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Acute peritoneal dialysis (PD) in the PICU. Constantinos J. Stefanidis. “P. & A. Kyriakou” Children's Hospital, Athens, Greece. HD. CRRT. or. ARF. Neonates and infants. Early referral. PD. Choice of dialysis in ARF. Late referral life-threatening hyperkalemia or severe volume overload.

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acute peritoneal dialysis pd in the picu

Acute peritoneal dialysis (PD) in the PICU

Constantinos J. Stefanidis

“P. & A. Kyriakou” Children's Hospital, Athens, Greece

slide2

HD

CRRT

or

ARF

Neonates and infants

Early referral

PD

Choice of dialysis in ARF

Late referral

life-threatening hyperkalemia or severe volume overload

C J Stefanidis 2002

slide3

Were used as the primary means of acute renal replacement therapy in a nearly equal percentage of centers

Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3

Choice of dialysis in ARF

PD

HD

CRRT

C J Stefanidis 2002

slide4

Preferential use of PD and CRRT

PD

CRRT

Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3

C J Stefanidis 2002

slide5

When to start PD in ARF ?

  • Symptomatic uraemia
  • Hyperkalaemia
  • Volume overload
  • Severe metabolic acidosis
  • ( refractory to medical treatment)

Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831

C J Stefanidis 2002

slide6

When to start PD in ARF ?

S. creatinine and blood urea are not primary indications for dialysis unless they relate to mental status changes

Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831

C J Stefanidis 2002

slide7

When to start PD in ARF ?

There are essentially no data

In the absence of data it is advisable to start dialysis at the earliest sign that it may be needed

Flynn JT. Pediatr Nephrol 2002;17(1):61-9

C J Stefanidis 2002

slide8

Benefits of PD

PD still remains the modality of renal replacement therapy of choice in many pediatric nephrology centers, because:

1. it requires minimal equipment and infrastructure

2. it is fairly inexpensive compared with other modalities

3. it is relatively easy to perform and

does not require additional nursing personnel.

Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9

C J Stefanidis 2002

slide9

Benefits of PD

1. Less haemodynamic instability

Children with ARF who are hypotensive, requiring vasopressor support and children with multiple organ failure are successfully managed with PD

2. Avoidance of systemic anticoagulation

3. Avoidance of angioaccess

Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9

C J Stefanidis 2002

slide10

Disadvantages of PD

1. Slower correction of metabolic parameters

lower urea clearances

2. Lower ultrafiltration

3. Risk of peritonitis

Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9

C J Stefanidis 2002

slide11

Efficiency

Volume

Anticoa-

Use in hy-

control

gulation

potension

Moderate

Moderate

No

Yes

HD

Moderate

High

No

Yes

CAVH

Moderate

Low and

Good

No

Yes

variable

CVVH

Moderate

High

Good

Yes

Yes

CVVHD

High

High

Good

Yes

Yes

Choice of dialysis in ARF

Complexity

PD

Low

Intermittent

Thadhani R et al Acute renal failure. N Engl J Med 1996; 334: 1448-1460

C J Stefanidis 2002

acute pd in the picu
Acute PD in the PICU

Choice of dialysis treatment

PD catheters for ARF

Prescription of PD in ARF

C J Stefanidis 2002

trocath catheters
Trocath catheters
  • Their prolonged use (> 3 days) was associated with a significant risk of:
  • leakage
  • malfunction
  • peritonitis

A major complication was viscus perforation.

In our days very few centers use these catheters

C J Stefanidis 2002

acute pd catheters
Acute PD catheters

Trocath catheters

Percutaneus guidewire inserted catheters

Tenckhoff catheters implanted under general anesthesia

C J Stefanidis 2002

percutaneus guidewire inserted catheters
Percutaneus guidewire inserted catheters

Site of introduction: Level of umbilicus lateral to the rectus sheath (newborns)

or any where along a line parallel to the rectus sheath.

Local anesthetic

C J Stefanidis 2002

percutaneus guidewire inserted catheters1

Angiocath

18 G

Insertion of Angiocath 18 G

Flushed with 5 ml of N/S and aspirated to ensure bowel content is not retrieved

Percutaneus guidewire inserted catheters

C J Stefanidis 2002

percutaneus guidewire inserted catheters2

The Angiocath 18 G is removed

Priming of the abdomen is not essential

Percutaneus guidewire inserted catheters

The wire is advanced through the needle in the peritoneal cavity (3-4 cm)

Seldinger (Acta Radiologica, 38, [1953], 368-376)

C J Stefanidis 2002

percutaneus guidewire inserted catheters3

The catheter is threaded around the wire and is forced in the peritoneal cavity with a «screwing action»

Percutaneus guidewire inserted catheters

3-4 mm incision around the wire.

In newborns is not recommended `

The wire is removed

The catheter is taped to the skin

Seldinger (Acta Radiologica, 38, [1953], 368-376)

C J Stefanidis 2002

femoral vein catheter for neonates

It was used in 10 neonates.

