Peritoneal dialysis: Access, Techniques, Complication by Nursesnote

 Peritoneal dialysis Procedure 

A slow form of dialysis, utilising the peritoneum as the dialysis membrane. The technique does note require complex equipment although continuous flow techniques do require continuous generation of dialysate. Treatment is labour-intensive and there is considerable risk of peritoneal infection. 

Access

For acute peritoneal dialysis, a trochar and cannula are inserted through a small skin incision under local anesthetic. The skin is prepared and draped as for any sterile procedure. The commonest approach is through a small midline incision 1cm below the umbilicus. The subcutaneous tissues and peritoneum are punctured by the trocar which is withdrawn slightly before the cannula is advanced towards the pouch of Douglas. In order to avoid damage to intra-abdominal structures, 1-2L warmed peritoneal dialysate may be infused into the peritoneum by a standard, short intravascular cannula prior to placement of the trocar and cannula system.  If the midline access is not available, an alternative is to use a lateral approach, lateral to a line joining the umbilicus and the anterior superior iliac spine (avoiding the inferior epigastric vessels )

Techniques of peritoneal dialysis 

Warmed peritoneal dialysate is infused into the peritoneum in a volume of 1-2L at a time.  During the acute phase, fluid is flushed in and drained continuously (i.e. with no dwell time). Once biochemical control is achieved, it is usual to leave fluid in the peritoneal cavity for 4-6h before draining. Heparin 500 IU/L ) may be added to the first six cycle to prevent fibrincatheter blockage. Thereaftet, it is only necessary if there is blood or cloudiness in the drainage fluid.

Dialysate for peritoneal dialysis 

The dialysate is a sterile balanced electrolyte solution with glucose at 75 mmol/L for a standard fluid or 311 mmol/L for a hypertonic fluid(used for greater fluid removal ). The fluid is usually potassium - free since potassium exchanges slowly in peritoneal dialysis although potassium may be added if necessary.

Complications of peritoneal dialysis

• Fluid leak
• Catheter blockage
• Infection
• Hyperglycaemia
• Diaphragm splinting

Infection Treatment and Management

It is possible to sterilise the peritoneum and catheter by adding appropriate antibiotics to the dialysate. Suitable regimens include:

• Cefuroxime 500mg/L for two cycles, then 200mg/L for 10d.
• Gentamicin 8mg/L for one cycle daily