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Access Care and Complications Management

1. Intranasal mupirocin b i d for 5 7 days every month if patient is identified as a nasal carrier OR only if positive nose culture Gentamicin has been reported to be effective in reducing Pseudomonas aeruginosa as well It has been reported that mupirocin ointment may cause structural damage to polyurethane catheters STEP STEP The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Antibiotic Dosing Guidelines Peritonitis Management Intraperitoneal Antibiotic Dosing Recommendations for CAPD Patients CONTINUOUS mg per liter all exchanges INTERMITTENT per exchange once daily Aminoglycosides Amikacin 2 mg kg LD 25 MD 12 Gentamicin 0 6 mg kg LD 8 MD 4 Tobramycin 0 6 mg kg LD 8 MD 4 Cephalosporins Cefazolin 15 mg kg LD 500 MD 125 Cefepime 1000 mg LD 500 MD 125 Ceftazidime 1000 1500 mg LD 500 MD 125 Ceftizoxime 1000 mg LD 250 MD 125 Penicillins Amoxicillin ND LD 250 500 MD 50 Ampicillin ND MD 125 Nafcillin ND MD 125 Oxacillin ND MD 125 Penicillin G ND LD 50 000 units MD 25 000 units
2. Access management is an essential element for long term patient success with peritoneal dialysis Proper placement of the catheter and postoperative care of the healing exit site are key to establishing a successful permanent peritoneal access A decrease in access associated complications particularly peritonitis can be achieved if definitive focus is placed on proper catheter placement use of advanced disconnect systems exit site prophylaxis and most importantly the patient s adherence to aseptic technique during the exchange procedure and to the protocol for exit site care Early intervention and treatment of peritoneal catheter related complications if they do occur are essential to maintaining the peritoneal access for p olonged successful peritoneal dialysis While there have been improvements made in the catheter area in both hemodialysis HD and p patient PD catheter related infections and complications continue to be major reasons why ritoneal dialysis access issues continue to be significant causes of morbidity in the dialysis CD patients discontinue PD Access Care and Complications Management was developed based on review of the current medical literature the recommendations of the International Society of Peritoneal Dialysis ISPD ad hoc advisory committee on PD related infections and the authors clinical experience Sections include operative planning and processes chronic c
3. Dressing changes following implantation should be restricted to experienced PD staff or trained patients e Provide postoperative care instructions and if applicable supplies including soap alcohol based hand disinfectants masks absorbent dressing e g gauze tape and exit site cleansing agent skin disinfectant Review written operative instructions with patient caregiver Preoperative e Review catheter placement procedure e Fast after midnight or at least 8 hours prior to catheter insertion essential medications are permitted with a sip of water e Empty bladder 2 e Bowel preparation in case of previous history of constipation e g mineral oil enema or a stimulant suppository is administered on the evening before surgery to evacuate the lower colon 1 2 e Avoid using sodium phosphate bowel preps e Shower or bathe with disinfectant soap on the day of surgery Postoperative e Keep sterile dressing clean dry securely taped for one week unless there is excess drainage or bleeding e Report bleeding pain or tenderness immediately e Report severe cough Avoid high intra abdominal pressure until healed 2 to 6 weeks Heavy lifting e Straining and constipation e Pulling with upper extremities during stair climbing No showers or baths until completely healed up to two weeks except in case of buried catheter after one week of surgery 4 OUTCOMES EVALUATION Collect patient information to include e Patient
4. Inhibitory Concentration MIC Inhibitory Concentration MIC Upon identification of species and MIC values Amphotericin B can be replaced with an echinocandin e g caspofungin fluconazole posaconazole or voriconazole Treat for at least 10 days with fluconazole and or flucytosine after catheter STEP removal Depending on organism medication used mode of delivery and treatment response the treatments can be weeks to months Resumption of PD may be modified depending on clinical course Note P use of Amphotericin B can cause pain and chemical peritonitis IV use leads to poor peritoneal penetration Centers may prefer to reserve Amphotericin B for selected patients including those who are immunosuppressed are refractory or have had significant prior exposure to azoles i Fungal peritonitis is typically preceded by courses of antibiotics j Monitor serum concentration levels regularly to avoid bone marrow toxicity and hepatotoxicity Flucytosine PO may not be available in all regions Risk of flucytosine resistance is high when used alone The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide
5. The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 3 Preoperative Management e Patients with belt lines below the umbilicus may require a Tenckhoff style catheter that produces a laterally directed exit site above the belt see fig 2 e Patients with belt lines above the level of the umbilicus may require a catheter that is bent or manufactured with a preformed bend so called swan neck design that results in a downwardly directed exit site see fig 3 Patients with belt lines Patients with belt lines BELOW umbilicus ABOVE umbilicus FIG 2 Patients with belt lines below the umbilicus may require a Tenckhoff 8 style catheter that produces a laterally directed exit site above the belt FIG 3 Patients with belt lines above the level of the umbilicus may require a catheter that is bent or manufactured with a preformed bend that results in a downwardly directed exit site Illustrations courtesy of John Crabtree MD Indications for Presternal Upper Abdominal Peritoneal Dialysis Catheter e Morbid obesity e Multiple loose skin folds scars or o
6. 9 10 FIG 9 A Straight catheter implanted into arcuate configuration B Shape memory can cause catheter tip migration out of the pelvis FIG 10 A Straight catheter implanted into arcuate configuration B Shape memory can cause the superficial catheter cuff to extrude through the exit site Illustrations courtesy of John Crabtree MD e Position exit site downward or lateral e Create the smallest skin hole possible to provide for catheter exit site e Immobilze catheter with medical adhesive tincture if available and sterile adhesive strips e Do not utilize catheter anchoring sutures at the exit site due to risk of infection e Perform adjunctive procedures to catheter implantation such as hernia repair omentopexy omentectomy and adhesiolysis as needed The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 9 Perioperative and Intraoperative VEERG Verify function e Catheter patency and flow must be tested during surgical procedure prior to final closure e Catheter position should be revis
7. Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Postoperative Management PATIENT EDUCATION e Review postoperative instructions with patient e Maintain clean dry securely taped sterile dressing e Protect site from gross contamination and wetness e Immobilize catheter e Practice good hygiene e Take no shower or bath until healed 9 e Avoid heavy lifting stair climbing straining and constipation until catheter healed 2 to 6 weeks Notify PD unit in case of blood or other drainage pain or tenderness trauma to abdomen e Restrict dressing changes following implantation to experienced PD staff or trained patients if patient lives far from center Educate patients who perform postoperative dressing changes to e Recognize early signs of infection such as redness tenderness and discharge e Use aseptic technique with face mask and gloves e Inspect exit site and palpate tunnel e Maintain stability of catheter during inspection e Cleanse with nonirritating solutions when instructed by nurse OUTCOMES EVALUATION Collect data to include Exit site classification Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treat