Intraperitoneal bleed : 1 neonate

Dialysate leak: 1

Catheter blockade: 4

Incidence of peritonitis: 1

Kohli HS et al Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol 1999 Apr;13(3):241-4

Femoral vein catheter for neonates

Guide wire-inserted femoral vein

polyurethane catheter

(Medcomp-pediatric)

14 G 13.5 cm

3 sideports

C J Stefanidis 2002

slide20

Percutaneus guidewire inserted catheter

Cook catheter

8.5 French 8 cm

44 sideports

http://www.cookgroup.com/cook_incorporated/pdf/CDB11.pdf

C J Stefanidis 2002

slide21

5 French 5.5 cm

5 French Cook PD catheter

  • 29 infants
  • age 4.5 +/- 1.3 months
  • weight 4.8 +/- 0.5 kg
  • Complications:
  • inadequate inflow in one case
  • bleeding in one case
  • accidental removal in one case

Duration of the placed catheters was 9.9 +/- 2.7 days, without the problems associated with the use of a stiff catheter

Bunchman TE. Acute peritoneal dialysis access in infant renal failure

Perit Dial Int 1996;16 Suppl 1:S509-11.

C J Stefanidis 2002

slide22

Cook (pleuropericardial) pig tail catheter

8.5 French 15 cm 6 sideports

http://www.cookgroup.com/cook_incorporated/pdf/CADB14.pdf

C J Stefanidis 2002

slide23

Cook (pleuropericardial) pig tail catheter

Retrospective study (1992-1995) in 46 patientsComplications of the Seldinger-placed Cook (pleuropericard) catheter were limited:

leakage (1/44)

bleeding: n = 0

obstruction or dislocation: n = 4

peritonitis: n = 1 (Candida)

Vande Walle J et al New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Perit Dial 1997;13:190-4

C J Stefanidis 2002

slide24

Introducer 11 French

Tenckhoff catheters

9.5 French

Lewis MA, Nycyk JA.Practical peritoneal dialysis--the Tenckhoff catheter in acute renal failure. Pediatr Nephrol 1992 Sep;6(5):470-5

C J Stefanidis 2002

slide26

Tenckhoff catheters (TC) implanted under general anesthesia compaired with Cook catheters (CC)

TC in 22 patients and a CC in 37 patients

The duration of use of TCs (16 days) was significantly greater than the duration of CC use (5 days; P < 0.001).

By day 6 of dialysis, 90% of TCs were functioning without complications compared with 46% of CCs

Only 2 patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%).

  • Chadha V et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis. 2000;35(6):1111-6.

C J Stefanidis 2002

slide27

Laparoscopic Tenckhoff catheter implantation

In 25 children laparoscopic TCIs and in 23 conventional TCIs

The inner cuff was placed adjacent to the peritoneum, without sutures

leakage: n =1, bleeding: n = 0 ,obstruction : n = 2

Laparoscopic TCI is feasible in children of all age groups, with equivalent functional results compared to conventional TCI

An additional advantage is the option to identify and eliminate anatomical risk factors, such as intra-abdominal adhesions or preformed inguinal hernias in male infants

Daschner M et al Perit Dial Int 2002 Jan-Feb;22(1):22-6

C J Stefanidis 2002

acute pd catheters1
Acute PD catheters

A Tenckhoff catheter implanted under general anesthesia is recommended

If the patient can not undergo surgery, a percutaneus guidewire inserted PD catheter should be placed

C J Stefanidis 2002

acute pd in the picu1
Acute PD in the PICU

Choice of dialysis treatment

PD catheters for ARF

Prescription of PD in ARF

C J Stefanidis 2002

slide30

Prescription of acute PD

The patient should be connected and start automated PD immediately after surgical catheter implantation.

Complications (peritonitis and hypothermia) are significantly reduced with the use of a cycler compared with the manual method.

Kohli HS et al Ren Fail 1995

If APD is not available a closed-drainage system PD system with disconnection should be used.

The use of a closed-drainage system

reduced the incidence of system-related peritonitis

Valeri A et al Am J Kidney Dis 1993

C J Stefanidis 2002

slide31

Initial prescription of acute PD

Cefazoline (250 mg/liter) and Heparin 500 U/liter should be added to the dialysis solution for first two days

Dialysate with a glucose concentration of 1.36% for volume of urine > 1.5 ml/kg/hr and UF is not required

Otherwise a dialysate with a higher glucose concentration 2.27% (or even higher) should be prescribed

For children with severe lactic acidosis or hepatic failure a bicarbonate-based dialysate can be prepared in the hospital pharmacy

C J Stefanidis 2002

slide32

Initial prescription of acute PD

Initially the exchange volume is kept low (20 ml/kg,

100-200 ml/m²) to reduce the risk of dialysate leakage

After 24 hours the volume is increased by 100-200 ml/m²/day up to 800-1000 ml/m² as tolerated by the patient

The first day one-hour dwells are prescribed and usually two-hour dwells are recommended on the second day

C J Stefanidis 2002

slide33

Adapted prescription of acute PD

Prescription of PD should be individually adjusted in the next days according to the needs of ultrafiltration and the parameters of adequacy (bl. urea and s. creatinine levels)

Usually after the stabilization period 5 to 8 exchanges daily are effective in most children with ARF. The aim is to deliver a maximum clearance to compensate the catabolic stress

C J Stefanidis 2002

slide34

Messages to take home

1. Early referral and early initiation of PD is very important for the outcome of children with ARF

2. PD should not be used in children with severe life-threatening hyperkalemia or with severe volume overload

C J Stefanidis 2002

messages to take home
Messages to take home

3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD

4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time

C J Stefanidis 2002

messages to take home1
Messages to take home

3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD

4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time

C J Stefanidis 2002

slide37

Messages to take home

5. The perscription of PD treatment should be optimized in critically ill children with ARF in order to achieve the goal of controlling uremia and fluid overload, and giving appropriate nutritional support

C J Stefanidis 2002