcuate peritoneal dialysis catheter Perit Dial Bull 1985; 5: 219-3.].

Generally, a website 2-4 cm under (caudal) or above (cephalad) and left of the umbilicus is chosen for catheter insertion [23Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters preliminary experience Radiology 1992; 182: 251-5.28Rosenthal MA, Yang PS, Liu IA. Comparison of outcomes of peritoneal dialysis catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgical method J Vasc Interv Radiol 2008; 19: 1202-7.]. The situation must be recognized and marked previous to beginning the case as described above and as proven in Fig. (1). The pubic symphysis has been really useful as a dependable landmark for the perfect location of the catheter tip within the true pelvis [29Twardowski ZJ. Peritoneal catheter placement and management In: Mass y SG; Suki WN, Eds. Therapy of Renal Disease and Related Disorders. Kluwer Academic: 8wDordrecht 1997, 00: 953-.] and confirmed laparoscopically [30Crabtree JH, Fishman A. A laparoscopic method for optimal peritoneal dialysis access Am Surg 2005; 71: 135-43.].

Fig. (1)

Location of insertion website. (Reprinted with permission, ref. [33]).

Incision and Blunt Dissection

After infiltrating the pores and skin and underlying tissue with 2% lidocaine with epinephrine, a horizontal incision 3-4 cm lengthy is made to show subcutaneous tissue (overweight people may have an appropriately longer incision). Blunt dissection of the subcutaneous tissue is completed till the shiny anterior rectus sheath is seen and bleeding vessels are ligated or cauterized. The rectus sheath, rectus muscle, and peritoneum are infiltrated with native anesthestic (the needle is aspirated as it’s withdrawn to determine that the epigastric artery is just not in its path).

The above steps are widespread to the fluoroscopic and peritoneoscopic strategies of catheter placement. The steps distinctive to every method are described under.

FLUOROSCOPIC CATHETER INSERTION

A 22-gauge needle is inserted at an angle of 45 levels, directed towards the decrease pelvis (Fig. 2). It will be important that the needle enters the peritoneal cavity 2-3 cm caudal to (under) the entry into the rectus sheath. This orientation of the catheter entry into the peritoneal cavity would assist decrease catheter migration. The situation of the needle throughout the peritoneal cavity is confirmed by injecting 3-5 cc of distinction. A smudge at catheter tip (additional peritoneal tip) or a scaffolding sample (bowel lumen sample) would require alternative of the needle. A micropuncture (0.018 inch) wire is then inserted by the needle and its course famous below fluoroscopy (Fig. 3). After affirmation of its place within the decrease pelvis, a 5-French catheter is inserted over the wire. Distinction can once more be injected by the catheter to verify its place (Fig. 4). Perforation of the bowel with the micro-puncture needle has minimal danger of peritonitis. If perforation is suspected the best choice is to desert the process and administer broad-spectrum antibiotics for twenty-four hours.

Fig. (2)

A needle is inserted by the rectus muscle and information wire is then inserted by the needle.

Fig. (3)

Course of the wire launched by the needle famous below fluoroscopy.

Fig. (4)

Distinction injected outlines the bowel wall.

Use of a blunt tipped 18 g needle as an alternative of micro-puncture needle to entry the peritoneum minimizes the chance of bowel perforation [23Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters preliminary experience Radiology 1992; 182: 251-5.]. Apart from prevention of perforation, a pop and provides could be felt on entry into the peritoneal house with a blunt tipped needle. As well as, a bigger information wire (0.035-inch) could be handed into the stomach precluding using a micro-puncture needle and wire.

Gaining entry into the peritoneal cavity can be undertaken below actual time ultrasound steering [26Maya I. Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters Semin Dial 2007; 20: 611-5., 27Vaux EC, Torrie PH, Barker LC, Naik RB, Gibson MR. Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters: A 10-year experience Semin Dial 2008; 21: 459-65.]. Ultrasound measures the gap from the pores and skin to the peritoneal cavity and colour Doppler can find the epigastric and hypogastric vessels, minimizing the chance of bleeding [26Maya I. Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters Semin Dial 2007; 20: 611-5.].

