Peritoneal Dialysis at Home...You will hear some medical terms used when learning how dialysis...

Peritoneal Dialysis at Home

2 Peritoneal Dialysis at Home

How to Contact Your Peritoneal Dialysis Team

The PD Unit is on level 4 of the River zone, section B, at the main hospital campus. The PD Unit is open Monday through Friday from 8 a.m. to 8 p.m. We are closed on weekends, Thanksgiving, Christmas and New Year’s Day.

Address4800 Sand Point Way N.E.Seattle, WA 98105

Phone numbers

Main hospital 206-987-2000

PD Unit 206-987-1310

PD Unit dietitian 206-987-6358 or 206-987-5538

PD Unit social worker 206-987-9584 or 206-987-9876

After hours, weekends, and holidays:

If you have an urgent dialysis-related concern that cannot wait until the PD Unit is open, please call the main hospital at 206-987-2000. Calls will be forwarded to an operator who can help you to reach the on-call dialysis nurse.

For all other medical problems, please contact your primary care provider, kidney doctor or family doctor.

For any PD Cycler equipment related concern, please call Baxter Technical Support at 1-800-553-6898.

For life threatening emergencies dial 911.

3 Seattle Children’s Hospital

Table of Contents

Starting Peritoneal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Caring for Your Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Safe Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

PD Problem-Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Balancing Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Dialysis Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Automatic Dialysis with a Cycler Machine

Versus Manual Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

4 Peritoneal Dialysis at Home


Peritoneal Dialysis at Home – Lesson 1

Starting Peritoneal DialysisIn this lesson you will learn:

• What healthy kidneys do for your child’s body

• The condition of uremia and its symptoms

• All about peritoneal dialysis (PD) and a process called Automated Peritoneal Dialysis (APD)

• The steps of a peritoneal dialysis cycler or exchange

• Lifestyle benefits of APD

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Lesson 1: Starting Peritoneal Dialysis


Words to know

APDAutomated Peritoneal Dialysis, sometimes called CCPD.

CAPDContinuous Ambulatory Peritoneal Dialysis (also known as manual PD). This type of dialysis is done manually. Gravity is used to drain and fill your peritoneal cavity with dialysis solution.

CatheterA tube that carries the dialysate into and out of your body.

CCPD (APD)Continuous Cyclic Peritoneal Dialysis. This type of dialysis is done with a machine called a cycler. The cycler will automatically drain, fill and dwell the dialysis solution from your peritoneal cavity.

CyclerMachine used to do peritoneal dialysis.

DialysateA liquid that has a sugar called dextrose in it to help pull waste and extra fluid into the peritoneal cavity.

DialysisThe process of removing waste products and excess fluid from the body.

Dwell timeThe time the dialysis solution sits in your peritoneal cavity.

Exchange or cycleThe process of draining, filling, and dwelling the dialysis solution from your peritoneal cavity.

PeritoneumA layer of tissue covering the wall of the abdominal cavity. The peritoneum is a natural filter and lets waste product and fluid pass from your blood into the dialysis “sugar” solution.

Transfer setA 4- or 6-inch length of tubing that attaches to the PD catheter. The transfer set lets the catheter open and close.

UltrafiltrateThe fluid that is removed from the bloodstream during dialysis.

UremiaOccurs when the kidneys don’t work like they should. The toxins or “waste” build up in the body.

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Seattle Children’s Hospital

What do healthy kidneys do?

Remove wasteWaste products, such as blood urea nitrogen (BUN) and creatinine, are made by the body during normal daily functions. These products are removed from the blood by healthy kidneys.

Balance fluidHealthy kidneys know when there is too much or too little fluid in the body. When kidneys are working, they make urine to remove extra fluid your child drinks. If your child has too little fluid in their body from sweating, throwing up, or having diarrhea, the kidneys keep fluid and make less urine. More on this in Lesson 6.

Control blood pressure Healthy kidneys help keep the blood pressure in a safe range. They release a signal that tells the body when to raise or lower blood pressure. They also help control blood pressure by balancing the fluid in the body. More on this in Lessons 6 and 7.

Make red blood cellsHealthy kidneys release a signal that tells the body when to make more red blood cells. More on this in Lesson 7.

Balance electrolytesKidneys play an important role in the regulation (balance) of fluids and electrolytes. When they malfunction it often leads to an electrolyte imbalance. Electrolytes are charged particles involved in sending impulses to nerves and muscles. Excessive amounts of electrolytes are removed from the blood by healthy kidneys.

Maintain healthy bonesHealthy kidneys remove extra phosphorus (foss-for-us) from the blood and take it out of the body in the urine. Too much phosphorus causes low calcium. Low calcium leads to weak, brittle bones. Keeping phosphorus levels normal keeps calcium levels normal, so bones stay strong and healthy. Kidneys also make vitamin D, which helps your body to absorb calcium from food.

Growth and developmentMany things in the body affect your child’s growth and development. These include acids, bases, minerals, hormones and proteins. Healthy kidneys make sure these stay balanced so that children can grow and develop normally.

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What is uremia?

The kidneys filter waste from the blood. When the kidneys are not working well, they do not filter the blood and wastes build up in the blood causing a condition called uremia.

What is peritoneal dialysis?

During peritoneal dialysis (PD) your child’s blood is filtered and extra fluid is removed. During PD, a cleansing fluid called dialysate is circulated through a tube (catheter) inside part of your abdominal cavity (peritoneal cavity). The dialysate absorbs waste products from the blood vessels in your abdominal lining (peritoneum) and then is drawn back out of your body and discarded.

Imagine watching a teabag as the tea particles spread out through the water. A teabag steeping in water is like what happens during PD. The tea bag is the peritoneal membrane, the tea leaves are the blood vessels, the tea color that makes the tea is the waste in the blood vessels, and the water is the dialysate solution. This process is called diffusion.

Symptoms of uremia are:

Loss of appetiteTiredness/weakness

Bad taste in mouthDifficulty concentrating in school

Nausea/vomiting (throwing up)

Dialysis will help relieve the symptoms of urea.

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You will hear some medical terms used when learning how dialysis works. These are some of the medical terms the team may use:

Peritoneal membrane• The lining on the inside of your child’s abdomen between the abdominal wall

and internal organs. It contains a lot of blood vessels.

• Acts as a natural filter.

• Allows waste products and excess fluid to pass into the dialysate solution.

Osmosis• The movement of extra fluid from the bloodstream, across the peritoneal

membrane, and into the dialysate solution to be drained.

• The fluid that is removed is called ultrafiltrate (UF).

• The amount of ultrafiltrate (UF) is determined by the concentration of the dialysate solution used.

• PD does not remove a set amount of fluid each treatment.

Diffusion• The movement of waste products from the bloodstream, across the

peritoneal membrane, and into the dialysate fluid to be removed.

• The waste moves from the bloodstream where there is a high concentration of particles to the dialysate solution where there is a low concentration of particles.

It is through osmosis and diffusion using the peritoneal membrane and dialysate solution that dialysis removes wastes and fluids. Osmosis and diffusion are slow, gentle processes that your child will not feel. The processes stop on their own when each side of the peritoneal membrane is balanced.

Tea bag steeping in water (peritoneal membrane)

Tea leaves inside the tea bag (blood vessels)

Tea color (waste in the blood vessels)

Water (dialysate solution)

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What is a peritoneal dialysis catheter?

• The catheter is a small, flexible tube. It is surgically placed through the wall of the belly area (abdomen) into a space called the peritoneal cavity. The peritoneal cavity holds the abdominal organs.

• The lining of the peritoneal cavity is called the peritoneal membrane.

• Many blood vessels run throughout this peritoneal membrane.

• PD uses the peritoneal membrane, along with dialysate fluid, to filter and clean waste products and extra fluid from the blood. The blood is from the blood vessels along the peritoneal membrane wall.

• The catheter allows dialysate fluid to go in and out of the peritoneal cavity during a PD exchange.

