Placing PD Catheters - a Placing PD Catheters - a nephrologist's perspectivenephrologist's perspective

Nephrology Dept – 1971 > 25000 HD sessions annually > 75 transplants annually

Overview

Introduction

What does it involve?

Challenges

Opportunities

PD catheter insertion procedure

Our learning curve

Introduction incidence of CKD in developing countries Pts - inadequate access to HD & Tx - CAPD - obvious

preferred modality for renal replacement therapy

Laparotomy / direct visualization - conventional mainstay of access placement

Necessitates availability of surgeon / anaesthetist cost / duration of hospital stay

IntroductionPD catheter placement techniques

Laparotomy / open surgicalLaparoscopyPeritoneoscopyFluoroscopyBlind

Percutaneous

Introduction Percutaneous Blind PD catheter placement - 1984

[Nakanishi T et al. Nephron 1984;37:128–132]

popularity in the past decade

What does we need? Reasonably spacious area –

minor operating room in dialysis area Clean room with enough elbow space

Instruments / implements – most easily obtained

Willing nephrologist – usually the toughest part !!!

Challenges Obsession with aseptic / universal precautions

Skill of PD catheter placement – very easily acquired!

Knowledge of complications of technique Blind procedure Complications - laceration of viscera, bleeding, perforation Prompt recognition urgent surgical consultation /interventionWhat the mind does not know the eye does not see!

Challenges Co-operation / support of surgical colleagues –

imperative

Immediate consultation & intervention where needed

Challenges One of our earliest patients - Jejunal mesenteric artery

laceration – severe bleeding shock Multiple transfusions Urgent laparotomy & ligation of bleeder – save life

Challenges

Paramedian approach – Inf epigastric A injury reported

2% Bleeding in a case series (6/292)

Messana JM Injury to the Inferior Epigastric Artery Complicating Percutaneous Peritoneal Dialysis Catheter Insertion.Perit Dial Int. 2001;21: 313-15.

Mital S, Bleeding complications associated with peritoneal dialysis catheter insertion.Perit Dial Int 2004;24:478–80.

Challenges Clues to bleeding

Blood tinged PD effluent fluid Drop in blood pressures ± tachycardia

[BRADYcardia likely to be vagal response to pain]

Check Hematocrit If hematocrit up to 2% Conservative Rx sufficient Heparinization of PD fluid is necessary to prevent cath clotting

Farooq MM Peritoneal dialysis: An increasingly popular option. Semin Vasc Surg 1997;10:144-50.

Challenges One patient – upper abdominal distension &

obliteration of liver dullness bowel perforation

Laparotomy – self-sealed – no repair needed

Bladder injury pre-procedure bladder emptying or catherization

Blunt tip

Cutting edge

Challenges Constant attempts to refine / simplify technique

Using the Veress needle to fill peritoneal cavity

Attempt to decrease time taken for procedure Initially about 2 hours for uncomplicated cases Now less than 45 minutes (fastest 20 minutes)

Smaller incision sizes Initially 2-3 cm now < 1 cm in length – more cosmetic

Training of colleagues all become adept

Challenges

Opportunities No break-in period needed

51 consecutive pts - straight double-cuffed Tenckhoff cath Only 1 pericatheter leakage (1.9%)

Opportunities Time taken

Cost of procedure – saving of Rs. 15000 (~$ 300)

Hospital stay – reducing costs further

Non-requirement of surgical suite No Anaesthetist / Surgeon required Use for uremic CKD 5 patients as acute PD

16 patients in our initial cohort

In the Intensive care for renal replacement therapy

Opportunities Ideal procedure for HIV / HBV / HCV infected pts

Resource-constrained settings Already overstretched OR facilities Lack of personnel for one-to-one therapy 11 patients in our initial cohort

In those with past abdominal surgeries??? CONTRAINDICATED in those with previous abdominal surgery

Laparoscopy preferred – direct vision / adhesiolysis if needed

One patient with laparoscopic cholecystectomy + tubectomy

Opportunities

Peppelenbosch A Peritoneal dialysis catheter placement technique and complications. NDT Plus 2008;1 [Suppl 4]: iv23–8.

Successful percutaneous CAPD catheter insertion in a patient with past abdominal surgeries. Varughese S et al Saudi J Kidney Dis Transpl. 2012

Four patients - laparoscopic cholecystectomyOne patient - past intra-abdominal abscess in right lower quadrant of abdomen for which

laparotomy & surgically drainage had been doneOne patient – appendicectomyOne patient - lower segment caesarian sectionOne patient - right femoro-femoral arterio-venous graft was constructed due to

thrombosis in all vessels; very large perigraft collection occupying entire right lower quadrant left CAPD cath

Four patients – tubectomies (including 2 with past laparoscopic cholecystectomies)

Opportunities

Percutaneous PD catheter placement can be attempted in

patients with previous abdominal surgeries where risk of

peritoneal adhesions is minimal

Opportunities

Our initial insertion experience

From November 2007 to 2011 Feb Number of patients: 119 Age: 50.5 yrs (range 23–74 yrs) 64 males

Technique: Trocar and cannula or peel-away sheath using Seldinger technique

PD Catheter Insertion Procedure

Secret ingredient = Grace of God!

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End result!

Our learning curve!

119 patients

Poor flow (14) Surgical repositioning (9)

Cath Removal (2)

Percutaneous repositioning (3)Current number = 295

Complications encountered Intra-abdominal bleed - 2

Laparotomy required - 1[Varughese S et al. Jejunal Mesenteric Artery Laceration Following Blind Peritoneal Catheter Insertion Using the Trocar Method Perit. Dial. Int. 2010 30: 573-574.]

Conservative Rx - 1

Leak - 1 Suspected perforation - 1

Conclusions Percutaneous PD catheterization is a simple & safe

procedure – done by nephrologists

Easy training and practice makes one adept at it

Several challenges and opportunities for the nephrologist

Challengeso Willingness to learn and do

o Surgical team co-operation

o Aseptic / universal precautions

o Skill of PD catheter placement

o Knowledge of complications

o Refine / simplify technique

o Training of colleagues

o Attempt to decrease time

o Smaller incision sizes

Opportunities No break-in period costs, time taken, hospital stay No surgical suite, anesthestist, surgeon needed Procedure of choice in pts with HIV, HBV, HCV Use for uremic CKD 5 patients as acute PD Use in Intensive care for renal replacement therapy In pts with past abdominal surgeries with minimal risk

of peritoneal injury