8. Bernardini J Figueiredo A Gupta A et al Peritoneal dialysis related infections recommendations 2010 update Perit Dial Int 2010 30 393 423 Matuszkiewicz Rowinska J Update on fungal peritonitis and its treatment Perit Dial Int 2009 29 5161 S165 Prasad N Gupta A Fungal peritonitis in peritoneal dialysis patients Perit Dial Int 2005 25 207 222 Rocklin MA Teitelbaum Noninfectious causes of cloudy peritoneal dialysate Sem Dial 2001 14 37 40 Brooks G Carroll K Butel J Morse S Medical Microbiology 24th ed New York NY McGraw Hill 2007 Ponferrada L Prowant B Satalowich R Peritoneal Dialysis In Counts C ed Core Curriculum for Nephrology Nursing 5th ed Pitman NJ American Nephrology Nurses Association 2008 766 851 Jorgensen J Pfaller M A Clinician s Dictionary of Pathogenic Microorganisms Herndon VA AMS Press 2004 We are grateful for the contributions by Salim Mujais MD for his guidance and writing that enhanced the quality of the guide The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide Baxter PERITONEAL DIALYSIS Proven Effective Therapy Prepared by Medical Affairs Renal Divisio
9. CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Mycobacterium Peritonitis M tuberculosis or non TB mycobacterium on culture Special culture technique required M tuberculosis Treatment includes 4 drugs rifampin IP isoniazid 12 18 months pyrazinamide 3 months ofloxacin 3 months Non tuberculous mycobacteria Treatment protocol not well established Individualized protocol according to sensitivities Pyridoxine should be given to avoid isoniazid induced neurotoxicity Catheter removal may be considered The duration of antibiotic therapy following catheter removal and timing of resumption of PD may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Relapsing Peritonitis completion of the antibiotic course Relapse is defined as another episode of peritonitis caused by the same genus and species that caused the immediately preceding episode o
10. This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide Monitor girth Examine flank and back for subcutaneous fluid Examine for scrotal penile or labial swelling Order review abdominal computerized tomography CT with intraperitoneal IP contrast or magnetic resonance imaging MRI without gadolinium see imaging techniques 14 Increase Clinic visits as needed for observation CT peritoneography see Appendix Abdominal fluoroscopy with contrast Peritoneal scintigraphy see Appendix Peritoneal MRI with dialysate as contrast medium 14 CT without IP contrast revealing a pericatheter leak in a patient with improper placement of the cath White arrows indicate catheter and leak area identified by different contrast to other subcutaneous ti eter ssue Radiograph courtesy of Ali Abu Alfa MD The information published in this update for general and educational purposes only This information is in substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please re 0 way meant to be a er to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this gui de CLINICAL
11. clear e Add heparin 500 1 000 U L as long as the effluent has visible signs of blood or fibrin to maintain catheter patency e Intraperitoneal instillation of heparin does not affect systemic coagulation parameters and does not increase the risk of bleeding 2 However it has been reported that heparin may still reach the systemic circulation potentially via lymphatic absorption or with increased peritoneal membrane permeability with peritonitis Hence IP heparin is contraindicated in patients with heparin induced thrombocytopenia HIT Observe drain fluid color with dialysis exchanges Document duration of blood tinged exchanges and progression increase decrease e Check hematocrit serum and dialysis as needed e Consider investigating for peritonitis or other acute abdominal issue if prolonged The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Other causation 2 e Add heparin 500 1 000 U L as long as the effluent has visible signs of blood or fibrin to maintain catheter patency e Perform rapid exchanges with dialysate at room temperature
12. cuff ment unless there is a strong clinical indication that precludes choice bejeyen DONT Ela Locate exit site to maximize self care skills vision handedness Ue heal catheter left Extended strength and motor skills Patient should be able to look down and catheter system below easily visualize the proposed exit site Evaluate patient while dressed and in the sitting position to determine belt line location and other anatomical features that will influence selection of catheter type insertion site and exit site location Avoid scars belt line fat and skin folds moist areas due to perspiration pressure points from clothing or areas that cannot be sufficiently visualized during exit site care Determine whether midabdominal high abdominal or presternal location is most appropriate for individual patient see fig 4 and 5 Mark exit site location with indelible ink using stencils or actual catheter e Choose appropriate catheter configuration and operative methodology Despite innovative attempts to design peritoneal catheters to overcome problems with flow function none of these devices have been shown to outperform the standard Tenckhoff style catheter with or without a swan neck bend see fig 1 2 3 Choice of catheter type may be impacted by belt line location and body habitus Y3L3H1Y9 NOISNALX3 SNOANVLNDENS as Lu lu a lt e lt 2 e Qa a lt TITANIUM CONNECTOR
13. demographics e ESRD diagnosis e Comorbid conditions e Date of referral Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 6 Perioperative and Intraoperative EMEC Peritoneal catheter implantation must be performed by a competent and experienced surgeon interventional radiologist or nephrologist Optimal long term peritoneal catheter function and exit site healing are directly related to the skills and competence of the catheter insertion team Proper catheter insertion technique is one of the most important aspects in preventing catheter exit site and or tunnel infections Attention to detail and commitment to excellence should be foremost in goals for success Peritoneal catheter insertion procedures should meet the standards of any surgical procedure and inclusive of known best demonstrated practice whether performed by a surgeon in the operating room the nephrologist at the bedside or interventionalist at an access center KEY ASSESSMENTS e Verify completion of preoperative activities e Fasting state maintained e Shower
14. effusion e Cough or dyspnea e Chest pain e Weight gain e Decreased dialysis drain volumes Small pleural effusion may be symptom free Acute respiratory distress KEY ACTIVITIES Diagnostic 2 e Assess for decreased lung sounds pleural collection frequently on right side e Observe for shortness of breath or cough especially when supine e Shortness of breath increasing with hypertonic exchanges especially if drainage amount is decreased e Chest X ray showing unilateral pleural effusion e Isotope scanning to identify pleural peritoneal communication e High glucose low protein pleural fluid on thoracentesis IN 23149219 uyor Jo Asayinos ydesBoipey The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications CLINICAL APPROACH TO HYDROTHORAX e Conservative management for pleural leakage in the form of peritoneal rest and intermittent low volume dialysis is rarely successful24 e Temporary hemodialysis for 2 6 weeks usually required to allow pleuroperitoneal communication to seal especially following surgical intervent
15. episodes should not be counted as another peritonitis episode when determining the peritonitis rate Recurrent and repeat peritonitis episodes should be counted when determining the peritonitis rate The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Management of Exit Site Tunnel Infection An exit site infection is defined by the presence of purulent drainage with or without erythema of the skin at the catheter epidermal interface 2 KEY ASSESSMENTS e Purulent discharge from exit site spontaneous or expressed from tunnel cuff or sinus e Persistant erythema may be precursor to purulent drainage e Pain or tenderness at exit site or over the tunnel e If exit site is reddened without drainage and culture positive may indicate colonization e Erythema or skin reaction may be noted following catheter implantation or trauma e Staphylococcus aureus carrier status use of prophylaxis Compliance with prophylaxis e Precipitating or contributing conditions break in technique gross contamination etc e Suboptimal exit site care KEY ACTIV
16. for hospitalization e Discuss possibility of break in technique compliance to hand washing mask use e Inquire about recent procedures constipation diarrhea and antibiotic use e Review peritonitis and exit site infection history and treatment e Review use of exit site prophylaxis PATIENT EDUCATION e Immediately report cloudy effluent abdominal pain and or fever to PD unit e Save drained cloudy dialysate and bring to clinic e Stress importance of obtaining specimen prior to beginning antibiotics Patients previously educated on antibiotic administration should begin the following e Add intraperitoneal antibiotics for duration of required therapy Add heparin 500 U L to each bag until clear e Report persistent cloudiness to PD unit e Schedule retraining for technique issues OUTCOMES EVALUATION Collect data to include e Date of culture organism identified drug therapy used e Date infection resolved e Recurrent organisms date of drug therapy e Documentation of contributing factors e Break in technique patient factors exit site infections tunnel infections e Date of re education training Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full ov