• A peritoneal dialysis catheter is your child’s permanent access for PD treatments.

Internalorgans

Peritonealcatheter

Peritonealcavity

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What is a transfer set?

• Attached to your PD catheter is a transfer set that allows you to connect to your APD machine.

• The transfer set is attachments that make it easy to connect the tubing for dialysis to the machine and close off the tubes when they are not being used.

• The transfer set always stays connected to your catheter. It should only be changed by your PD nurse every 6 months or if there is a problem with the transfer set.

What is a PD cycle or exchange?

A PD exchange is a cyclical process that removes waste products and fluid from your child’s body and replaces it with new dialysate solution.

Transfer set PD catheter

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There are three steps to each PD exchange:

1. DrainRemoves old dialysate solution, along with waste products and extra body fluid.

2. FillReplaces old dialysate solution in the peritoneal cavity with new dialysate solution.

3. DwellThe time when dialysate solution is in the peritoneal cavity. This is when dialysis takes place. Dwell time is set by your kidney doctor.

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Automated peritoneal dialysis

Automated Peritoneal Dialysis (APD) is sometimes called CCPD (continuous cyclic peritoneal dialysis). This is a kind of peritoneal dialysis (PD) that uses a machine called a cycler.

• APD works during the night while your child sleeps.

• The cycler is set up to automatically do PD exchanges.

• Your nurse will tell you if your child needs a PD exchange during the day (in addition to or in place of nighttime exchange). Sometimes you will need to close off the APD with a manual exchange — see Lesson 9.

Below are some pictures of cycler machines used at Seattle Children’s. Your nurse will help decide which cycler is best for your child.

HomeChoice Pro Cycler (typically for babies

and toddlers)

AMIA Cycler (typically for older kids

and teenagers)

The name of the cycler I will be using at home is:

.

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APD offers you some nice lifestyle benefits

• It is done in the comfort of your own home, while your child sleeps.

• With guidance from your PD team, your child’s schedule can be personalized to match your family’s lifestyle.

• Unlike hemodialysis, your child’s dialysis treatment does not involve blood or needles. However, needles may be needed for medicines such as Epogen or growth hormones.

• It is easier for your family to travel. You can take the APD equipment with you when you travel to visit friends and relatives, stay in a hotel or go camping in a recreational vehicle.

Key points

• Healthy kidneys remove waste products, balance fluids, control blood pressure and make red blood cells.

• Symptoms of uremia are relieved by dialysis.

• The peritoneal membrane is used as the filter in peritoneal dialysis.

• The transfer set attaches to the peritoneal catheter using an adapter.

• The transfer set allows the catheter to connect to the cycler.

• There are 3 steps to a peritoneal dialysis exchange or cycle: drain, fill and dwell.

• Automated Peritoneal Dialysis (APD) is peritoneal dialysis using a cycler that automatically drains dialysis solution from the patient, fills the patient with dialysis solution, and allows the dialysis solution to dwell for the ordered amount of time.

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Teach-back moment

What does PD do?

Where is the PD catheter placed?

What are symptoms of uremia?

What happens during each of the 3 steps of peritoneal dialysis cycle or exchange?

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My questions:

My notes:

Important information from this lesson:

Notes



Hand HygieneIn this lesson you will learn:

• The importance of hand hygiene

• The difference between sterile, clean and dirty

• How to perform proper hand hygiene based on the World Health Organization (WHO) guidelines

• How proper hand hygiene may help protect against infection

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Lesson 2: Hand Hygiene


Words to know

Aseptic techniqueThe way to make sure clean items stay “clean” and sterile items stay “sterile.” The goals of aseptic technique are to protect your child from infection and to prevent the spread of germs.

CleanMost germs have been removed, but not all of them. For example, washing your hands makes them clean, not sterile.

ContaminatedAn item that was sterile that touches something that is either clean or dirty. It is no longer sterile.

DirtyNot clean or sterile.

Exit siteArea where the PD catheter comes out of the skin.

Peritoneal cavityThe space between the abdomen wall and the organs in the abdomen.

Peritoneal dialysis (PD) catheterFlexible plastic tube inserted into the peritoneal cavity by a surgical procedure.

PeritoneumA layer of tissue covering the inside wall of the abdominal cavity that contains a lot of blood vessels. Acts as a natural filter and lets waste product and fluid pass from your bloodstream into the dialysis “sugar” solution.

PeritonitisA serious infection of the peritoneum.

SterileFree from bacteria and other germs. For example: supplies in sterile packaging.

Tunnel areaThe space under the skin surrounding the PD catheter.

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Germs are everywhere

Germs, sometimes called “bugs,” are bacteria, viruses and fungi that are too small to see without a microscope. Germs are everywhere around us. We come into contact with millions of germs every day. Germs live on work surfaces, equipment and skin, and in the nose and the gut, even when there is no visible dirt or someone is healthy.

Not to worry! Most bugs are harmless, and some even help to keep your child healthy. But some can make your child very sick. Germs can spread to others when people touch things that others touch (like door handles, keyboards, phones and TV remote controls).

When these germs get on your hands, they can spread to other parts of your body when you touch your eyes, ears, nose or mouth. And they don’t stop there — you spread germs every time you touch something or someone else!

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You should perform hand hygiene before:

Handling food Performing peritoneal dialysis care:

• Cycler setup

• Connecting to or disconnecting the catheter to the cycler lines

• Exit site dressing changes

Eating

Putting in or taking out contact lenses

You should perform hand hygiene after:

Eating Coughing or sneezing

Handling dirty dishes or utensils, or touching countertops where food is prepared

Being around someone who is sick

Going to the bathroom or helping someone go to the bathroom

Playing with pets or animals

Blowing or wiping your nose

Completing peritoneal dialysis care, such as throwing away used peritoneal dialysis lines, drainage bags and soiled supplies

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How to perform hand hygiene

You cannot rub your dirty hands on your clothes or rinse them with water to get rid of germs.

Water by itself is not enough to get rid of all germs. You need to use soap! Germs can stick to the oils that your skin naturally produces. Soap helps to break down that oil, making it harder for germs to stay on your hands. Then the germs can be rinsed away by water.

When washing with soap and water, a quick rinse is not effective. Don’t just wipe those wet hands on your clothes! Drying hands thoroughly after each washing is important. If you have a choice, use a paper towel instead of a cloth to prevent the spread of germs to others who might use the same towel. Throw away the paper towel once you’re done drying your hands. If you’re using a cloth towel, use a new clean towel. Do not use an already used towel, because it could have germs on it.

Time must be spent cleaning all areas of the hands.This includes the back of hands, between the fingers and even the fingernails. Dirt and germs can easily get stuck underneath your fingernails. This is the area that contains the highest number of germs on the hand. Keep fingernails short and clean. Several studies show that long fingernails or artificial nails are linked to infections with a very serious bug named Pseudomonas aeruginosa. These infections are very hard to treat and are a common reason why PD catheters need to be replaced.

If soap and water is not available, use an alcohol-based hand sanitizer gel.Alcohol-based sanitizer gel must contain at least 60% alcohol to kill germs. It is really important when using alcohol-based sanitizer gel to make sure that your hands are completely dry before handling your child’s PD catheter. Alcohol that is left on your hands from the gel may lead to holes or leaks in the catheter.

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Hand hygiene information from the World Health Organization

• Hand hygiene is the best, most simple and effective way to stop the spread of germs and prevent infection.

• Good hand hygiene takes 40 to 60 seconds when washing your hands with soap and water.

• Good hand hygiene takes 20 to 30 seconds when using alcohol-based gel.

Sterile, clean or dirty?

Aseptic technique means the use of practices to prevent contamination with germs to keep an object or area clean. We use these words when talking about aseptic technique:

Sterile means completely free of all germs. The peritoneum is sterile.

Clean means free of dirt. Hands are clean after a 1-minute scrubbing.

