PD: Troubleshooting

Concern for peritonitis - cloudy effluent, abdominal pain, fever. Sometimes bloody effluent merits workup too.

• Have family collect PD fluid sample for cell count, gram stain, culture

• Presumed peritonitis if PD fluid WBC >100/mm3 with >50% PMNs

• Consider previous episodes of peritonitis in decision for antibiotic (gram negative or gram positive coverage)

• Empiric choice usually IP cefepime and/or vanc. If patient ill appearing and being admitted, can give IV abx dose in ED as it often takes a long time for PD and antibiotics to be set up once admitted

• Refer to ISPD (International Society of Peritoneal Dialysis) guidelines for peritonitis

• If starting antibiotics for peritonitis or any other infection or as ppx, also start fungal prophylaxis - Nystatin 10,000 units/kg PO daily for duration of antibiotics and for 7 days afterwards

• PD samples [LPCH Policy]

• Standard protocol is to dwell PD fluid for 1 hour. PD sample is 60 mL (e.g., 55 mL for culture, 5 mL for cell count) or 80% of fill volume (FV), whichever is less

  • For small fill volumes (i.e., unable to draw off 60 mL): use 2 mL for cell count, the rest for culture

Refractory peritonitis

• PD catheter should be removed if:

  • [***ISPD guidelines]

• Consider etiologies:

  • Biofilm

  • Fungal infection

  • Poor adherence

  • Catheter related infection (usually due to infection of the subcutaneous tissue around the catheter cuff)

    • Refractory exit site infection

  • Bowel perforation

  • Abscesses

  • Consider other possibilities of cloudy fluid:

    • Eosinophilic peritonitis (e.g., allergy to IP drug) - rare

Hypogammaglobulinemia - common

• Has not been shown to be associated with peritonitis [Lalan 2017]

Vomiting - fairly common for PD patients, so if they’re calling, triage why it might have worsened

• Polyuric - no fluid restriction so can give additional saline through GT instead of formula

• Do they need an infectious workup?

Hypotension - typical for polyuric patients, but some anuric patients who haven’t been eating well or have had a lot of vomiting.

• Polyuric - no fluid restriction so can give additional saline through GT instead of formula

• If not polyuric, be more gentle about fluids.

• Should have a sliding scale to use less dextrose fluid for PD

• Can call about weights and BP trend over the last few days.

• PD nurses can also follow-up in AM. Consider adjusting sliding scale if we think PD is being too aggressive.

Drain pain/not draining well

• Causes and management

  • Constipation/obstipation, ileus: laxatives

  • Malposition: radiograph

  • [***]

• Further out from surgery:

  • E.g., positionality (able to drain on left but not right)

  • KUB to evaluate catheter tip position

Management of catheter tip migration

• Fluoroscopic guidewire, stiff rod [***]

  • Unlikely to be successful if entrapment of the tip of the catheter in a small peritoneal space

• Laparoscopy [***]

• Prevention of migration:

  • Can be prevented with rectus sheath tunneling, deep cuff suture

  • Swan neck catheters associated with less migration in single center retrospective study

  • Mild malposition can be caused by constipation and treated with bowel regimen

  • Urgent start PD is associated with increased incidence of migration

Constipation management:

• Medication review

  • Any narcotics?

• Comorbidities

• Previous BM

• Goal: 1-3 soft BM every day

• Proactive stool softeners

• Avoid fleets enema or magnesium-based laxatives

• Oil based or lactulose

  • Other types of stimulant laxatives can increase risk of bacterial transmigration and peritonitis [***]

Lost dwell time (i.e., prolonged drain time)

• Catheter tip migration

• Radiograph or fluorscopic intraperitoneal [***]

• Lysis of adhesions

  • Adhesions can form compartments or loculations that preclude free flow of PD fluid

  • Usually found in individuals with previous abdominal surgery or trauama

  • Extensive peritoneal scarring or adhesions usually prevents successful PD

  • Laparoscopy is the [***]

Prevention

• Clinic visits:

  • Inquire about preoperative bowel habits

  • Review intraoperative report to see if it was a difficult insertion

  • Observe the drain and well times during training

  • Inquire about the loss dwell time on cycler/drain time on CAPD at home

• Monthly quality assurance:

  • Review access related events, outcomes, machine and infrastructure

  • Address team member concerns and boost morale

  • Identify target patients for drop out (if any) and discuss modality transitions

Pain specifically during drain phase, not necessarily during fill or dwell

• Evaluate for constipation and consider increasing bowel regimen

• Evaluate for catheter position. KUB will help

Catheter won't flush

• If recent catheter placement

• Inflow problems suggest obstruction of catheter

• Most common causes are fibrin strands or thrombus in the catheter

• Obstipation is common too

• Steps:

  • Power flush

    • 30 mL saline or 500 mL dialysate

  • KBUS to assess for catheter migration and to evaluate stool burden

  • If significant stool burden and/or history consistent with constipation, needs bowel regimen

    • Oral osmotic agents are preferred (e.g., lactulose, polyethylene glycol, sorbitol)

      • Stimulant laxatives (bisacodyl) and saline enemas are reserved

    • [***preoperative and postoperative management]

  • Ask about previous exchanges (presence of fibrin, cloudy or bloody effluent)

    • If fibrin present:

      • Heparin instillation:

        • Concentration: 500 U/L vs 2500 U/L or 7500 U/L [***adults]

      • Thrombolytics:

        • Infuse alteplase 0.5-1 mg/mL into PD catheter at a volume equal to the priming volume [***]

        • Dwell 1-4 hours

        • May take 2-3 attempts

  • Referral to IR for wire manipulation or to surgery [***]

Concern for PD fluid leak:

• POCT UA dipstick test: glucose >2000 is highly suggestive of (+) PD leak.

• LPCH: Dipsticks can be found in PD office. Bedside RNs are not signed off to do POCT UA dipstick test, but kidney fellows can test.

TPAing PD catheter [LPCH Policy]

• Avoid TPAing fresh PD catheters.

• Have pt with full fill before instilling TPA.

• LPCH: Please review policy to calculate priming volumes for TPA dose. Please contact PD coordinator if you need help calculating TPA dose.

https://learn.openpediatrics.org/learn/course/internal/view/elearning/2795/complications-of-peritoneal-dialysis