17. on day of surgery with antibacterial soap 2 Bladder emptied or Foley catheter as needed 2 Bowel preparation complete 1 2 e Verify exit site marked appropriately KEY ACTIVITIES Prepare patient e Administer antistaphylococcal antibiotic preoperatively e First generation cephalosporin 1000 mg intravenously 1 to 3 hours preoperatively OR Vancomycin 1000 mg intravenously administered approximately 12 hours preoperatively 7 e A prospective randomized trial determined that vancomycin was superior to cephalosporin or no treatment in reducing post operative peritonitis e If vancomycin is used weigh potential benefits versus risk of resistant organisms e Perform surgical skin prep use electric clipper to avoid skin nicks 2 Prepare catheter e Eliminate air from catheter cuffs prior to implantation by soaking and gently squeezing cuffs in saline solution The half life of vancomycin and cefazolin are different possibly influencing the results of this study The epidemiology and resistance patterns contributing to peritonitis should be considered in determining the appropriate pre operative antibiotics The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers represe
18. patients with no residual renal function if low volume APD is not feasible or does not adequately control azotemia e Recurrent pericatheter leaks may require catheter replacement PATIENT EDUCATION e Monitor for signs and symptoms of exit site infection and peritonitis in presence of leaks e Alter dressing change procedure and frequency to accommodate increased drainage e Report physical examination changes indicating potential leak e Alter dialysis regimen if required to minimize intra abdominal pressure following surgical correction e Reduce activities that increase intra abdominal pressure such as lifting coughing or straining OUTCOMES EVALUATION Collect data to include e Type of catheter and insertion technique e Condition of exit site wound e Condition of subcutaneous cuff and tunnel Type of leak e Diagnostic testing and results e Dialysis prescription alterations Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Peritoneal Catheter Obstruction Inflow and outflow obstruction
19. when mixed in a dialysis solution volume greater than 1 L however they are incompatible when mixed in the same syringe or empty dialysis solution bag for reinfusion Aminoglycosides should not be added to the same exchange with penicillins as this results in incompatibility The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Staphyloccocus aureus Peritonitis Staphylococcus aureus on Culture Continue gram positive coverage based on sensitivities Stop gram negative coverage assess exit site again STEP lf methicillin resistant adjust coverage to vancomycin Add rifampin 600 mg day orally in single or split dose for 5 7 days 450 mg day if BW lt 50 kg Assess Clinical improvement repeat dialysis effluent cell count and culture at days 3 5 Clinical improvement No clinical improvement p symptoms persist effluent remains cloudy symptoms resolve bags clear Reculture amp evaluatet STEP e Continue antibiotics 2 e Reevaluate for ex
20. ASSESSMENTS e Assess exit site and wound healing for Absence of bleeding drainage or leakage e Absence of pain or tenderness on palpation KEY ACTIVITIES e Inspect and change dressing weekly or more frequently in the presence of Delayed healing Infection e Gross contamination e Wetness e Maintain clean dry intact dressings e Utilize aseptic technique using mask and gloves e Exit site care e Minimize manipulation of catheter e Use aseptic technique including masking and wearing sterile gloves for postoperative dressing changes until healed e Inspect and classify exit site 1 e Palpate tunnel Clean with nonirritating solution i e nonionic surfactant normal saline or chlorhexidine Protect sinus tract and wound from povidone iodine and hydrogen peroxide 10 e Tape dressing securely Immobilize catheter If the catheter is not used for a period of time it is not necessary to check catheter patency and function Catheters that are exteriorized secondarily Moncrief technique can be used immediately for full volume peritoneal dialysis Exit site management for secondarily exteriorized catheters is the same as described for primary exteriorization The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of
21. Access Care and Complications Management Update zon Bax ter PERITONEAL DIALYSIS Proven Effective Therapy Care of the Adult Patient on Peritoneal Dialysis John H Crabtree MD Catherine A Firanek BSN MBA Beth Piraino MD Ali K Abu Alfa MD Steven Guest MD Access Care and Complications Management Update 2012 Care of the Adult Patient on Peritoneal Dialysis Based in part on recommendations from the International Society for Peritoneal Dialysis Author Affiliations John H Crabtree M D F A C S Department of Surgery Southern California Permanente Medical Group Kaiser Permanente Downey Medical Center Catherine A Firanek B S N M B A Director Medical Affairs Renal Division Baxter Healthcare Corporation Beth Piraino M D Professor of Medicine Associate Dean of Admissions University of Pittsburgh School of Medicine Ali K Abu Alfa M D F A S N Associate Professor of Medicine Director Peritoneal Dialysis Program Yale School of Medicine Steven Guest M D Medical Director Renal Division Baxter Healthcare Corporation Optimal long term management of the peritoneal dialysis PD patient hinges on achievement of best demonstrated practices and prevention of complications associated with peritoneal dialysis Published recommendations enhance our understanding of how to achieve these goals and encourage focus on prevention leading to improved management of our patients overall
22. ITIES Initiate the following e Culture and Gram stain of purulent exudate and or drainage Experienced PD nurse may express fluid by pressing on the superficial cuff or with a gentle downward pull of catheter e Initiate empiric antibiotic therapy as indicated by Clinical appearance e Empiric therapy should include Staphylococcus aureus coverage e In patients with history of pseudomonas ESI empiric therapy should include targeted antibiotic therapy e In the absence of purulence tenderness or swelling consider intensified local care e g hypertonic saline soaks see right e Monitor classify and document condition of exit site sinus and tunnel ESI due to SA and pseudomonas may be related to tunnel involvement e If tunnel infection suspected ultrasound of subcutaneous pathway may be helpful e Increase frequency of exit site care and dressing changes e Retrain patient on appropriate exit site care Schedule clinic visits to evaluate response to treatment plan PATIENT EDUCATION e Revise exit site care e Clean 1 to 2 times a day e Avoid toxic agents entering sinus Change cleansing agent if required e In the case of severe exit site infection saline soaks in addition to antibiotics may be used Add 1 table spoon of salt to 1 pint 500mL sterile water This solution is applied to gauze and wrapped around the exit site for 15 minutes one to two times per day e Soften crust and scabs with saline or soap and water e Neve
23. PROCESS FOR OPTIMAL OUTCOMES Wd Noninfectious Complications CT Peritoneography CT peritoneography with IP contrast showing dye around the cord structures in the upper scrotum on the right side arrow at the level of the root of the penis Peritoneal Scintigraphy Peritoneal scintigraphy postdrain image demonstrating right inguino scrotal fluid collection Radiographs courtesy of John Crabtree MD The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications CLINICAL APPROACH TO LEAKS Dialysis therapy e Initiate PD or APD in supine position using low volume exchanges 500 to 1500 mL until leak has sealed Keep abdomen dry when not in supine position If required use HD backup for 1 to 2 weeks In new patients in whom dialysis is not urgently required Delay use of PD for up to 3 weeks if necessary until leakage subsides e Reinitiate PD in presence of trained staff to assess for recurrence Invasive steps e Persistent leak may require surgical repair Provide HD backup if needed during healing in