Dirty means not clean or sterile. Dirty objects should not be used in dialysis procedures where clean or sterile items are needed.

Contaminated means a sterile item has been touched by something that is not sterile. Germs are now on the sterile item.

Follow these guidelines when using this method:• Before handling packages of sterile items, wash your hands!

• Do not put packages on wet surfaces or let them get wet. The wetness lets germs into the wrapper. This will contaminate the item.

• Do not use contaminated items!

• Prepackaged sterile items are sterile only if the package is not opened and not damaged. Remember, only the inside of the packaging is sterile.

• Once sterile solutions are opened, they are exposed to germs in the air. Open sterile solutions just before use.

• When in doubt, throw it out!

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Wash your hands! Stop germs!

Keeping hands clean is one of the most important things we can do to prevent peritonitis.

Steps for using soap and water

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Clean your hands! Stop germs!

Keeping hands clean is one of the most important things we can do to prevent peritonitis.

Steps for using hand sanitizer

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Peritonitis

The peritoneal cavity (the space between the abdominal wall and the organs in the abdomen) is sterile, meaning it is free from germs. It is very important to keep germs from getting inside your child’s peritoneal cavity where they can cause a serious infection called peritonitis. Most germs that cause peritonitis are bacteria, tiny invisible organisms that are always in our environment.

Common causes of peritonitis include:

• Bacteria directly entering the body through the dialysis catheter because of mistakes with connections or disconnections or a problem with the catheter itself. Common problems include:

• The open ends of the catheter or dialysis lines are touched during connections.

• The lines are accidentally disconnected during treatment.

• A hole or crack develops in the catheter.

• An infection of the tunnel area around the catheter that spreads to the peritoneal cavity.

• An infection of the exit site where the dialysis catheter leaves the abdomen, allowing germs to enter the peritoneal cavity through the tunnel area.

• Issues with the bowels that allow bowel bacteria to cross into the peritoneal cavity, such as:

• Constipation

• Diarrhea

• Surgical procedures

Hand hygiene is the #1 way to prevent peritonitis!

Resources

https://www.cdc.gov/cdctv/healthyliving/hygiene/fight-germs-wash-hands.html

https://www.cdc.gov/cdctv/healthyliving/hygiene/wash-your-hands.html

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Key points

• Because of the risk and seriousness of infection, everything that comes in contact with your child’s peritoneal cavity or the open ends of the dialysis catheter or dialysis lines must be sterile or germ-free.

• Germs are everywhere! You never know when you may come into contact with a bug that can cause illness. Most often bugs are spread into our bodies by our hands!

Teach-back moment

What is the most important thing you can do to protect your child from germs?

What is the difference between clean and sterile?

Should you use towels hanging in the bathroom or kitchen to dry your hands after washing prior to dialysis care?

True/False: When washing hands or using alcohol-based gel, it is important to clean under the fingernails, front and back of hands, between fingers and around thumbs.

What is the best way to prevent peritonitis?

According to the World Health Organization (WHO) guidelines, how long should hand washing take when done correctly with soap and water?

What do you need to do if you touch something that is not clean with your freshly washed hands, such as putting on your mask or scratching an itch?

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My questions:

My notes:


Notes

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Caring for Your CatheterIn this lesson you will learn:

• All about your peritoneal dialysis (PD) catheter

• How to keep your PD catheter safe after surgery

• How to care for your PD catheter at home

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Lesson 3: Caring for Your Catheter


Words to know

AdapterSmall metal or plastic piece connecting the PD catheter to the transfer set.

AntibioticA prescribed medicine to treat bacterial infections.

AntifungalA prescribed medicine to treat or prevent fungal (yeast) infections.

AntisepticPrescribed cleaning solution (for example, ExSept Plus).

CultureLab test to determine the type of infection.

Cuff (deep)Fabric piece around the catheter deep under the muscle.

Cuff (subcutaneous)Fabric piece around the catheter just under the skin.

DressingBandage with padding and adhesive to cover the exit site.

Exit sitePlace on the stomach area where the catheter comes out of the skin.

FibrinWhitish strings or strands of protein seen in the drain bags.

MiniCap/Stay-Safe capIodine-filled cap that protects the end of the transfer set.

OmentumFatty layer of peritoneum that can clog up the catheter.

Peritoneal dialysis (PD) catheterFlexible plastic tube inserted into the peritoneal cavity by a surgical procedure.

Peritoneal membrane or peritoneumSemipermeable membrane that lines the abdominal cavity and covers abdominal organs; it is a stretchy sac filled with many tiny blood vessels.

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Peritoneal cavityThe space between the abdomen wall and the organs in the abdomen where PD solution dwells.

Transfer setA 4- to 6-inch length of tubing that attaches to the PD catheter. The transfer set lets the catheter open and close.

True catheterA soft plastic tube that is surgically implanted in the peritoneal cavity. It is permanent unless removed in surgery.

Tunnel areaThe space between where the catheter exits the skin (exit site) and where it enters the muscle layers of the abdomen and into the peritoneum. The catheter can usually be felt under the skin in the tunnel area.

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What is a peritoneal dialysis (PD) catheter?

Your child’s catheter is their lifeline, because without the catheter you cannot perform PD exchanges. The exit site and catheter tunnel must be free of germs. If an infection happens, the catheter may have to be removed. Look at the exit site every day and call the dialysis nurse if you think your child has an infection.

A PD catheter is a flexible plastic tube that allows dialysate to enter and exit your child’s peritoneal cavity.

• The catheter is surgically placed in the body.

• The catheter passes through the skin layers before it enters the peritoneal cavity. This is called the tunnel area.

• There are usually two small fabric cuffs on the catheter. As the catheter heals, your child’s skin will grow into the cuffs. This prevents the catheter from slipping out and keeps germs out of the peritoneal cavity.

• The internal end of the catheter has many small holes. These holes allow the fluid to flow into and drain out of the peritoneal cavity.

Catheter in peritoneal cavity

Skin

Exit site

Tunnel area

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Care of the peritoneal dialysis catheter exit site dressing after surgery

• Ensure the dressing is secured on all four sides. Use surgical tape or Tegaderm as needed to keep the dressing in place.

• The catheter must be prevented from moving for proper healing to occur at the exit site. Secure the catheter to the dressing with tape.

• The clamp of the transfer set must remain closed at all times with a MiniCap or disconnect cap in place.

• No showering or tub baths are allowed until the site is totally healed. Only sponge baths are allowed. Keep the dressing covering the peritoneal dialysis catheter dry at all times. Do not submerge any part of the catheter or dressing in water.

A PD exit site with gauze dressing and a Tegaderm covering

• Until the exit site is healed completely, you will need to go to the dialysis center weekly so the dialysis nurse can do a sterile dressing change. You may also need to come in if the dressing becomes wet, soiled or is removed.

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When to call the unit

Call the Dialysis Unit if:

• The dressing becomes wet, soiled or falls off.

• There is any kind of break or hole in the catheter. If you discover a hole or break, place a clamp between the break or hole and your child’s abdomen first and then call the Dialysis Unit.

• Your child has a temperature over 100.5 degrees Fahrenheit.

• The MiniCap falls off the transfer set.

• Your child is not having daily bowel movements. Pain medicines and immobility can cause constipation.

Activity after surgery

Try to have your child rest as much as possible for the first 48 hours after the peritoneal dialysis catheter placement.

• Your child should not return to school until .

• Do not allow your older child to carry anything weighing more than 10 pounds for the 3 to 6 weeks after catheter placement. Your younger child should not carry anything weighing more than 5 pounds for 3 to 6 weeks after catheter placement.

• Your doctor and nurse will let you know when the exit site is healed enough for your child to return to normal exercise and activities.

• Your nurse will let you know if you need to continue using a dressing or not.

MiniCap

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What is a transfer set?

The transfer set is a small segment of tubing with a clamping device. It is placed on the end of the PD catheter by a trained professional, using sterile techniques.

