Peritoneal Dialysis Catheter Medical Insertion Programme ...
Transcript of Peritoneal Dialysis Catheter Medical Insertion Programme ...
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Peritoneal Dialysis Catheter
Medical Insertion Programme
South West Home Therapies Conference
March 2016
David Lewis
Consultant Nephrologist
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A personal physician inserted peritoneal dialysis catheter journey
Conflict of interest: I have received honoraria from Baxter Healthcare
http://www.heardfamilyhistory.org.uk/Photo%20Gallery/Exeter/EX78.html
Killingbeck Hospital, Leeds
Post cardiac surgery/bypass AKI
Presumed recoverable
Ventilated on ICU
Hospital 4 miles from renal inpatient site
Junior renal registrar travel to site
Hard cannula “stab” PD
Royal Devon and Exeter Hospital
Devil’s Slide, Lundy Island
Standard issue Renal Registrar transport, 1990’s
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Background
• Large, innovative PD service
• Differential tariff HD lines vs fistula
• Borderline financial viability NHS
haemodialysis
• Maintaining strong home therapy
option for patients
• Mortality associated with
haemodialysis on lines
• Line related infection : MRSA
MSSA
• Failed permanent access
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The ageing dialysis population: PD, HD and multi-morbidity
• Giving an alternative to hospital HD
• Time spent in travel and treatment
• Tolerate HD: fluid shifts, BP?
• Clinical and moral dilemma permanent access
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PD catheter insertion techniques
• Percutaneous needle-guidewire insertion without imaging
• Percutaneous needle-guidewire insertion with imaging
• Peritoneoscope
• Surgical – mini laparotomy
• Surgical - laparoscopic
• Simple technique, simple organisation, start with thin non-scarred abdomen
• Requires angio lab / IRMER training
• Kit to buy, pain of air
insufflation, ?conscious sedation
• General anaesthetic, simple abdominal wall surgery
• GA, kit, complexity, training, surgical enthusiasm
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Medical and Surgical insertion Medical • Choice of avoiding general
anaesthetic (GA) • Patients too sick for GA • Immediate use (supine automated
PD) • Short preparation time – bowel
clearance • Minor surgical scars acceptable
(simple appendix, caesarean, kidney transplant)
• Higher BMI with experience • High potassium, anaemia, AF • Much easier to manipulate and
remove • Avoidance of central lines –
infection, future stenoses • Medical ownership – exit site • Cheaper/more flexible frees up
theatre
Surgical • Previous complex abdominal surgery not
absolute contraindication • Controlled surgical environment • Adhesions and omentum divided/resected • Simultaneous hernia repairs • Easier to direct the catheter into the pelvis
(although not fool proof) • Kidney patients high risk general anaesthesia • Patients with advanced CKD or on HD, high
potassium, fluid overload, anaemia likely to be cancelled
• Surgical time zero sum game – reserve for complex cases or vascular access
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Elective AAA repair
Vagotomy and pyloroplasty + R nephrectomy
Small umbilical hernia
Patient says renal stone surgery No history of bowel surgery
Do you think tenckhoff insertion is possible?
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What are the important factors?