The 0.035-inch glide wire is then handed by the 5-French catheter till enough wire varieties a cushty curve within the pelvis (Fig. 3). Rectus sheath, rectus muscle, deep fascia and the peritoneal membrane are dilated sequentially utilizing 10F to 17F dilators over the information wire (Figs. 5, 6). The ultimate 18-French dilator with a peel-away sheath is positioned into the peritoneal cavity. After eradicating the dilator within the sheath (wire to be left in place if placement of catheter is completed over wire); the PD catheter is then superior over the glide wire. The radio-opaque line on the PD catheter permits for affirmation of its place within the decrease pelvis (Fig. 7). The catheter could be rotated and moved at this level to make sure that the “pigtail” portion is positioned within the pelvis. Distinction could be injected into the catheter for higher visualization. One liter of PD fluid is infused into the stomach by the catheter to guage its operate. Influx must be speedy and ache free and outflow must be a quick drip or stream that will increase with deep inspiration. The catheter could be repositioned utilizing a metallic stylet till optimum operate is achieved.

Fig. (5)

Dilators from 10 Fr to 17 Fr are superior sequentially over the information wire.

Fig. (6)

Fluoroscopic view of a dilator being superior over a guidewire.

Fig. (7)

Distinction injected into the PD catheter for higher visualization.

The deep cuff is buried within the rectus muscle with using the cuff pusher because the catheter is stabilized on the stylet [25Zaman F, Pervez A, Atray NK, Murphy S, Work J, Abreo KD. Fluoroscopically-assisted placement of peritoneal dialysis catheters by nephrologists Semin Dial 2005; 18: 247-51.]. When placement is completed over wire, a set of non traumatic forceps are used to go the cuff past the rectus sheath, the peel away sheath is withdrawn slowly making certain that the cuff stays throughout the rectus muscle [26Maya I. Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters Semin Dial 2007; 20: 611-5., 27Vaux EC, Torrie PH, Barker LC, Naik RB, Gibson MR. Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters: A 10-year experience Semin Dial 2008; 21: 459-65.]. Holding the cuff in place with the blunt forceps, when the peel-away sheath is eliminated, helps stop its dislodgement. Some operators go an absorbable suture by the deep cuff and the outer rectus sheath and subcutaneous tissues and tie the suture as soon as the cuff is buried within the rectus muscle to anchor the cuff [24Savader SJ, Geschwind JF, Lund GB, Scheel PJ. Percutaneous radiological placement of peritoneal dialysis catheters: long-term results J Vasc Interv Radiol 2000; 11: 965-70., 28Rosenthal MA, Yang PS, Liu IA. Comparison of outcomes of peritoneal dialysis catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgical method J Vasc Interv Radiol 2008; 19: 1202-7.].

PERITONEOSCOPIC CATHETER PLACEMENT:

Peritoneoscopic placement is completed below native anesthesia with a single puncture website for the Quill® Catheter Information [31Y-Tec Instructions: Laparoscopic & Percutaneoscopic Placement of Peritoneal Dialysis Catheters http://www.medigroupinc.com/ytec-instructions.pdf. ] by which the scope is inserted and later turns into the pathway for the catheter insertion. As soon as the rectus sheath is recognized, extra lidocaine is infiltrated into the rectus sheath and muscle. The affected person is requested to tighten his/her belly muscle tissue previous to inserting the Quill® catheter information meeting. Simply as with the fluoroscopic catheter placement, this step is vital to orient the catheter in the direction of the pelvis. The catheter information meeting ought to enter the rectus sheath at a 30% angle and directed in the direction of the coccyx. Peritoneal entry must be felt with the giveaway sensation at entry into the peritoneal cavity.