24. Quinolones Ciprofloxacin ND LD 50 MD 25 Others Aztreonam ND LD 1000 MD 250 Daptomycin ND LD 100 MD 20 Linezolid Oral 200 300 mg q day Vancomycin 15 30 mg kg every 5 7 days LD 1000 MD 25 Antifungals Amphotericin NA 1 5 Fluconazole 200 mg q 24 48 hrs Combinations Ampicillin sulbactam 2 g every 12 hours LD 1000 MD 100 Imipenem cilastatin 1 g bid LD 250 MD 50 Quinupristin dalfopristin 25 mg L in alternate bags Trimethoprim sulfamethoxazole Oral 960 mg b i d This dosing applies to anuric patients For dosing of drugs with renal clearance in patients with residual renal function defined as gt 100mL day urine output Dose should be empirically increased by 25 ND no data b i d two times per day NA not applicable LD loading dose in mg MD maintenance dose in mg Given in conjunction with 500 mg intravenous twice daily Table used adapted with permission MultiMed 2010 The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Antibiotic Dosing Guidelines Peritonitis Management Intermittent Dosing of Antibiotics in Automa
25. a Safe and Clean Environment 2 e Prior to each exchange clean the work area The exchange area must Be well lit and private e Have no open windows or doors Have fans and air conditioners turned off Be free of pets e For handwashing use soap and or alcohol based products followed by thorough drying with paper towels e The patient and partner or nurse must wear a face mask when performing exit site care and dialysis exchange procedures e Do not touch STERILE areas of the PD system including e Open solution port of the new bag e Tip of the exposed transfer set Connections of the twin bag Y set cycler set e Interior of the MINICAP disconnect cap or connection shield and TWIN BAG system Encourage the patient to practice good hygiene e Perform connections of PD APD sets to solution bags and transfer sets using aseptic technique each time an exchange is performed Use only clean and dry port clamps Wash clamps with soap and water Let outlet port clamps dry with open end facing downward The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Normal Bacterial Fl
26. ak requiring exploration of the incision site or evaluation for an anatomical defect Delaying peritoneal dialysis for 14 days following catheter insertion is a useful preventative measure in order to avoid early leakage Attention to surgical recommendations on insertion location paramedian approach and positioning of internal cuff reduce the risk of leakage KEY ASSESSMENTS Patients at risk e Patients with poor tissue healing diabetics elderly malnourished and those taking corticosteroids Patients with increased intra abdominal pressure Findings that require evaluation for leaks 2 External fluid at wound or exit site e Reduced exchange outflow volume Weight gain e Abdominal swelling and edema increased girth e Scrotal penile or labial edema e Peripheral edema e Unilateral pleural effusion with or without volume overload see Noninfectious Complications Hydrothorax KEY ACTIVITIES External leaks e Verify that clear fluid at incision or exit site contains glucose using glucose test strip e Document condition of exit site subcutaneous cuff tunnel and or wound Alter dressing change procedure to accommodate increased fluid drainage e Reduce leak by use of a dry day or suspension of PD to be considered These leaks increase the risk of peritonitis and consideration should be given to prophylactic antibiotic administration The information published in this update for general and educational purposes only
27. al hernias occur more often when the peritoneal catheter is placed through the midline instead of the paramedial approach through the rectus muscle KEY ASSESSMENTS e Protrusion at umbilicus inguinal area genitalia or incision e Determine reducibility pain size e Evaluate for tenderness and inflammation If incisional review catheter placement procedure KEY ACTIVITIES Inspect and examine suspect sites e Refer to surgeon to determine intervention in symptomatic patients e Umbilical hernias may be asymptomatic and can be managed by avoiding large fill volumes e Schedule patient follow up THERAPEUTICS e Significant hernia requires surgical repair e Hernias should be repaired with prosthetic mesh techniques to minimize the high risk of recurrence in patients on PD 17 18 Appropriate surgical attention to details in producing a watertight peritoneal closure and the use of supine low volume intermittent PD permits immediate resumption of therapy after hernia repair and avoids the need for temporary hemodialysis e Provide HD backup if needed in patients with no residual renal function in whom small volume frequent exchanges are insufficient to control azotemia The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page
28. and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide 21 22 23 24 25 26 27 28 29 30 31 32 33 CLINICAL PROCESS FOR OPTIMAL OUTCOMES References Bargman J Noninfectious complications in peritoneal dialysis In Gokal R Khanna R Krediet R Nolph K Textbook of peritoneal dialysis 2nd ed Dordrecht Netherlands Kluwer Academic Publishers 2000 609 646 Tse KC Yip PS Lam MF Recurrent hemoperitoneum complicating continuous ambulatory peritoneal dialysis Perit Dial Int 2002 22 488 491 Kaplan GG Manns B McLaughlin K Heparin induced thrombocytopenia to intraperitoneal heparin exposure Nephrol Dial Transplant 2005 20 2561 2562 Chow KM Szeto CS Li PK Management options for hydrothorax complicating peritoneal dialysis Sem Dial 2003 16 389 394 Tang S Chui WH Tang AWC Li FK Chau WS Ho YW Chan TM Lai KN Video assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis Nephrol Dial Transplant 2003 18 804 808 Ponferrada LP Prowant BF Satalowich RJ Peritoneal dialysis access Core curriculum for nephrology nursing In Counts CS 5th ed Pitman NJ American Nephrology Nurses Association 2008 768 794 Li PK Szeto CC Piraino B
29. atheter care and infectious and noninfectious complications with suggested references and additional information in the appendix By its nature this guide cannot be considered to be exhaustive and users are encouraged to pursue specific issues that may not be covered herein This guide is not intended to be the practice of medicine nor does it replace medical clinical judgment This guide was developed as an aid to improve PD catheter management in the adult patient It is our hope that these guidelines will assist you in improving patient care by optimizing PD catheter outcomes Please note Certain products discussed in this guide are not available in all geographic locations Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Table of Contents Section 1 Catheter Insertion and Care 01 Preoperative Management 02 Perioperative and Intraoperative Management 06 Postoperative Management 10 Chronic Care of Peritoneal Dialysis Catheter 12 Section 2 Noninfectious Complications 14 Pericatheter and Subcutaneous Leaks 15 Peritoneal Catheter Obstruction 19 Hernia 21 Abdominal Discomfort During Infusion and Drain 23 Pneumoperitoneum Shoulder Pain 24 Hemoperitoneum 29 Hydrothorax 27 Catheter Adapter Disconnect or Fracture of Peritoneal Catheter 29 Section 3 Infectious Complications Peritonitis Management 31 Initial Empiric Management of Peritonitis 32 Staphyloccocus aureus Peritonitis 35 Enterococcus Streptococcus Peritonitis 36 Oth
30. be paid to sink water baths showers hot tubs and other wet areas Acinetobacter species Gram negative soil and water Serratia marcescens Gram negative soil and water Pasteurella species Gram negative cats and dogs e Mycobacteria Gram positive water and food The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide 10 11 12 13 14 15 16 17 18 19 20 CLINICAL PROCESS FOR OPTIMAL OUTCOMES References Guide to Optimal Catheter and Complications Management References Gokal R Alexander S Ash S Chen TW Danielson A Holmes C et al Peritoneal catheters and exit site practices toward optimum peritoneal access 1998 update Perit Dial Int 1998 18 11 33 Flanigan M Gokal R Peritoneal catheters and exit site practices toward optimum peritoneal access a review of current developments Perit Dial Int 2005 25 132 139 Crabtree JH Selected best demonstrated practices in peritoneal dialysis access Kidney Int 2006 70 S27 S37 Moncrief JW Popovich RP Broadrick LJ He ZZ Simmons EE Tate RA The Moncrief Popovich catheter A new peritoneal access technique fo