A transfer set right out of the package

Checking your child’s catheter and transfer set

Check your child’s catheter, transfer set and exit site before and after every treatment.

• The exit site is where the catheter exits your child’s body (see pages 10 and 11).

• The skin around the catheter and tunnel area should not be red, painful, or swollen. It should not have any drainage or pus.

• The transfer set and catheter should be free of tears, cracks, slits and holes.

• The connection between the true catheter and the transfer set should be secure.

• The transfer set cap (MiniCap) should be in place and secured tightly.

• Your child’s transfer set needs be changed every 6 months or if the PD nurse has concerns. You don’t change the transfer set. The dialysis nurse will change the transfer set as needed.

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Taking good care of your child’s catheter

The catheter should be secured and unable to move at all times to prevent pulling and injury or damage at the exit site. Tape the true catheter to your child’s skin to prevent tugging and possible injury. We may recommend a PD belt (not pictured).

Transfer set

True PD catheter

The skin around the exit site will take up to 6 weeks to fully heal. Until the exit site is healed, it must stay completely dry and covered with a dressing. This means absolutely no showers or swimming. Sponge baths only are allowed during this time.

A dressing must always cover the exit site until it heals.

Once healed, your child may not need a dressing; your nurse will discuss with you the need for a dressing. If your child needs dressings, your child’s nurse will teach you how to perform a dressing change.

• Once the exit site is fully healed, your child may take a daily shower. No baths! (Bath water is considered dirty.)

• If your child is old enough to shower on their own, your PD nurse will teach them the best way to safely take a shower.

• Never apply lotion, oil or powder to the exit site.

• Never use scissors, pins or other sharp objects near the catheter. For example, do not use scissors to cut the dressing off. Any defect in your child’s catheter can cause an infection. This may lead to more surgeries to replace the catheter.

• No swimming or bathing is allowed in rivers, lakes, streams, baths, hot tubs or hot springs. The International Society of Peritoneal Dialysis does not recommend salt pools; only chlorinated pools.

• Swimming is allowed once the catheter is healed, but only in chlorinated pools or the ocean.

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When to call the unit

Call the dialysis nurse:

• If you notice any tears, cracks or openings in your child’s catheter. Do not start dialysis. Clamp the catheter as you were taught and call the dialysis nurse.

• If your child develops a fever or stomach pain.

• If there are warning signs of infection, such as pain, redness, swelling or pus along the tunnel area or exit site.

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Changing the dressing

Your dialysis nurse will teach you how to change the peritoneal dialysis catheter dressing using the steps below. The dressing should be changed as directed by your dialysis nurse, as well as any time it gets wet or dirty or is coming off.

1. Gather supplies.

• Antibacterial soap or ExSept solution• Antibiotic cream• Gauze• Cotton-tip applicator (Q-tip)• New dressing or tape • Tegaderm (if needed to protect

from soiling)• Masks

2. Maintain a safe environment.

• Pets should remain outside of the room.• Everyone in the room should wear a mask.• Close doors and windows, and turn off fans.

• Wash hands.

3. Remove the old dressing.

Never use scissors, pins or any other sharp objects to remove the dressing. When you pull off the dressing, make sure to support the catheter so it does not get pulled on.

4. Clean the site using cleanser as you were taught. Leave crusts or scabs in place to heal. Allow them to fall off naturally, as part of the normal healing process.

5. Apply a pea-sized drop of antibiotic cream to the exit site using the corner of clean gauze or a Q-tip.

Look at your exit site. Wash. Apply cream and secure

the catheter.

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6. Place a new dressing as you were taught. Make sure that the edges of the dressing stick securely to the skin. If the dressing is coming off, start over with a new dressing.

7. Secure the transfer set in a PD belt.

Troubleshooting catheter problems

Any child can have problems with the dialysis catheter, even if extra caution is used. Your child’s nurse will help you to understand common problems to watch out for and what actions to take.

Catheter trauma (rips, tears or comes out)

Cause • Not properly secured

• Pulling, rough-housing or contact sports

Symptoms • Pain at the exit site

• Skin tear near the exit site

• Blood draining from the exit site

• The catheter has migrated outward and the cuff has become visible

Action • Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.

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Exit site infection

Cause • Despite extra caution, some kids will still get germs into the exit site. These germs can cause a bad infection that will need to be treated with antibiotics.

Symptoms • Redness (irregular pattern)

• Swelling

• Pain at the exit site

• Drainage or pus from the exit site

Action 1. Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.

2. Obtain a culture if instructed by your nurse.

3. Start antibiotics and antifungal medication as instructed by the dialysis nurse and ordered by the dialysis doctor.

4. Clean the exit site carefully as instructed while it heals from the infection. During the early stages of the infection, it may be appropriate to cleanse the exit site and change the dressing more than once each day.

41



Tunnel area or cuff infection

Cause • Germs get into the tunnel area. Tunnel area infections can be very difficult to treat and clear.

Symptoms • Redness along the tunnel area or at the cuff may look streaky

• Swelling along the tunnel area or at the cuff

• Pain or tenderness along the tunnel area, especially when touching the tunnel area

• Rash or “pimples” along the tunnel area

• May or may not have drainage

Action 1. Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.

2. You may need to come to the hospital to have cultures drawn.

3. Start medicines (antibiotics) as instructed by the dialysis nurse and nephrologist. Children with tunnel area or cuff infections need treatment with antibiotics.

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Other catheter complications

A clog or clot in the catheter

Problem Fibrin or blood can collect in the tiny holes at the end of the catheter. The catheter may need to be manually flushed by a medical professional if the dialysis fluid cannot flow in and out.

Action Check the fluid for fibrin and blood and add a medicine called heparin to the dialysis fluid as needed.

Improper position of the catheter (migration)

Problem The end of the true catheter should be located in the lower abdominal cavity. Problems with the fill or drain can occur if the catheter tip has moved away from this area.

Action The doctor may order an X-ray to look at the location of the catheter tip. If the dialysis treatment is not working, or if your child is having severe discomfort with fills or drains, surgery may be required to move the catheter back into position.

Obstruction of the catheter

Problem The catheter shares the peritoneal cavity with many other organs, including a special tissue called omentum. The catheter can become wrapped in and obstructed by the omentum and stop working.

Action Surgery is usually required to relieve this type of obstruction.

The image shows proper placement of the catheter inside the abdomen.

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Constipation

Problem Constipation can be a problem for peritoneal dialysis patients. If constipation occurs, your child may have some stomach pain and hard stools. Even if stools appear soft or runny, constipation may still be present as softer stool passes around harder stool. Severe constipation can cause the bowel to press on the catheter and block it or keep the catheter from moving. In severe cases, constipation can cause peritonitis as bacteria from the bowel crosses over into the sterile peritoneal cavity.

Constipation can be caused from medicines, diet restrictions and lack of exercise.

Action To prevent constipation from becoming a problem, your child should:• Exercise each day.

• Eat fresh fruit and vegetables (as allowed).

• Eat high-fiber foods each day.

Your child may need to take medicine daily to help with constipation. The use of MiraLAX and/or stool softeners is common with peritoneal dialysis. If your child has not had a bowel movement within 2 days, you need to call your dialysis nurse or doctor. It is important to keep track of your child’s bowel habits and to call the doctor if constipation develops.

Exit site leak

Problem Dialysis fluid is coming out of the exit site, causing the dressing to become very wet with clear or yellow liquid. This may be due to incomplete healing around the deep cuff and tunnel area, and increases the risk for infection.

Action Stop dialysis and call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.

44



Remember

Peritoneal dialysis will not work without a functioning catheter. As caregiver, it is important to follow the guidelines below to ensure that it continues to work properly.

Wash hands often. Wash hands with liquid antibacterial soap (a pump bottle) and warm running water before cleaning the exit site, before connecting or disconnecting your child and before connecting any dialysis solution bags.

Secure the catheter. Always secure and stabilize the catheter to the skin to prevent tension or tugging. Your nurse will have suggestions for you on how to stabilize the catheter.