Bowel perforation has been described in <1% of trocar insertions into the peritoneal cavity. Insufflating peritoneal cavity with fuel previous to trocar insertion can additional lower this complication. A blunt tip needle or Veress insufflation needle is used to entry the peritoneal cavity and air is injected (the affected person is positioned in Trendelenburg place and roughly 700-1200 cc of air, relying on affected person measurement) previous to tocar use [23Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters preliminary experience Radiology 1992; 182: 251-5., 32Asif A, Tawakol J, Khan T. Modification of the peritoneoscopic technique of peritoneal dialysis catheter insertion: experience of an interventional nephrology program Semin Dial 2004; 17: 171-3.].

The Y-TEC® scope, modified optic scope for peritoneoscopic catheter insertion, is handed into the cannula, locked, the sunshine information snapped on to the scope and site throughout the peritoneum is confirmed. Each time the scope is handed into the cannula it’s locked previous to visualizing the peritoneal cavity.

The Y-TEC® System itself consists of reusable devices (2.2 mm diameter endoscope, fiberoptic gentle information, sterilization tray, and a fiberoptic gentle supply) and a selection of two disposable catheter implantation kits, known as “pacs” by Y-Tec. This package and process can be utilized to implant virtually all PD catheters together with the Flex-Neck®, Swan-Neck™, and traditional catheters. (The Toronto Western™ and Missouri Swan-Neck™ catheters can’t be implanted with this system).

Peritoneoscopic examination of the peritoneal cavity ensures placement of the trocar meeting into the peritoneal cavity. If the bowel floor is just not visualized or the picture is all white, the scope is withdrawn and the peritoneal cavity is considered once more. It is vitally vital that bowel floor be seen and motion seen together with respiration, to confirm that the scope is throughout the peritoneum. If there is no such thing as a motion the scope is withdrawn slowly whereas asking the affected person to take deep breaths. As soon as the location is confirmed to be within the peritoneal cavity, the scope is withdrawn and air injected (if not achieved earlier). The scope is changed and locked, the sunshine supply is connected, the tip of the scope positioned (with the Quill meeting) within the desired location. After visualizing adhesions and omental folds, the very best location for the catheter is recognized. The Quill® Information Meeting is superior totally into the peritoneum in order that the distal finish is on the decrease a part of the inguinal space. The scope is then withdrawn and the tape holding the Quill® Information to the cannula is eliminated with a hemostat.

The outer finish of the Quill sheath is secured utilizing a hemostat 2 mm above the shoulder of the Quill Catheter information and the cannula is eliminated with a slight twisting/rotating movement. The Quill Catheter information stays in the identical location the place the scope had directed it. Dilators are inserted into the Quill information beginning with the smaller 4.8 mm after lubrication with gel and adopted by the 6.4 mm dilator. The catheter is ready for insertion by inserting it on a stylette with sterile gel or saline with its tip even with the catheter tip. Catheter orientation (marked on catheter with a white stripe) must be aligned in order the catheter is just not twisted or rotated on its axis. The catheter with stylette is inserted fastidiously into the Quill® Information. Catheter positioned on the left ought to have the white stripe on catheter at 12 o’ clock place and at 6 o’clock when positioned on proper. You will need to observe the Quill® Information by the rectus muscle and into the specified location within the peritoneum. The catheter is superior by the Quill® Information and holding the outer finish of the stylette the catheter is pushed off the stylette into the peritoneal cavity. The tip of the stylette must be saved throughout the stomach to assist place the catheter cuff by the rectus. The operater ought to make sure that the catheter is just not doubled on itself, kinked, or twisted. The Y-TEC® Cuff Implantor® is positioned parallel with and over the catheter between the 2 cuffs. The catheter and Cuff Implantor® are superior concurrently 1 cm to each dilate the Quill® Information (and rectus) and advance the cuff into the rectus muscle. The Quill® Information is retracted by folding it on a hemostat, adopted by removing of the stylette [23Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters preliminary experience Radiology 1992; 182: 251-5., 31Y-Tec Instructions: Laparoscopic & Percutaneoscopic Placement of Peritoneal Dialysis Catheters http://www.medigroupinc.com/ytec-instructions.pdf. ].

Fig. (8)

Tenckhoff catheter modifications for a wide range of exit websites. (Reprinted with permission, ref. [33]).

