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Peritoneal dialysis (PD): access

Peritoneal dialysis catheter placement in pediatric patients

Catheter and exit site selection

Catheter selection

  • Intraperitoneal configurations (i.e., catheter tip): straight vs curled
    • No data support one over the other, but good reason to use the curled catheter whenever possible
      • Curled catheter is larger and may be difficult for babies to accommodate, so straight catheter often used in neonates
  • Cuffs: one vs two
    • Two cuffs may decrease infection rate
      • This difference may be attenuated by the regular use of exit site antibiotics (infection rates may be equivalent)
    • Cuff extrusion (with double cuff) increases infection risk
      • Can occur if large amounts of tension on the catheter (e.g., large catheter in small patient, excessive catheter bend) and/or if thin abdominal wall (e.g., babies, malnourished), so single cuff often used in neonates
  • Extra-peritoneal configuration: straight vs swan neck
    • Pre-bent swan neck catheter ensures downward facing exit site which reduces risk of infection
    • If swan neck catheter not available in appropriate size, can use three incisions to more gently curve a straight catheter
    • Swan neck catheter has superior technique survival [Biblaki et al., 2015]

Catheter exit site

  • Downward direction reduces infection risk
    • If downward (i.e., inferior/caudal) not possible, then lateral
    • Never upward (i.e., superior/cranial)
      • Tenting of the skin at the exit site creates a little upward-facing cup that allows for things (e.g., bacteria) draining by gravity to pool at the exit site, greatly increasing the risk of infection
  • Away from stomas and G-tubes (or future G-tubes)
  • Exit site should be ~2 cm from subcutaneous (outer) cuff
    • If >2 cm, epithelium cannot grow up to the cuff and granulation tissue will form, increasing infection risk
    • If <2 cm, increased risk of catheter extrusion
  • Catheter should be fixed securely
    • Avoid the use of sutures at the exit site
      • Can result in ischemia of skin or foreign body reaction
    • If not secured, movement of the catheter can lead to granulation tissue

Best practices

  • Bowel regimen to prevent perioperative constipation, which can make catheter positioning difficult and displace the catheter postoperatively
  • Empty bladder before procedure; otherwise, Foley catheter should be inserted
  • Single preoperative dose of IV antibiotic to provide antistaphylococcal coverage
  • Paramedian insertion of PD catheter through the body of the rectus muscle with deep duff within or below the muscle fibers
  • Pelvic position of the catheter tip
    • Upper part of the true pelvic bowl
    • Majority of dialysate pools in the pelvic region
  • Purse string suture to prevent leaks
  • Subcutaneous tunneling instrument does not exceed diameter of the catheter
  • Flow test to confirm function
  • Exit site ≥2 cm beyond superficial cuff
    • Minimize risk of extrusion
    • Minimize risk of involvement of the cuff if there is an exit site infection
  • No catheter anchoring sutures
    • Predisposes to early exit site and tunnel infection
    • If noted to be present after surgery, they should be removed
  • Non-occlusive dressing
    • Occlusive dressing can macerate exit site or insertion incision

Early exit site care

  • Dressing changes should be avoided in the first week after catheter placement, then performed weekly by experienced
    staff until the site is well healed
    • Avoid additional dressing changes unless dressing becomes soiled/wet
    • Healing typically takes 2-3 weeks but can take up to 6 weeks
  • Avoid showering/bathing during the healing phase

Dressing change technique

  • Use an aseptic technique, including sterile gloves and face mask
  • Clean around the site with sterile gauze soaked in sterile cleansing solution (e.g., chlorhexidine, saline, or Shur-Clens)
    • Avoid using irritating cytotoxic agents such as povidone iodine or hydrogen peroxide
    • Do not forcibly remove any crusts
  • Use another piece of soaked gauze to clean the tubing, starting with the exit site and working up the tubing away from the body
  • Pat the exit site dry with gauze and ensure it is completely dry
    • Some centers will apply an antibiotic ointment (e.g., gentamicin, mupirocin, Medihoney) during dressing changes
      • Only a small amount (e.g., pea sized) is necessary
        • Excessive ointment is wasteful and can crust on the dressing, confusing exit site assessment
      • Do not use ointments containing polyethylene glycol as this can degrade the polyurethane catheter
  • Allow the catheter to fall to its natural position
  • Completely cover the exit site with several layers of sterile gauze and secure with a dressing
  • Immobilize the catheter below the exit site dressing, anchoring the tube to restrict movement
    • Commercially available immobilization devices may be used, but tape or a dressing are also adequate

PD catheter insertion techniques


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Selecting an insertion technique

  • Two techniques may be used: advanced laparoscopic or open dissection

Principles of catheter insertion

  • Create an oblique, watertight subcutaneous tunnel through the abdominal wall
    • Oblique (rather than straight) path through the abdominal wall reduces the risk of hernia and leak
  • Position the tip in the pelvis
  • Do an omentectomy when possible to help reduce the risk of early catheter failure [PMID 20223324]
    • Relatively simple for both open and laparoscopic technique
  • Laparoscopy preferred over open
    • Data is becoming more convincing that laparoscopic is generally superior to open technique [PMID 19306986]
      • Better flow
        • Easier to achieve optimal catheter position
      • Longer catheter life
        • May be because of lower rate of adhesion formation with laparoscopic technique
      • Ability to perform additional surgeries (e.g., hernia repair)
  • Deep cuff secured in the muscle between anterior and posterior sheaths of the abdominal rectus
  • Regardless of whether laparoscopic or open technique is used, the subcutaneous tissue should be smaller than the catheter
    • Do not use a hemostat to push the catheter through; hemostats have a wide triangular shape that will widen the tunnel when pushed through
    • Use Steinmann pin or can use peel-away sheath with guidewire (Seldinger technique)
  • Exit site should be as small as is feasible
    • Can use skin punch biopsy to make the incision (round hole for round catheter helps minimize the hole size)