31. ccurring within four weeks of Initiate empiric therapy Relapsing Relapsing Relapsing Relapsing Relapsing coagulase methicillin enterococci gram negative pseudomonas positive negative eee Adjust therapy Adjust therapy Stenotrophomonas staphylococci 5 epidermidis according to according to Adjust therapy Adjust therapy Adjust therapy organism and organism and according to according to according to sensitivity sensitivity organism and organism and organism and sensitivity sensitivity sensitivity Assess for Consider adding Assess for Assess for Remove occult tunnel rifampin intra abdominal intra abdominal catheter infection and for MRSA pathology abscess biofilm consider catheter removal and surgical intervention If relapsing coagulase If relapsing negative S aureus staphylococci consider catheter consider catheter removal exchange If no clinical response after 96 hours consider removal of catheter Reinsertion should be individualized based on HD option presence of intra abdominal abscess exit site or tunnel infections patient and physician preferences If clinical improvement is followed by additional relapse catheter removal and replacement is recommended Refer to Empiric Therapy The duration of antibiotic therapy following catheter removal and timing of resump
32. continue starting antibiotics Start continuous ampicillin 125 mg L each bag consider adding aminoglycoside for Enterococcust STEP hl If ampicillin resistant start vancomycin lf vancomycin resistant enterococcus consider quinupristin dalfopristin daptomycin or linezolid Assess Clinical improvement repeat dialysis effluent cell count and culture at days 3 5 Clinical improvement No clinical improvement symptoms resolve bags clear symptoms persist effluent remains cloudy STEP e Continue antibiotics e Reculture amp evaluate e Reevaluate for exit site or occult tunnel infection intra abdominal No clinical improvement by 5 days on abscess catheter colonization etc appropriate antibiotics remove catheter Duration of therapy Peritonitis with exit site or tunnel infection STEP 14 days Streptococcus Consider catheter removalt 21 days Enterococcus Duration of therapy 21 days Choice of therapy should always be guided by sensitivity patterns If linezolid is used for vancomycin resistant enterococcus bone marrow suppression has been noted after 10 14 days The manufacturer s precaution label states that these antibiotics should not be mixed together in the same solution container Physicians own judgment is necessary The duration of antibiotic therapy following catheter removal and timing of resumption of peritoneal dialysis
33. d peritoneal scintigraphy are suggested when there is suspected dialysis fluid leakage in the abdominal wall genital region or pleural space This information is important in order to localize the leakage site and to assist the surgeon if surgical intervention is necessary Peritoneal imaging can also be used to identify fluid loculation a result of peritoneal adhesions 1 Note Communicate the purpose of the test to the radiologist and review radiographs personally It is advisable to coordinate the diagnostic study with the PD nursing staff to perform the addition of the imaging marker to the dialysate and to make the tubing connections to prevent contamination of the catheter by healthcare personnel who may be unfamiliar with dialysis technique CT Peritoneography Procedure e Add 80 mL of water soluble contrast media 80 mL OMNIPAQUE 350 to 1 5 L of dialysis solution e Infuse dialysis solution with radiocontrast into supine patient e Instruct patient to move and walk to promote intraperitoneal mixing and to raise intra abdominal pressure to drive the contrast into the source of the leak If pleuroperitoneal fistula is suspected CT should include the chest If scrotal swelling has been noted the examination should include this area otherwise avoid radiation of the testes Peritoneal Scintigraphy Procedure e Add 2 mCi of technetium 99m sulfur colloid to 2 L of dialysis solution Infuse radionucleotide containing dialysa
34. dialysis fluid leak from peritoneal catheter or transfer set e Obtain culture to rule out peritonitis KEY ACTIVITIES Initiate prophylactic antibiotics For adapter disconnect or catheter fracture Stop dialysis e Clamp catheter proximal to damage f catheter length is adequate use sterile technique to e Disinfect catheter proximal to damaged area e Trim catheter proximal to expanded area on catheter or fracture e Using sterile scissors trim the catheter above area that is damaged or stretched Fit a sterile new adapter into the catheter e Attach transfer set to adapter If catheter portion is marginal length e Repair with appropriate manufacturer s repair kit or catheter extension PATIENT EDUCATION Instruct patient to 2 e Stop dialysis e Clamp catheter proximal to damaged spot e Cover area with sterile dressing e Go to clinic or emergency room as soon as possible Teach patient to e Secure catheter and transfer set under clothing avoiding sharp bends in catheter e Keep sharp objects and tools away from catheter e Avoid using scissors to remove catheter dressing e Avoid using unsuitable disinfectants and soaps on catheter e Do not use toothed hemastat on catheter e Avoid using mupirocin cream if catheter is made of polyurethane OUTCOMES EVALUATION Collect data to include Type of peritoneal catheter Type of perforation Intervention Response to intervention e Patient outcome Enter data into cath
35. eatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 61 Appendix Noncellular causes Increased fibrin e Post peritonitis e Starting PD Increased triglycerides Acute pancreatitis e Neoplasms lymphoma e Superior vena cava syndrome e Drug associated e Calcium channel blockers eChylous ascites The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Providing for a Safe Environment for Peritoneal Dialysis Prevention of exit site infections and peritonitis requires that both clinicians and patients understand and practice aseptic technique In the course of daily practice staff must demonstrate and teach patients how to recognize the potential sources of contamination and to practice measures that will decrease the risk of infection These preventative measures will reduce complications and promote positive patient outcomes Recommendations for
36. ed until satisfactory flow function is achieved before procedure end e A trial irrigation of the catheter is performed to identify potential problems with flow With the patient in reverse Trendelenburg position infuse a standard one liter bag of normal saline with heparin 1000 U per liter and observe for unimpeded inflow and drainage by gravity e A residual volume of 250 to 300 mL is left in the abdomen to reduce the likelihood of intraperitoneal structures being drawn into catheter tip and side holes toward the end of the drainage phase e With nonlaparoscopic implantation methods it is advisable to check for catheter patency and flow prior to exteriorizing the catheter through the exit site This will prevent unnecessary tunnel tract and exit site trauma in the event that catheter repositioning is required Final catheter preparation e Place catheter adapter e Attach catheter cap or transfer set with cap as per individual center policy Make sure transfer set is in closed position e Apply sterile gauze or other absorbent dressing and tape securely 9 e Tape catheter securely to abdomen in several places e Transparent occlusive dressings alone are not recommended 9 PATIENT EDUCATION e Review postoperative instructions prior to patient discharge e Provide written instructions regarding follow up care see Appendix e Review postoperative medications e Review postoperative pain management Schedule return appointment for postopera
37. edding procedure can be performed with any catheter type i e upper abdominal catheter and presternal catheter 3 Advantages of Embedded Peritoneal Dialysis Catheter e Catheter heals in environment without exposure to contamination from exit site lt Greater patient acceptance for earlier catheter implantation No catheter maintenance until dialysis started Avoids urgent temporary hemodialysis Start full dose peritoneal dialysis without break in period after exteriorization FIG 6A FIG 6B The external limb of catheter is External limb of catheter is buried under the skin permitting exteriorized when time to initiate healing and tissue ingrowth of the dialysis cuffs in a sterile environment Illustrations courtesy of John Crabtree MD The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 5 Preoperative Management PATIENT EDUCATION Ensure PD education program is underway including the following topics e Home dialysis concept e Basics of PD therapy e Permanency of catheter until transplantation e Self care concept e Postoperative catheter care