Exit Web site and Superficial Cuff (Each Strategies)

The situation of the exit website must be decided as described above. The swan neck catheter is finest suited to the placement of the exit website within the decrease stomach and the straight catheter for exit websites on the higher stomach. Sufferers who’re overweight, have belly stomas, are incontinent of urine or feces, and who need to take a deep tub bathtub would profit from an prolonged catheter system that may permit for an exit website positioned within the higher stomach or chest (Fig. 8) [33Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access Kidney Internat 2006; 70: S27-37., 34Sreenarasimhaiah VP, Margassery SK, Martin KJ, Bander SJ. Percutaneous technique of presternal peritoneal dialysis catheter placement Semin Dial 2004; 17: 407-10.].

Utilizing native anesthesia, a stab wound is made and a tunneling gadget or a Kelly clamp is inserted into the stab incision and tunneled into the subcutaneous tissues to have interaction or grasp the catheter tip. The catheter is pulled by the tunnel and out of the exit website [23Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters preliminary experience Radiology 1992; 182: 251-5., 25Zaman F, Pervez A, Atray NK, Murphy S, Work J, Abreo KD. Fluoroscopically-assisted placement of peritoneal dialysis catheters by nephrologists Semin Dial 2005; 18: 247-51., 26Maya I. Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters Semin Dial 2007; 20: 611-5.].

Wound Closure

The subcutaneous tissue of the first incision is closed with absorbable sutures and the pores and skin is closed with non-absorbable sutures [25Zaman F, Pervez A, Atray NK, Murphy S, Work J, Abreo KD. Fluoroscopically-assisted placement of peritoneal dialysis catheters by nephrologists Semin Dial 2005; 18: 247-51.]. The exit website shouldn’t be sutured [24Savader SJ, Geschwind JF, Lund GB, Scheel PJ. Percutaneous radiological placement of peritoneal dialysis catheters: long-term results J Vasc Interv Radiol 2000; 11: 965-70.], as this may increasingly trigger an exit website an infection. The 2 cuffs present enough anchoring to forestall the catheter from falling out. The catheter is flushed with saline and 7000 U of heparin are instilled within the catheter after the connectors are connected.

POST-OPERATIVE MANAGEMENT

The catheter could be capped after the peritoneal cavity is flushed with 500 to 1500 ml of heparinized dialysate till the effluent turns into clear [35Gokol R, Ash SR, Helfrich B. Peritoneal catheters and exit-site practices: toward optimum peritoneal access Perit Dial Int 1993; 13: 29-39.]. The affected person’s very important indicators are then monitored to guarantee stability. Some facilities carry out the process on an outpatient foundation with the affected person returning residence 4-6 hours post-procedure, whereas others favor to look at the affected person in a single day [36Maya ID. Ambulatory setting for peritoneal dialysis catheter placement Semin Dial 2008; 21: 457-8.]. The exit website and surgical incision are coated with sterile gauze and a non-occlusive dressing. The affected person is suggested to reduce contact with the catheter and surgical incisions till the injuries have healed and the tunnel has matured. The catheter is taped securely and stays motionless when not in use. After discharge, a PD nurse ought to consider the affected person every week and carry out a low quantity alternate with 1 liter of 1.5% dextrose (Dianeal) to check the operate of the catheter and educate the affected person about PD and applicable catheter use. Full quantity exchanges can start in 2-3 weeks after catheter placement [35Gokol R, Ash SR, Helfrich B. Peritoneal catheters and exit-site practices: toward optimum peritoneal access Perit Dial Int 1993; 13: 29-39.]. Sufferers ought to keep away from baths that immerse the exit website and swimming in lakes, rivers or public baths [35Gokol R, Ash SR, Helfrich B. Peritoneal catheters and exit-site practices: toward optimum peritoneal access Perit Dial Int 1993; 13: 29-39.].