• Indications
• Contraindications
• relative
• absolute
• Anatomy
• PD catheter
• Procedure
• who
• where
• when
• Complications
• governance
• Post procedure ward care
• Discharge follow up
• Community team
• assisted APD
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Preparation for dialysis clinic outcomes
• Consent: surgical pathway document
• Explanation of procedure and PD catheter/dressing
• PD options: CAPD, APD & assisted APD
• History and examination
• Anaesthetic risk assessment-referral to pre-op/consultant anaesthetist
• Surgical or percutaneous approach
• Pre-operative optimisation medications / BP/ fluid status
• Community team visit: laxatives,body wash
• patient concerns, continuity of care,
• Minimised cancellations
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Post procedure
• Eat and drink
• Can start immediate APD 1litre fill
• Dry abdomen while mobilising
• Laxatives
• Avoid codeine
• Don’t touch the dressing, keep dry
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Salford Peritoneal Dialysis Pathway
Advanced Kidney Care Service clinic
Late referral from General Nephrology or Transplant clinics
Unplanned start
Preparation for PD clinic MDT
Elective percutaneous PD insertion list fortnightly
AKCS for Transplant clinic
Ad hoc catheter insertion
APD for 4 hours
Remain on ward APD
Discharged home nurse follow up
Home training
AKI
CKD team home visit
Assisted APD
PD nurse home visit
Catheter manipulation
Day case automated PD in Renal Unit Short Stay
Elective Insertion
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PD for a multi-morbid & ageing dialysis population
• Giving an alternative to hospital HD
• Time spent in treatment not travel
• Tolerability, diet and fluid balance
• Assisted APD for planned and unplanned start
• aAPD infrastructure
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Salford medical and surgical peritoneal dialysis catheter insertion by quarter, 2011-2015
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Repositioning of a displaced catheter: guidewire down existing catheter to avoid a new puncture of the
peritoneum, adopted from Elaine Bowes/Hugh Cairns Kings
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Central lines – not a victimless crime
Occluded left brachiocephalic vein
12mm balloon angioplasty
Return of patency but likely to recur
Occluded right brachiocephalic unable to recannulate, left IJ line in situ
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Setting up a service
• Operators: 2 consultants & ANP
• Assistant: Adele
• Location: ward procedure room
• WHO Surgical checklist
• Protocol:
– bowel prep/antibiotics/sedation/analgesia
– flucloxacillin IV 1G, paracetamol IV 1G, lorazepam sublingual 1-2mg
• Ultrasound: empty bladder/abdominal wall
• Governance: surgical back up
• Teaching/support: Baxter access academy, peer support, Liverpool PD
catheter insertion course
• Ward post procedure care: adjusted APD regime
• PD nursing structure follow up: patient wellbeing, catheter and wound review
• Assisted APD programme
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Case 1: unknown
CKD 5
• 51 years old female one year history non-specific symptoms, fatigue
• eGFR 3, Hb 51, small kidneys on USS
• Transfusion, transferred local hospital Friday morning
• Well, few comorbidities, family, works
• Dialysis modality discussed agreed PD
• Accelerated preparation: enema rather than picolax
• Hb 75 urea 70, avoided further transfusion
• Successful procedure Friday afternoon immediate APD
• PD until bowel obstruction from rare tumour
• Fully resected, surgical reinsertion after a period on HD
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Case 2: failed HD
access
• 58 year old female, multiple co-morbidities, hysterectomy
• Haemodialysis with multiple failed permanent access
• Progressively difficult central lines
• Unable to dialyse admitted from unit
• Ward inserted percutaneous catheter used immediately
• Discharged home on PD • Trained at home post
discharge
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Case 3: bridging or
permanent?
• 73 year old male
• CKD 5 post-infective GN
• Due for AV fistula formation
• Admitted from clinic uraemia
symptoms and fluid overload
• Agreed PD pending permanent
HD access formation
• Catheter inserted, home on PD
• Successful home therapy
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Case 4: failed transplant
and surgical risk
• 50 year old female kidney transplant
• Aware slowly failing but acute deterioration
• Chronic hypotension
• Previous peritoneal dialysis wished to restart
• Admitted acutely planned percutaneous PD catheter
• Fast AF at time of insertion
• Clinical decision to continue procedure
• Catheter inserted and used immediately
• Cardiac review, rate control
• Discharged home on PD, retraining by community team
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Large PD programme, not at the expense of home HD
• Unit HD 367
• PD 101
• Home HD increasing
• NxStage platform increasingly popular
• 20 patients undertaking home HD beginning March 2016
• Predicted 24/25 by end March 2016
• 13 on NxStage
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Medical PD catheter insertion
• Improves choice
• Role in frail/elderly, unplanned
start, AKI
• Stronger home therapy
programme
• Accelerated discharge
• Central line avoidance
• Role for assisted APD
• Connect and disconnect before
training
• Drop in APD?
• Thanks to those helped
establish and improve service
• Thanks MDT maintaining high
quality service
27 25/04/2014 11:56 25/04/2014 16:15
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