Keep sharp objects away from the tube. Never use sharp objects anywhere near the catheter. No scissors or knives should be used to remove tape or dressings.

Inspect daily. Inspect the exit site daily for signs of infections and the catheter for wear, cracks or tears. Ensure that the transfer set is securely connected to the true catheter.

Keep good care of the exit site. Carefully remove the old PD dressing, taking care not to disrupt the catheter exit site. Perform exit site care. It is important that the exit site be completely dry before placing a new dressing on it. Bacteria love moist, warm and dark places to grow.

Use good overall hygiene. Shower daily (after the exit site has healed), wear clean clothes and keep bedding clean.

45



Infants and young children

Infants and young children have a higher risk of infection and catheter breaks or holes. This is because:

• Their immune system is not as well developed as that of an older child.

• The catheter exit site is close to the diaper area.

• Infants and children who are crawling or scooting with their belly toward the ground are at high risk for injury to the catheter and exit site.

• Small children do not understand the importance of their catheter. You need to monitor their catheter for them.

• Young children are naturally curious and may want to play with or pull at the catheter.

To prevent infection and help keep your child’s catheter protected, all infants and young children must:

• Wear a dressing.

• Secure and immobilize the catheter against their tummy wall.

• Contain their entire catheter and transfer set beneath their clothing, preferably with a snug-fitting onesie.

• Do not tuck the catheter or transfer set into the diaper.

• If the transfer set gets any stool on it, immediately perform a cleaning procedure or transfer set change, as directed by your individual center.

• If the exit site is near a stoma or diaper, consider using a bio-occlusive dressing such as Tegaderm as a barrier.

There are many ways to help you immobilize the catheter. Mesh fabric called BandNet works well for many families. There are also several companies that offer PD catheter belts or other immobilizing products. Your child’s nurse can help connect you with the resources or share other ideas.

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Key points

• Peritoneal dialysis requires a soft plastic tube to be surgically implanted in the peritoneal cavity. This is called the “true catheter” because it is permanent unless removed in surgery.

• Some activity restrictions are required while a peritoneal dialysis catheter is in place. This might include handling pets. (Speak to your PD nurse about this.)

• Inspect the exit site and catheter with each dressing change.

• Your child’s exit site should not appear red, swollen, tender or be draining. Any of these could mean there’s an infection at the exit site. Call your nurse immediately if you suspect an infection.

• Inspect the catheter and transfer set daily. They should be free from cracks, tears or debris.

• Gently feel the catheter tunnel area and cuff daily. Note any swelling or tenderness. Secure the catheter to avoid tension or tugging.

• General hygiene is a very important part of your child’s catheter care.

• Never put anything on your child’s exit site such as lotion, powder or Vaseline. Only use approved gentamicin cream and antiseptic as directed by your PD nurse.

• Do not pick at or remove scabs from the exit site.

47



Teach-back moment

What is the most important step you do to prevent exit site infections?

When should you call the Dialysis Unit or your peritoneal dialysis nurse?

What are the signs of an exit site infection?

What are the signs of a tunnel area infection?

Point out the:

• Peritoneal catheter

• Adapter

• Transfer set

• Minicap/Stay-Safe cap

Practice a dressing change.

48



Notes

My questions:

My notes:


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PD catheter dressing change

Supplies ExSept or liquid antibacterial soap (Dial soap)

4" x 4" gauze

Dressing (Oasis or Island)

Tegaderm (if needed to protect from soiling)

Cotton tip applicator (Q-tip)

Masks (if instructed to use)

Antibiotic cream

Hand sanitizer

50



Nonshowering procedure1. Gather supplies.

2. Wash your hands.

3. Open the 4" x 4" gauze packages to have ready for the dressing change.

4. Put on clean gloves. This is to protect you – not your child.

5. Remove the old dressing and assess the exit site for redness, swelling, drainage, crusts and pain on pressure. Do this each time the dressing is changed.

6. Remove gloves and gel your hands.

7. Put on new clean gloves.

8. Soak the 4" x 4" gauze with liquid antibacterial soap and water or ExSept.

9. Place the 4" x 4" gauze (soaked with ExSept) on the catheter site. Leave on for about 1 to 2 minutes.

10. Using a new clean soaked 4" x 4" gauze, gently clean the skin at the catheter site.

• Begin cleaning at the catheter and work outwards using a circular pattern.

• Do not forcibly remove crusts or scabs.

• Crusts and scabs act as a natural barrier and should not be removed. Aggressive exit site cleansing should be avoided to minimize trauma to the exit site.

• Never go back to the catheter with this gauze.

11. Repeat as needed, usually 2 to 3 times. Let it dry completely.

12. Using a cotton tip applicator (Q-tip) or corner of clean gauze, apply antibiotic cream to the skin at the catheter site.

13. Put the dressing on over the catheter site.

14. Secure the catheter with tape or tuck into Flexinet or PD belt.

• Catheters should not hang freely.

• Ensure that the catheter is lying within the tract.

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Full showering procedure1. Gather supplies.

Leave dry supplies for dressing in a dry area to prevent them from getting wet.

2. Before showering, support the catheter by securing it to the abdomen above the belly button with tape or Tegaderm to prevent dangling of the catheter.

3. Begin showering by washing the hair and body.

4. Remove the old dressing and assess the exit site for redness, swelling, drainage, crusts and pain on pressure. Do this each time the dressing is changed.

5. Cleanse the area around the exit site and under the catheter with antibacterial liquid soap or ExSept on a clean washcloth (you will need a new washcloth for each shower) or use 4" x 4" gauze.

• Begin cleaning at the catheter and work outwards using a circular pattern. Rinse in the shower and allow water to run over and off the exit site.

• Do not forcibly remove crusts or scabs.

• Crusts and scabs act as a natural barrier and should not be removed. Aggressive exit site cleansing should be avoided to minimize trauma to the exit site.

• Never go back to catheter with this gauze.

6. After showering, thoroughly dry the exit site by patting with a clean, dry 4" x 4" gauze.

7. Dry the rest of the body with a towel.

8. Once the child is out of the shower, apply antibiotic cream or ointment sparingly to the exit site if ordered.

9. Allow the catheter to assume a natural lie on the abdomen, ensuring that there are no kinks in the tubing and that the connector/adapter is not lying on the exit site.

10. Cover the exit site with dressing.

11. Secure the catheter with tape or tuck into Flexinet or PD belt.

• Catheters should not hang freely.

• Ensure that the catheter is lying within the tract.

52





Steps for a Safe TreatmentIn this lesson you will learn:

• The 3 “Rs” to help prevent infection

• Clean versus sterile

54

Lesson 4: Steps for a Safe Treatment


Words to know

Aseptic techniqueThe way to make sure clean items stay “clean” and sterile items stay “sterile.” The goals of aseptic technique are to protect your child from infection and to prevent the spread of germs.

CleanMost germs have been removed, but not all of them. For example, washing your hands makes them clean, not sterile.

ContaminatedAn item that was sterile that touches something that is either clean or dirty. It is no longer sterile.

DirtyNot clean or sterile.

SterileFree from bacteria and other germs. For example: supplies in sterile packaging.

Steps for a safe treatment

Congratulations! You have learned so much. This lesson reviews what you have learned to perform a safe treatment for your loved one.

Here are 3 “Rs” to help prevent infection:

R

RRR

ealizeecognizeeact

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When germs get into the sterile area of the peritoneal cavity, they cause serious illness and injury to the peritoneal membrane. If the damage is severe enough, your child may not be able to continue PD.

Germs are invisible to the naked eye, but they live on everything! Your mouth, nose and skin have many germs.

The peritoneal cavity is the perfect breeding ground for germs! They love to grow in a dark, warm, moist, sugary environment.

Keeping things clean

Bed and clothing• Wash bed sheets and clothing, including sleepwear, regularly and whenever

soiled.