Starting PD earlier than the deep cuff matures will increase the chance of leakage. If the affected person requires dialysis instantly following the process, low quantity exchanges are most well-liked. This might spare the affected person the necessity for a central venous catheter. Nevertheless, the affected person ought to stay supine throughout catheter use to keep away from pericatheter leakage [35Gokol R, Ash SR, Helfrich B. Peritoneal catheters and exit-site practices: toward optimum peritoneal access Perit Dial Int 1993; 13: 29-39.].

COMPLICATIONS OF CATHETER PLACEMENT

The percutaneous technique of catheter placement has low complication charges when carried out by skilled operators (Desk 1). The most typical peri-operative issues of catheter placement are dialysate leakage, an infection, and catheter drainage failure. Bowel and bladder perforation together with bleeding and hematoma are uncommon issues.

Desk 1

Abstract of Problems of Catheter Placement

Catheter associated an infection consists of exit website an infection and peritonitis. Solely these cases occurring quickly after catheter placement must be attributed to the process. Research differ with regard to the definition of an early an infection, with the time interval starting from 2 weeks or longer. Arguably, an an infection occurring extra that 2 weeks after a process shouldn’t be attributed to the location. An exit website an infection has induration, erythema, or drainage from the positioning the place the catheter exits the pores and skin. This is among the most frequent issues of PD catheters on the whole. Directing the exit website laterally or inferiorly reduces the prevalence of an infection. Additionally, use of antibiotic cream on the exit site– both mupirocin [44Wong S, Chu K, Cheuk A. Prophylaxis against gram-positive organisms causing exit-site infection and peritonitis in continuous ambulatory peritoneal dialysis patients by applying mupirocin ointment at the catheter exit site Perit Dial Int 2003; 23: S153-S8.] to forestall gram constructive infections or gentamicin [45Bernardini J, Bender F, Florio T. Randomized double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients J Am Soc Nephrol 2005; 16: 539-45.] to forestall gram constructive and gram destructive infections — reduces the prevalence of exit website infections and peritonitis. Research have reported a fee of early exit website infections starting from 0 to six.5% utilizing the percutaneous technique [25Zaman F, Pervez A, Atray NK, Murphy S, Work J, Abreo KD. Fluoroscopically-assisted placement of peritoneal dialysis catheters by nephrologists Semin Dial 2005; 18: 247-51.27Vaux EC, Torrie PH, Barker LC, Naik RB, Gibson MR. Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters: A 10-year experience Semin Dial 2008; 21: 459-65.]. Modifying the swan-neck catheter to a pre-sternal exit website location has proven a rise in entry survival as much as 95% at 2 years and in addition a lower in peritonitis and exit website an infection [46Twardowski ZJ, Prowant BF, Nichols WK, Nolph KD, Khanna R. Six-year experience with swan neck presternal peritoneal dialysis catheter Perit Dial Int 1998; 18: 598-602.]. Prophylactic antibiotics can stop an infection throughout the first 30 days of catheter insertion. Early peritonitis occurred in 1.5% to 4% of research [27Vaux EC, Torrie PH, Barker LC, Naik RB, Gibson MR. Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters: A 10-year experience Semin Dial 2008; 21: 459-65., 37Moon J-Y, Sebin S, Jung K-H. Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center Perit Dial Int 2008; 28: 163-9.39Henderson S, Brown E, Levy J. Safety and efficacy of percutaneous insertion of peritoneal dialysis catheters under sedation and local anaesthetic Nephrol Dial Transplant 2009; 24: 3499-504.].

Leakage of dialysate happens when the deep cuff both is displaced or doesn’t kind a fibrotic response throughout the rectus muscle. Therapy of leakage entails resting the peritoneum for two days to three weeks whereas the affected person is briefly on hemodialysis or utilizing low quantity exchanges, ideally with the affected person in supine place. Leakage occurred in 3% to eight% of percutaneous placements, with one research displaying a 23% leakage fee (see Desk 1).