38. eneration cephalosporin preferred to dialysate in following exchange PATIENT EDUCATION Tape catheter and transfer set to avoid kinking e Position tubing to prevent kinking while asleep if using APD e Prevent constipation with diet exercise and stool softeners e Patient to report reduced drain volume OUTCOMES EVALUATION Collect data to include e Type of obstruction inflow outflow e Etiology e Results of diagnostic testing e Findings and responses to interventions Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Hernia Significant abdominal wall hernias should be surgically repaired prior to the initiation of peritoneal dialysis Enlargement of the herniation may occur as a result of increased abdominal wall pressure from intraperitoneal dialysate Significant hernias left untreated increase the risk of further enlargement pain bowel entrapment and subsequent discontinuation of peritoneal dialysis The most commonly seen hernias are incisional umbilical and inguinal Incision
39. ent symptoms resolve bags clear e Continue antibiotics e Duration of therapy 14 21 days No clinical improvement by 5 days on appropriate antibiotics symptoms persist effluent remains cloudy remove catheter symptoms resolve bags Clear e Continue antibiotics e Duration of therapy 21 28 days Choice of therapy should always be guided by sensitivity patterns The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Polymicrobial Peritonitis Polymicrobial Peritonitis Days 1 3 Multiple gram negative organisms Multiple gram positive organisms mixed gram negative gram positive e Touch contamination STEP Consider GI problem e Consider catheter infection Change therapy to metronidazole in conjunction with ampicillin Continue therapy based on sensitivities ceftazidime or aminoglycoside Obtain urgent surgical assessment Without exit site With exit site or ER or tunnel infection tunnel infec
40. er Single Gram positive Organism Peritonitis 37 Pseudomonas Peritonitis 38 Other Single Gram negative Organism Peritonitis 39 Polymicrobial Peritonitis 40 Culture negative Peritonitis 41 Fungal Peritonitis 42 Mycobacterium Peritonitis 43 Relapsing Peritonitis 44 Peritonitis Terminology 45 All content and images used on this site are owned or licensed by Baxter International Inc or its affiliates Baxter for use on this site only Unauthorized use is prohibited Nothing contained herein shall be construed as conferring any license or right under any Baxter patent copyright or trademark CLINICAL PROCESS FOR OPTIMAL OUTCOMES Table of Contents Infectious Complications Management of the Exit site Tunnel Infection 46 Diagnosis and Management of Exit site Tunnel Infection 47 Section 4 Antibiotic Dosing Guidelines 48 Oral Antibiotics Used in Exit site and Tunnel Infections 49 Exit site Antibiotic Prophylaxis 50 Intraperitoneal Antibiotic Dosing Recommendations for CAPD Patients 51 Intermittent Dosing of Antibiotics in Automated Peritoneal Dialysis APD 52 Section 5 Appendix 53 Preoperative and Postoperative PD Catheter Insertion Instructions for Patients 54 Peritoneal Imaging 56 Principles of Accurate Peritoneal Dialysis Effluent Sampling and Culturing 57 Peritoneal Effluent Culture Laboratory Processing 58 Peritonitis Rate Calculations 59 Differential Diagnosis of Non infectious Cloudy Effluent 60 Providing for a Safe Env
41. erform physical exam including abdominal palpation degree and location of pain exit site and tunnel assessment Disconnect drained bag and send sample to laboratory for cell count with differential Gram stain and culture Dwell time should be at least one to two hours e Obtain specimen and inject 5 10 mLs into each blood culture bottle Send 50 mL of peritoneal effluent to be centrifuged at 3000g for 15 min followed by resuspension of the sediment for innoculation For full detail on specimen handling see Appendix The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management In presence of cloudy effluent with pain and or fever Initiate empiric antibiotic therapy within one hour while waiting for test results In presence of cloudy effluent add heparin 500 U L to new bag until effluent clears usually 48 to 72 hours Initiate adequate pain management intervention Peritonitis related pain may require opiates for adequate control which should be prescribed in adequate amounts to control pain appropriately Assess for need
42. erview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Start intraperitoneal antibiotics as soon as possible Allow to dwell for at least 6 hours Ensure gram positive and gram negative coverage Base selection on historical patient and center sensitivity patterns as available N cc 2 j wo oye Gram positive coverage Gram negative coverage Either first generation Either third generation cephalosporin or vancomycint cephalosporint or aminoglycoside Determine and prescribe ongoing antibiotic treatment T Ensure follow up arrangements are clear or patient admitted T Await sensitivity results Continued assessment and modification of therapy based on culture and sensitivity results refer to subsequent sections for specific organisms cultured Dwell time of the exchange for intermittent therapy must be a minimum of 6 hours tVancomycin may be considered if patient has a history of methicillin resistant Staphylococcus aureus colonization infection is seriously unwell or has a history of severe allergy to penicillins and cephalosporins If the center has an increased rate of methicillin resistance vancomycin may also be considered tlf the patient is cephalosporin allergic aztreonam is an alternative to ceftazidime or cefepime Vancomycin and ceftazidime are compatible
43. est Patients or PD staff should send the first cloudy bag or an aliquot thereof to the laboratory as quickly as possible e While delay of several hours from time of collection to time of culture does not decrease accuracy of bacteriological diagnosis it is preferable to expedite this process As large a volume 20 to 100 mL as possible should be cultured or concentrated to maxlmize bacterial recovery rates e Draw fluid from medication port Blood culture techniques are considered most optimal Inject fluid into standard blood culture medium 5 10 mLs required per bottle e The collection and processing of specimens require meticulous care in order to avoid contamination of the fluid Laboratory should be notified of specimens obtained from patients receiving antibiotic therapy as they may require special handling Identification and sensitivity testing should be expedited to facilitate initiation of specific antibiotic therapy Sterile or Culture negative Peritonitis e Incidence of sterile peritonitis varies from 2 to 20 and is more common when the laboratory facility does not have experience in processing peritoneal dialysis effluent e Other factors contributing to a high incidence of sterile peritonitis include e Insufficient culture sample volume e Causative organism difficult to culture e Causative organism requiring specialized culture media i e mycobacteria e Patient may not have informed PD center of current antibiotic
44. eter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications notes The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES section Infectious Complications This section contains information on adding medications to dialysis solutions It is important to ensure that the medication and specific dialysis solution are compatible Please contact dialysis solution manufacturer for more information Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Initial Empiric Management of Peritonitis The following steps including
45. ific diagnosis can be made by culturing the sediment after centrifugation of a large volume of effluent 50 100 mL using a solid medium such as Lowenstein Jensen agar and a fluid medium Septi Chek BACTEC Becton Dickinson etc The time of detection for growth of mycobacteria is decreased considerably in fluid medium Repeat microscopic smear examination and culture of dialysis effluent is mandatory for better yield in suspected cases of mycobacterial peritonitis The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Peritonitis Rate Calculations The most accurate peritonitis rate is one that is cumulative over a period of 12 months Measuring peritonitis rates both for the individual patient and PD facility provides insight into the peritoneal dialysis outcomes leading to interventions that may improve results Knowing peritonitis rates also allows for intercenter comparisons at different time points METHOD 1 Peritonitis Rate One episode per number of patient months Total number CAPD APD patient days at risk 30 4 days per month Patient months experie