• If a sheet, bedding or clothing becomes wet, investigate to figure out where that liquid is coming from. It could be a loose connection of the PD catheter, disconnection or damage to catheter or tubing.

Bathing• Follow PD team instructions for how often your child can bathe.

• Only use a sponge bath to keep your child clean in the beginning when the PD catheter is placed. Once approved by your dialysis team, your child can shower.

• Secure the catheter to prevent pulling or tugging on it.

• Exit site care is best done at bathing time for ease and timing. Perform exit site care if the bandage is wet or loose, using the techniques you have learned.

Treatment environment • Keep floors, storage areas, cycler and work surfaces clean.

• Work surfaces must be large enough to perform dialysis tasks and store supplies.

• Work surfaces must be washable, so they can be cleaned with a disinfectant like germicidal wipes, diluted bleach solution or mild household cleaning products.

ealizeR

RRR

ealizeecognizeeact

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• Disinfect work surfaces before beginning tasks each day and any time they become soiled.

• Keep windows, doors and vents closed and fans turned off to prevent air flow during setup, connection and disconnection.

• Have masks (covering mouth and nose), hand sanitizer and emergency supplies readily available.

• Keep pets away during the setup of the cycler, during connection and disconnection from tubing and during dressing changes. Be careful with all animals around sterile supplies. Germs from pets can cause serious infections. Try not to allow pets to sleep with your child, especially cats (they typically like to play with the tubing and can bite a hole in it).

Clean hands! Clean hands! Clean hands!Hand hygiene is the most important thing you can do to prevent infection. Performing thorough hand hygiene reduces the number of germs on your hands. This action is so simple yet so critical.

Wash your hands with running warm water, soap and single-use towels or use hand sanitizer before beginning any PD process. This includes:

• A dressing change

• Cycler (APD) setup

• CAPD (manual) setup

• Connection process

• Disconnection process

Remember to perform hand hygiene:

• After applying mask to self and child.

• If you have touched anything other than PD supplies or setup.

• Immediately before opening your child’s catheter cap.

• Rewash using soap and water any time your hands have become visibly soiled.

Remove distractionsRemove potential sources of distraction from the room:

• Turn off cell phone ringer, TV and radio.

• Plan time to perform PD procedures when you will not feel rushed, distracted, too tired or hungry.

Bacterial growth from dirty hands versus clean hands on a petri dish

57



• Limit the number of people present. Everyone must wear masks and only those properly trained may perform PD processes.

• Ensure the room has good lighting.

• Wear your corrective lenses (contacts or eye glasses) if needed.

• Do not eat or drink in the treatment environment during aseptic procedures.

Remain sterileUse aseptic techniques to remain sterile.

Areas and items that must remain sterile:

• Your child’s peritoneum

• The transfer set tip (dark blue part)

• The inside of the transfer set and catheter

• The inside of the PD tubing and cassette

• Dialysate fluid inside each bag

• Dialysate connection under the cap or pull ring

• Inside area of the MiniCap (catheter cap)

• Inside area of the FlexiCap (tubing cap)

For items to remain sterile during setup:

• Perform hand hygiene at all appropriate times.

• Mask (cover mouth and nose) all people present.

• Decrease drafts and air flow by turning off fans and closing windows.

• Remove pets from the room during these procedures.

• Have needed and extra supplies handy.

• Reduce distractions.

• Prevent transfer of germs by touch with non-sterile things.

• Perform hand hygiene when moving from one task to another, like from preparing the environment to preparing supplies, or from cycler setup to the connection with the catheter.

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Recognize when something has been contaminated.

Daily tasks with high risk for contamination:

Adding medicine into dialysate bag

Connecting dialysate bag(s) to cycler cassette tubing

Connecting to treatment

ecognizeR

RRR

ealizeecognizeeact

59



Disconnecting from treatment

Other ways contamination can occur:

Constipation

• Accidental loosening or disconnecting of the tubing from the transfer set

• Accidental loosening or disconnecting of the transfer set from the catheter

• Loosened or lost catheter cap (MiniCap)

Cracks, tears or breaks in the catheter or transfer set

Punctures or damage to the dialysate bags or tubing

Pets playing with the tubing

Use of sharp objects (scissors) near catheter, tubing or dialysate bags

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React to contamination quickly.

Being disciplined means being alert, skipping no steps, and cutting no corners. Ignoring a contamination and failing to take action can result in peritonitis, a serious infection. Contaminations do happen. Always react on the side of caution.

When in doubt, throw it out.

• Expired product or supply.

• Damaged or wet package.

• Sterile item is dropped or touched.

• PD fluid is contaminated when adding a medicine through the medication port. (The medication port is the shorter line located on the solution bag next to the where the cycler tubing is connected to the solution bag.)

• You forgot to mask or perform hand hygiene before working with sterile supplies.

• You forgot to close doors and windows or turn fans off.

eactR

RRR

ealizeecognizeeact

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“Stop, Clamp and Call”

This chart helps explain what to do if contamination occurs.

What if… What you need to do

Contamination of the patient line, transfer set, cycler tubing or dialysate bags during dialysis.

• Place a clamp or close the white twist clamp on the transfer set between the contamination and the patient abdomen or exit site.

• Call the dialysis nurse immediately for instructions. Follow the directions provided to you by your dialysis nurse.

Contamination of the end of the transfer set.

or

The MiniCap falls off of the transfer set.

• Close the white twist clamp on the transfer set between contamination and the patient abdomen or exit site.

• Place the new MiniCap on the transfer set.

• Call the dialysis nurse immediately for instructions.

• You may need to come to the Seattle Children’s for further treatment.

The exit site looks infected. • Call the dialysis nurse immediately for instructions.

• You may need to come to Seattle Children’s for evaluation.

• Increase the exit site care to twice a day.

• Your child may need to start antibiotics.

Contamination of the dialysate bags or PD tubing before the patient is connected to dialysis.

• Throw away all of the contaminated supplies. Start over.

The transfer set has fallen off or come apart from the catheter, or there is a hole in the PD catheter.

• Place a clamp or close the white twist clamp on the transfer set between the patient and the hole/disconnection.

• Call the dialysis nurse immediately for instructions.

• You may need to come to Seattle Children’s for treatment.

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Preparing supplies for treatmentHave everyone in the room put on a mask.

1. Perform hand hygiene.

2. Prepare workspace and environment.

• Clean the cycler and workspace.

• Close the door to the room.

• Turn off fans and close vents.

• Do not allow pets in the room.

3. Gather supplies.

• Dialysis tubing/ cassette

• Drain bag(s)

• Manifold if needed

• Dialysate bag(s)

• MiniCap

• Mask(s)

4. Check each dialysate bag using SEAL (see the picture above):

Strength of solution concentration is correct

Expiration date and clarity of solution

Amount or size of dialysate fluid

Leaks from the dialysate fluid, or loose or missing pull tabs

5. Place dialysate bags properly for treatment.

6. Use the aseptic technique to connect dialysate bags to cycler tubing.

Expiration date

Amount in mL

Strength of solution

concentration %

Check for leaks

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Connection process

• When the cycler is finished priming and ready to connect, check that the dialysate has reached the end of the patient line.

• Close the door to the room. Turn off all fans and close vents. Have everyone in the room put on masks and perform hand hygiene.

• Make sure the transfer set is closed or clamped.

• Connect the transfer set to the patient line of the cycler using the method taught to you.

• Make sure the clamps are open and the transfer set is open.

• Start treatment.

• When finished, remove mask(s) and perform hand hygiene.

• Always be sure to have a disconnect cap or MiniCap in reach.

Ready

Set

Go

64



Disconnection process

When the treatment is finished:

• Close the door to the room. Turn off all fans and close the vents. Have everyone in the room put on masks and perform hand hygiene.

• Open the disconnect cap or MiniCap package.

• Using the aseptic technique, disconnect your child from the cycler as you are taught by your nurse.