Catheter dysfunction entails drainage issues as a consequence of migration of the catheter, omental wrapping, or obstruction. Inserting the catheter by the percutaneous technique even utilizing fluoroscopic steering may end up in obstruction by omentum or adhesions. The laparoscopic method provides a bonus on this regard as a result of the omentum within the pelvis could be tacked to the belly wall or eliminated and adhesions could be lysed. Migration of the catheter tip is attributable to peristaltic motion of the bowel that strikes the catheter tip into the proper higher quadrant. One report famous that placement of the catheter on the proper facet of the stomach with the tip within the left iliac fossa can scale back the incidence of catheter migration [22Twardowski ZJ, Nolph KD, Khanna R, Prowant BF, Ryan LP, Nichols K. The need for a “swan neck” permanently bent arcuate peritoneal dialysis catheter Perit Dial Bull 1985; 5: 219-3.]. With migration, the dialysate will simply fill the peritoneum however won’t drain. This has occurred in as much as 15% of percutaneous procedures and as much as 28% in laparoscopic procedures [40Perakis KE, Stylianou KG, Kyriazis JP. Long-term complication rates and survival of peritoneal dialysis catheters: the role of percutaneous versus surgical placement Semin Dial 2009; 22: 569-75.]. Migration could be associated to constipation, and preliminary remedy must be laxatives to stimulate the bowel. Different remedies for migration are fluoroscopic manipulation, catheter alternative, or surgical salvage procedures [47Santos CR, Branco PQ, Martinho A. Salvage of malpositioned and malfunctioning peritoneal dialysis catheters by manipulation with a modified Malecot introducer Semin Dial 2010; 23: 95-.]. Some analysis has proven that the swan neck catheter design reduces the incidence of tip migration [12Flanigan M, Gokal R. Peritoneal catheters and exit site practices toward optimum peritoneal access: a review of current developments Perit Dial Int 2005; 25: 132-9.]. Influx dysfunction is probably going associated to fibrin or clot within the catheter. This may be handled with forceful infusion of dialysate or thrombolytics.

Bowel and bladder perforations are very uncommon with numerous research reporting no occurrences. With the percutaneous technique, it’s attainable to perforate the bowel with the micro-puncture needle. This might be found instantly and on this occasion, the needle must be withdrawn and the affected person given broad spectrum antibiotics intravenously in a single day. If the affected person stays afebrile, the process could be tried once more the following day.

Hematomas and bleeding can happen when the epigastric vessels are perforated. Utilizing ultrasound to visualise these vessels considerably reduces the chance of this complication.

COMPARISON WITH SURGICAL TECHNIQUES

Each laparoscopic and percutaneous procedures have low complication charges when carried out by skilled operators. Sufferers must be referred for laparoscopic catheter placement when they’re overweight, have had earlier belly surgical procedure or have had repeated episodes of peritonitis that may trigger adhesions. Some have argued that evaluating complication charges between the 2 procedures is flawed as a result of there’s a choice bias in favor of much less difficult topics for the percutaneous strategy. The outcomes of the laparoscopic process must be considered in gentle of the truth that in some research the laparoscopic topics are tougher [48Crabtree JH. Fluoroscopic placement of peritoneal dialysis catheters: a harvest of the low-hanging fruits Perit Dial Int 2008; 28: 134-7.]. Total, the complication fee is decrease for the percutaneous technique. The one yr survival fee of catheters is lowest for catheters positioned surgically by the dissection technique, however highest for catheters positioned by laparoscopic technique. The one yr survival for laparoscopic placement is barely higher than that of the percutaneous technique (Desk 1).

CONCLUSION

Sufferers who’re overweight, with a historical past of belly surgical procedure or with a historical past of repeated episodes of peritonitis must be referred to a succesful surgeon for the laparoscopic placement of the catheter. For sufferers with out these components, percutaneous placement of peritoneal dialysis catheters by interventional nephrologists must be tried. The complication charges for the percutaneous technique are just like these of laparoscopic procedures. This assessment summarizes the catheter varieties, pre-procedure work-up, catheter placement method, post-procedure care and issues. Moreover, having an interventional nephrologist concerned within the placement of PD catheters will increase utilization of this modality of dialysis.

CONFLICT OF INTEREST

Declared none.

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