46. individual healthcare practitioner for his or her specific recommendations The instructions below may offer your patient guidance during the process of planning PD catheter placement and follow up with their healthcare team in order to assure both patient education and successful outcomes during initial access placement Before Surgery The catheter placement procedure will be thoroughly explained Marking of the catheter site determination of the optimal location i e away from the belt line within easy reach and sight right or left side may be completed at this time Questions and concerns will be addressed Shower with a disinfectant soap as directed Do not eat or drink after Bowel preparation if required Alert the surgeon doctor of any known hernias Medications Take Do not take hold Adjust dosage Antibiotics Report any unusual cough fever chills or ill feelings prior to surgery Date of catheter placement Report to location Please notify the dialysis clinic when your catheter surgery has been scheduled Additional instructions notes The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers
47. information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Invasive steps e Laparoscopy e Open surgical repositioning of catheter or replacement e Partial omentectomy or omentopexy Adhesiolysis if indicated e Fluoroscopically guided stiff wires or stylet manipulation e Fogarty catheter manipulation CLINICAL APPROACH TO CATHETER OBSTRUCTION In case of fibrin related obstruction e Add heparin 500 U L to dialysate each exchange Instill recombinant tissue plasminogen activator tPA 6 Administration of tPA Prepare a solution of sterile water that has tPA 1 mg mL Instill up to 8 mLs 1 8 mg after the filling of the abdomen with dialysis solution and allow to dwell for 1 2 hours If the dialysate does not drain adequately ensure that there is enough dialysate in the abdomen and re instill the tPA at the same dose and allow to remain for an additional 90 minutes Upon clearance of catheter allow effluent to drain by gravity Prior to initiating dialysis the catheter may be flushed with sterile heparinized solution Add antibiotics first g
48. ions24 Thoracentesis or chest tube drainage with chemical pleurodesis talc slurry autologous blood OK 432 Picibanil minocycline has been successful e Video assisted thorascopic surgery VATS may permit visualization of a pleuroperitoneal communication and direct surgical obliteration if appropriate e Thoracoscopic pleurodesis with talc poudrage and or mechanical rub produces 87 93 success rate in resolving pleural leaks Follow up radiograph to establish closure of pleuroperitoneal communication may be utilized before restarting PD PATIENT EDUCATION e Report physical changes indicating potential leak e Alter dialysis regimen if required e Schedule more frequent clinic visits for observation OUTCOMES EVALUATION Collect data to include Type of leak e Diagnostic testing and results e Interventions e Response to interventions Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Catheter Adapter Disconnect or Fracture of Peritoneal Catheter KEY ASSESSMENTS Observe for
49. ironment for Peritoneal Dialysis 62 Normal Bacterial Flora of the Human Body 63 References 64 All tables used adapted with permission MultiMed 2010 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Use of the Guide Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Use of the Guide The format of the guide has been designed to provide the user a consistent approach for optimal peritoneal catheter and complications management Each section is intended to proactively address the key activities required to achieve desired clinical outcomes to promote early recognition of complications with appropriate clinical interventions and for collection of clinical data necessary for outcomes assessment CLINICAL PROCESS FOR OPTIMAL OUTCOMES Use of the Guide Clinical Process of Care Identifies the clinical processes of care that contribute to the overall outcome of improved catheter and complications management KEY ASSESSMENTS Identifies major clinical findings that must be incorporated into development of the plan of care The intent is to supplement good clinical judgement and to facilitate coordination of team activities KEY ACTIVITIES Identifies major activities of the renal team that organize and support achievement of the desired clinical outcome PATIENT EDUCATION Utilizes assessment and diagnostic findings to create an individualized patient caregiver education program maximize self care skills and promote adaptation t
50. it site or occult tunnel infection intra abdominal eet ca pane No clinical improvement by 5 days on pater aa appropriate antibiotics remove catheter STEP Duration of Peritonitis with exit site or tunnel infection may prove to be refractory therapy and catheter removal should be seriously considered at least 21 days Allow a minimum rest period of 3 weeks before reinitiating PDT If vancomycin resistant 5 aureus linezolid daptomycin or quinupristin dalfopristin should be used tln areas where tuberculosis is endemic rifampicin use for treatment of S aureus should be restricted Refractory is defined as failure to respond to appropriate antibiotics within 5 days The duration of antibiotic therapy following catheter removal and timing of resumption of peritoneal dialysis may be modified depending on clinical course BW body weight PD peritoneal dialysis The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Enterococcus Streptococcus Peritonitis Enterococcus Streptococcus on Culture Dis
51. itrated to the response and serum response levels 25 50 pg mL Isoniazid 200 300 mg q d Linezolid 400 600 mg b i d Metronidazole 400 mg t i d Moxifloxacin 400 mg q d Ofloxacin 400 mg first day then 200 mg q d Pyrazinamide 25 35 mg kg three times week Rifampin 450 mg q d for lt 50 kg 600 mg q d for gt 50 kg Trimethoprim sulfamethoxazole 80 400 mg q d mg milligram b i d two times per day q d every day g gram p o orally kg kilogram t i d three times per day q i d four times per day Table used adapted with permission MultiMed 2010 The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Antibiotic Dosing Guidelines Exit Site Prophylaxis Exit Site Antibiotic Prophylaxis Cleanse exit site daily Choose one of the following Q Q Q Apply gentamicin cream to exit site daily in all patients Apply mupirocin cream or ointment to exit site daily in all patients OR in nasal carriers only OR in noting a positive exit site culture for Staphylococcus aureus indicating carriage
52. key assessments key activities patient education and outcomes evaluation are applicable to all peritonitis algorithms shown on subsequent pages ISPD guidelines suggest a peritonitis rate of minimum of 1 in 18 patient months Rates of 1 in 41 52 months have been reported in some centers The center s overall peritonitis rate should be monitored at a minimum on an annual basis 2 KEY ASSESSMENTS The clinical presentation of peritonitis may include any of the following cloudy effluent abdominal pain fever and acutely declining peritoneal ultrafiltration Clinical Diagnosis e The following three criteria alone or in combination may be indicative of the presence of peritonitis Abdominal pain e Cloudy effluent with WBC gt 100 uL of which at least 50 are polymorphonuclear neutrophils PMN If absolute cell count is less than 100 uL with a predominance of PMNs the diagnosis of peritonitis is probable Identification of organisms on Gram stain or culture Differential Diagnosis of Cloudy Effluent 28 e Culture positive infectious peritonitis Infectious peritonitis with sterile cultures e Faulty culture techniques Inadequate specimen Inadequate culture conditions e Prior antibiotic usage e Slow growing organisms e Noninfectious causes of cloudy effluent see Appendix e Specimen taken from dry abdomen KEY ACTIVITIES Initiate the following Performed by the patient or by the PD nurse in the dialysis unit P
53. l and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Differential Diagnosis of Non infectious Cloudy Effluent Cellular causes Increased neutrophils Intra abdominal pathology e Cholecystitis Appendicitis e Bowel ischemia e Pancreatitis e Organ infarction Drug associated e Amphotericin B Vancomycin Contamination of PD fluid Endotoxin Acetaldehyde Specimen from dry abdomen Increased eosinophils Allergic reaction to sterilant or plasticizer e Tubing transfer sets e Dialysis solution bags Peritoneal catheter e Intraperitoneal air Drug associated Vancomycin e Gentamicin e Cephalosporins Increased erythrocytes Any cause of hemoperitoneum Retrograde menstruation e Ovulation e Ovarian hepatic cyst rupture Peritoneal adhesions e Strenuous exercise e Catheter associated trauma Drug associated e Tissue plasminogen activator tPA Increased malignant cells e Lymphoma Peritoneal metastases The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical tr