• Apply the disconnect cap or the MiniCap to the transfer set.

• Securely immobilize the catheter using a PD belt, tape, dressing, Grip-Lok or ElastiNet.

• Measure vital signs, including blood pressure and weight, and record them as instructed.

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Drain fluid appearance

Note the characteristic of the drain fluid.

Is it:

Clear like apple juice (normal pee color)?

Cloudy like pineapple juice?

Colored or blood-tinged? Containing fibrin? (looks like jellyfish floating)

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Disposal

Tubing and bags• Empty all fluid in the toilet, tub or shower. The drain bags can be heavy and

awkward if full.

• Rinse in the shower or under the tub faucet for 1 minute. Place in the trash bag and tie off.

• Remove mask and perform hand hygiene.

Resources

World Health Organization hygiene video https://youtu.be/3PmVJQUCm4E

Baxter HomeChoice Cycler training videos https://www.youtube.com/playlist?list=PLxOc1MKY05MODOAp8jxa1Bz_crk--b5IH

Key points

• When germs get into the sterile area of the peritoneal cavity, they cause serious illness and injury to the peritoneal membrane.

• Hand hygiene is the most important thing you can do to prevent infection.

• Remove all possible distractions.

• Use the aseptic technique to keep things sterile.

• Recognize when something has been contaminated.

• When in doubt, throw it out.

• Check each dialysate bag using SEAL.

• Always check your drain fluid. Is it clear, cloudy, yellow, or pink, or does it have fibrin in it?

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Teach-back moment

What do you do when you contaminate the dialysis tubing setup?

What do you do when you contaminate the transfer set?

What do you do when you contaminate a bag of dialysate?

Practice setting up the cycler and connecting it to the transfer set.

Practice disconnecting.

68



Notes

My questions:

My notes:




PD Problem-SolvingIn this lesson you will learn:

• How to identify complications from infections and what to do

• How to identify other noninfectious complications and troubleshooting chart

70

Lesson 5: PD Problem-Solving


Complications from infection

Infection is always a concern of your child being on peritoneal dialysis because they have a foreign object (a PD catheter or central line) placed in their body. Germs can enter the inside of the body through the opening in the skin. It is very important to understand the signs and symptoms of an infection, and how to prevent an infection from happening.

Infections can be prevented! By washing your hands, using sterile connection and disconnection practices and being mindful of touch contaminations, you can greatly lessen the chance of infection. In the next few pages, you will find a list of signs and symptoms of trouble, possible causes and what to do if you are concerned your child might have an infection.

Note: A fever is always a sign to call the dialysis nurse. Be prepared to answer questions about your child that the nurse will ask to better understand the best next steps to keep your child healthy.

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My child has these symptoms• Fever

• Abdominal pain

• Fussiness (infants)

• Cloudy fluid (can you read writing clearly when you look through it?)

Possible cause

Peritonitis. Germs have caused an infection in the peritoneal cavity.

• Possible contamination of sterile supplies or work area.

• Can be from another infection (for example, a urinary tract infection or UTI).

Who to call

• Call the on-call kidney doctor immediately.

• Let the PD nurse know.

Treatment plan

• Get the cell count and culture of the PD fluid from your child’s peritoneal effluent.

• If your child still urinates, get a urinalysis and culture of their urine.

Your child will need:

• Antibiotics through an IV or through the peritoneum (IP) as soon as possible.

• A meeting with your dialysis team to discuss probable causes of the infection.

• Possible admission to the hospital for treatment.

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My child has these symptoms• Pain at the exit site

• Redness or swelling at the exit site

• Pus or drainage at the exit site or on the dressing

Possible cause

Exit site infection. Germs have caused an infection where the PD catheter exits the body.

Who to call



Treatment plan

• Culture any pus or drainage.

• Clean the exit site thoroughly and more often until it has improved.

• Your child:

• May be started on antibiotics, depending on the culture growth

• Could be admitted to the hospital for treatment

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My child has these symptoms• Pain along the tunnel area or at the cuff site

• Redness or swelling along the catheter

• Pus or drainage from the exit site or on the dressing

Possible cause

Tunnel area infection. Germs have caused an infection along the tunnel area of the catheter.

• Possible touch contamination or exit site infection may have introduced germs into the tunnel area.

Who to call



Treatment plan

• Culture of any pus/drainage.

• Possibly get an ultrasound to look for areas of fluid or pus collection near the tunnel area.

• Your child:

• May be started on antibiotics, depending on the culture growth

• May be admitted to the hospital for treatment

Note: Some germs are very hard to treat and may require catheter removal.

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My child has these symptoms• Cloudy or foul-smelling urine

• Fever

• Abdominal pain

• Pain with urination

Possible cause

Urinary tract infection (UTI)

• If your child pees, they are still at risk for a UTI due to poor wiping practices or urinary reflux (when urine doesn’t flow in the right direction).

• A UTI can lead to infections, sepsis and secondary peritonitis in PD patients.

Who to call


• Call to schedule an appointment with your primary care provider.


Treatment plan

• You may need:

• To come in for a visit and/or go to the emergency room

• To have a urinalysis/urine culture

• Treatment with antibiotics and may be admitted to the hospital

If your child gets UTIs often, they may be prescribed an antibiotic to take regularly to prevent infection.

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My child has these symptoms• Common cold symptoms (cough, congestion and nasal drainage)

• Ear infection (ear tugging and drainage)

Possible cause

Viral illness or ear infection

Who to call

• Call to schedule an appointment with your primary care provider.


Treatment plan

• Your primary care provider (PCP) may prescribe antibiotics if it’s a bacterial infection or over-the-counter medicines. (Be sure to make sure they are on an approved list for dialysis patients.)

• See the list of over-the-counter medications.

• Call your PD nurse if your child is started on antibiotics. Ask for an antifungal medicine. (Antibiotics can destroy natural protective germs so fungus grows more easily.)

Key points

• Infections can happen when your child is on peritoneal dialysis.

• Examples of PD-related infection are peritonitis, tunnel area infections and exit site infections.

• If your child has fever, abdominal pain, cloudy fluid or redness/swelling around the catheter, you should call your kidney doctor and let the PD nurse know.

• PD-related infection can be prevented by using good hand hygiene, using sterile connection/disconnection procedures and avoiding contaminations from touch.

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Complications not caused by germs

Other problems may occur while your child is on peritoneal dialysis. Many of these are problems with the catheter tubing or equipment. They can lead to infection, but if you act quickly, you may be able to prevent infection or make it less severe.

Catheter malfunctionThe 3 main connection points of the catheter are pictured below.

Touch contamination or problems with connection/disconnection can happen. In the next few pages, you will find a list of possible problems or issues that might happen and what to do.

PD catheter Baxter MiniCap Baxter transfer set

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The issueThe MiniCap cap accidentally came off.

Possible cause

• The MiniCap cap was loose.

• Your child may have removed it.

What to do

• Ensure the transfer set is closed or clamped.

• Replace with a new MiniCap immediately.

• Call the PD nurse.

Treatment plan

Remember the “3 Cs” (pictured below)

• Clamp

• Cover

• Call

Clamp Cover Call

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The issueMy transfer set came apart from the catheter.

Possible cause

• The child disconnected it.

• The catheter got caught or pulled.

What to do

• Place a clamp (pictured below) on the catheter to stop the drainage.

• Cover the end of the catheter with gauze and secure with tape.

• Do not complete any exchanges.


Treatment plan

• You will need to come in for a visit.

• Your child will need a new transfer set.

Clamp Cover Call

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The issueI accidentally touched or dropped the end of the transfer set when the cap was off during connection or disconnection.

Possible cause

• Possible distractions

• Hands slipped

What to do

• Make sure the transfer set is closed or clamped.

• Put on a new MiniCap.

• Do not complete any exchanges.


Treatment plan

• You may need to come in for a visit.

• Your child may need to be treated with antibiotics.

The issueThe dialysis tubing accidentally disconnected during treatment.

Possible cause

• The connection wasn’t tight.

• Your child disconnected it.

What to do

• Clamp the catheter or close the clamp on the transfer set.

• Do not start dialysis.

• If dialysis is already in progress, press Stop.

• Put on a new MiniCap as instructed by your PD nurse.


Treatment plan

• You may need to come in to the PD Clinic or the hospital for treatment with antibiotics.

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The issueThere is a crack or hole in my child’s catheter or transfer set.

Possible cause

• Your child may have chewed on or bitten the catheter.

• The catheter may have been repetitively kinked when secured.

• Pets could have bitten the catheter; this is why pets should not be allowed in the room where you do PD.

What to do

• Clamp the catheter between your child and the crack or hole.

• Cover the end of the catheter with gauze and secure with tape.

• Do not start dialysis.

• If dialysis was already in progress, press Stop.


Treatment plan

• You will need to come in for a visit.

• Your child will need a new transfer set.

• Your child may need to be treated with antibiotics.

Clamp Cover Call

81



The issueI accidentally touched the sterile connections when connecting the lines to my dialysate bags.

Possible cause

• Possible distractions

• Hands slipped

What to do

• Throw away supplies.

• Start with new sterile supplies.

Treatment plan

• No concerns if you throw away the contaminated bags or cassette.

The issueThere is fluid leaking from my child’s exit site.

Possible cause

• Poor healing

• Trauma or tugging on the catheter

What to do


Treatment plan

• You may need to stop dialysis or change your fill volume.


82



The issueI can see the cuff at the exit site.

Possible cause

• The catheter may have been pulled or tugged on.

• Infection

What to do

• Make sure the catheter is secured to the body.

• Use the wrap you have been provided with or tape if the wrap is not available.


Treatment plan

• You may need a new PD catheter.

The issue• There is fluid leaking under the skin.

• There is bulging around the exit site, tunnel area, belly button or other parts of my child’s belly.

Possible cause

• PD solution has leaked from the peritoneal cavity and collected under the skin.

What to do


Treatment plan


83



The issueThe PD fluid looks pink or bloody.

Possible cause

Hemoperitoneum

• New catheter

• Trauma (pulling or tugging)

• Menstruation or ovulation

• Infection

Only a small amount (1/2 teaspoon) of blood will turn the effluent cloudy or pink.

What to do


Treatment plan

• You may be instructed by the PD nurse to add heparin to the dialysate.

• Blood in the drain fluid can sometimes cause the catheter to clog.

84



The issue• There are white strands in the PD fluid.

• The machine shows this message:

No Drain or Slow Drain

Possible cause

Fibrin

• New catheter

• Irritation or trauma (a hit to the stomach or the catheter gets pulled on)

• Menstruation

What to do

• Add heparin (as instructed by PD nurse) to the dialysate fluid to prevent clotting.

Treatment plan

• You may need to treat the dialysate bags with heparin as instructed by your nurse to prevent clotting.

85



The issueThere is a bulging area at the belly button, belly or groin/private area.

Possible cause

Hernia

• A weak spot in the abdominal muscle is allowing an intestine or dialysis fluid to poke through the peritoneum.

• Can be common due to increased pressure in the abdomen from dialysate fluid

What to do


Treatment plan

• You will need to see the kidney doctor.

• Your child may need surgery to repair the hernia.

• You may need to lower your child’s fill volume to prevent added strain or pressure on the weakened muscles.

86



The issue• Shoulder pain and/or upper abdominal pain

• I see air in the dialysis tubing

Possible cause

Air in the peritoneal cavity

• Starting dialysis with unprimed tubing

• Loose connections or accidental disconnection during treatment

• Holes in the catheter or tubing

What to do

• Secure any loose dialysis tubing and PD catheter connections.

• Place your child with their hips above their head (Trendelenburg position) or knee-chest position to drain dialysate fluid from your child.


• If a hole or crack is found, see the instructions above.

Treatment plan


• Your child may need:

• To be treated with antibiotics

• The transfer set/tubing changed

87



The issue • The machine shows this message:

No Fill or Slow Fill

Possible cause

Obstruction

• Tubing can be kinked, twisted or clamped.

• Fibrin may be present (see the Fibrin section above).

Catheter position

• Child may be in a position that is kinking the catheter or blocking the flow.

• The catheter may have migrated (moved) to a new position, causing obstruction.

What to do

• Check the clamps and tubing for kinks or bends.

• Check your child’s position: change or turn, stand or roll side-to-side.

• Call the PD nurse if the fill takes longer than 15 minutes every cycle.

Treatment plan

• Your child may need imaging to check the catheter placement in the abdomen if there is obstruction or migration.

• You may need to add heparin to the dialysate for fibrin (see the Fibrin section above).

88



The issue • The machine shows this message:

No Drain or Slow Drain

Possible cause

Obstruction

• (See above.)

Catheter position

• (See above.)

Constipation

• Can cause fluid to be trapped, causing drainage problems

• Can contribute to catheter migration

What to do

• For obstruction or positioning, see above.

• For constipation: Make sure your child has a bowel regimen, which possibly includes MiraLAX and/or stool softeners, exercise and a high-fiber diet.

• If your child has not had a bowel movement In more than 2 days, call your PD nurse. See the Bristol Stool Chart on the next page.

Treatment plan

You may need to:

• Adjust your child’s bowel regimen medicines.

• Add more fiber-rich foods in your child’s diet.

• Encourage your child to exercise more.

89



Bristol Stool Chart

90



My child has these symptomsPain during fill

Possible cause

• Dialysate too cold

• Fill too fast

• Sensitive to solution

• Poor catheter position

• Fill volume may be too large

What to do

• Make sure the dialysate bags cover the heater thermostat button.

• Change your child’s body position.

• Have your child use the restroom.

• Call the PD nurse if your child has pain during every fill.

Treatment plan

• Your child’s prescription fill volume may need to change temporarily.

91



My child has these symptomsPain during drain

Possible cause

• Drain too fast

• Catheter irritation when the peritoneal cavity is empty

• Constipation

What to do

• Raise the cycler several inches.

• Change your child’s body position.

• Have your child use the restroom.


Treatment plan

• Your child’s prescription may need to change.

92



My child has these symptomsVomiting or gagging during or at the end of dialysis

Possible cause

• PD patients can have nausea, vomiting or gagging at the end of dialysis as they approach their estimated dry weight.

• Infants may have difficulty tolerating certain fill volumes with their feeds.

• Vomiting can be a symptom of peritonitis. Please assess fluid, abdominal pain and fever.

What to do

• Call the PD nurse or dietitian if your child is vomiting large amount of formula feeds every night/day.

• Call the PD nurse about redosing important medicines if your child is vomiting.

Treatment plan

• Your child’s PD prescription fill volume or feeding volume may need to be adjusted.

• Your child may need medicine (i.e., Zofran) to help them tolerate feeds or medicines.

93



My child has these symptomsSpit-up, vomiting or upper abdominal pain

Possible cause

GERD or reflux

• PD patients can have gastro-esophageal reflux (GERD) due to large amounts of fluid and pressure in the abdomen.

What to do

• Let your primary PD nurse and kidney doctor know about these symptoms at your next visit.

• Call the PD nurse if you are concerned about dehydration or weight loss.

• If your child has a fever and abdominal pain, call the kidney doctor immediately because these are signs of peritonitis.

Treatment plan

• You might need to come in for a visit to make sure your child is not getting too dry or losing weight.

• Your kidney doctor may prescribe a medicine to help with acid production in the stomach to stop some of the symptoms of reflux.

94



My child has these symptoms• Not ultrafiltrating as much

• PD adequacy is decreasing

Possible cause

Loss of peritoneal membrane function due to:

• Multiple abdominal surgeries, causing scarring or adhesions (a band of scar tis

Peritoneal Dialysis at Home...You will hear some medical terms used when learning how dialysis...

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