54. leaks and abnormal collections in patients on CAPD Nephrol Dial Transplant 1994 9 1449 1452 Prischl FC Muhr T Seiringer EM Funk S Kronabethleitner G Wallner M Artmann W Kramar R Magnetic resonance imaging of the peritoneal cavity among peritoneal dialysis patients using the dialysate as contrast medium JASN 2002 13 197 203 Juergensen PH Rizvi H Caride VJ Kliger AS Finkelstein FO Value of scintigraphy in chronic peritoneal dialysis patients Kidney Int 1999 55 1111 1119 Zorzanello M Fleming W Prowant B Use of tissue plasminogen activator in peritoneal dialysis catheters a literature review and one center s experience Neph Nurs J 2004 31 534 537 Crabtree JH Hernia repair without delay in initiating and continuing peritoneal dialysis Perit Dial Int 2006 26 178 182 Lewis DM Bingham C Beaman M Nicholls AJ Riad HN Polypropylene mesh hernia repair an alternative permitting rapid return to peritoneal dialysis Nephrol Dial Transplant 1998 13 2488 2489 Maaz DE Troubleshooting non infectious peritoneal dialysis issues Neph Nurs J 2004 31 521 533 Ponferrada LP Prowant BF Satalowich RJ Peritoneal dialysis complications Core curriculum for nephrology nursing In Counts CS 5th ed Pitman NJ American Nephrology Nurses Association 2008 824 847 The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment
55. may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide STEP STEP STEP CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Other Single Gram Positive Organism Peritonitis Other Gram Positive Organisms Including Coagulase Negative Staphylococcus on Culture Continue gram positive coverage based on sensitivities Stop gram negative coverage Assess clinical improvement repeat dialysis effluent cell count and culture at days 3 5 Clinical improvement symptoms resolve bags clear e Continue antibiotics Reevaluate for exit site or occult tunnel infection intra abdominal abscess catheter colonization etc No clinical improvement symptoms persist effluent remains cloudy Reculture amp evaluate BE Sn Nsnz tUUU No clinical improvement by 5 days on appropriate antibiotics remove catheter Duration of therapy at least 21 days Peritonitis with exit site or tunnel infection Consider catheter removalt Duration of therapy 14 21 day
56. ment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Chronic Care of Peritoneal Dialysis Catheter Optimal long term peritoneal catheter management focuses on maintaining a healthy exit site and catheter tract Catheter survival of greater than 80 at one year is desired 2 The primary preventative steps are ongoing assessment of the exit site institution of antibiotic prophylaxis early identification and treatment of exit site problems prevention of contamination and immobilization of the catheter to protect from trauma KEY ASSESSMENTS e Inspect exit site using magnifying glass as needed e Evaluate exit site and sinus tract e Classify exit site appearance by checking for e absence of drainage erythema crust scab granulation tissue swelling and pain or tenderness on palpation e Palpate tunnel e Compare exit site appearance on each Clinic visit e Verify function and assess integrity of peritoneal catheter by querying patients on CAPD for fill and drain duration or by reviewing cycler logs for fill and drain profiles for APD patients e Review chronic catheter care with patient Ensure compliance with topical antibiotic prophylaxis KEY ACTIVITIES e Document exit site and tunnel appearance at each Clinic visit e Obtain exit site culture if drainage or wetness noted e Perform e
57. mersion in water Assure the exit site is well dried after swimming OUTCOMES EVALUATION Collect data to include e Exit site classification assessment e Culture date result and treatment e Topical antibiotic regimen e Evaluation of catheter outcomes Peritonitis rate e Exit site tunnel infection rate e Catheter survival Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES section Noninfectious Complications Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Pericatheter and Subcutaneous Leaks Pericatheter and subcutaneous leaks are often related to poor catheter implantation technique anatomical abnormalities utilizing the catheter prior to healing or trauma Leakage occurring in the first 30 days following catheter implantation is usually external in nature and is evident at the catheter exit or incision site Subcutaneous leaks may resolve with a prolonged rest period or dry day Subcutaneous leakage involving the genital region or abdominal wall usually indicates a larger le
58. method less than 5 will be culture negative The solid media should be incubated in aerobic microaerophilic and anaerobic environments Blood culture bottles can be directly injected with 5 10 mL of effluent if equipment for centrifuging large amounts of fluid is not available this method generally results in a culture negative rate of 20 e The removal of antibiotics present in the specimen may increase the isolation rate if the patient is already on antibiotics Important Points The speed with which bacteriological diagnosis can be established is very important Concentration methods not only facilitate correct microbial identification but also reduce the time necessary for bacteriological cultures to turn positive e Rapid blood culture techniques e g BACTEC SEPTI CHEK BacT ALERT may further speed up isolation and identification A resin culture bottle should be used if patient is on antibiotics or antibiotics were discontinued less than 24 hours prior to culture e The majority of cultures will become positive after the first 24 hours and in over 75 of cases diagnosis can be established in less than 3 days Mycobacterium Examination e Examine smear of the peritoneal effluent with the Ziehl Neelsen stain smear negative disease is common e The sensitivity of the smear examination by the Ziehl Neelsen technique can be enhanced by centrifuging 100 150 mL of the dialysate sample e Prepare smear from the pellet e A spec
59. n Baxter Healthcare Corporation Baxter Baxter MiniCap and Twin Bag are trademarks of Baxter International Inc All other products trademarks are the property of their respective owners ALO6058C 04 12
60. nce step 1 P Example 2 000 days 30 4 days per month 65 8 months experience Number of patient months Number of episodes of peritonitis 1 episode per number of patient months step 2 i Example 65 8 months 2 episodes 32 9 or 1 episode every 32 9 patient months METHOD 2 Peritonitis Rate Episodes per patient year Total number CAPD APD patient days at risk 365 days per year Patient years experience step 1 JER R Example 2 000 days 365 days per year 5 5 years experience Number of episodes of peritonitis Number of years experience Episodes per st ep 2 patient year Example 2 episodes peritonitis 5 5 patient years 0 36 episodes per patient year Important points Include hospital days once home therapy begins in total days at risk Include hospital acquired peritonitis once home therapy begins in total peritonitis rate Relapsing episodes of peritonitis are counted as a single episode of peritonitis Recurrent peritonitis is a new episode of peritonitis and should be counted as an individual occurrence e Peritonitis rates should be no more than 1 episode every 18 months or 0 67 episodes per patient year per ISPD Programs should also be aware of the percentage of patients who are peritonitis free to include in unit s quality management programs e Exit site infection rates are calculated in the same manner as above The information published in this update for genera
61. ntations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES if Perioperative and Intraoperative VEERA Insert catheter Several methods of catheter implantation have been developed including open dissection simple laparoscopic modified advanced laparoscopic blind techniques ultrasound or flouroscopically assisted percutaneous techniques The following general guidelines should be adhered to irrespective of implantation technique chosen e Preoperative determination of most appropriate catheter type insertion site and exit site location e Use of double cuff catheter preferred Curled compared with straight intraperitoneal segment associated with less infusion pain e Paramedian insertion with deep cuff resting within the muscle see fig 7 FIG 7 Linea alba Peritoneal dialysis catheter implanted through paramedian approach with deep cuff resting within the muscle Rectus sheath and muscle e Position deep cuff in rectus sheath of abdominal wall e Implanting the cuff superficial to the rectus fascia can lead to the formation of a hernia or pseudohernia and late pericatheter leak see fig 8 FIG 8 Top Deep catheter cuff implanted external to the fascia The mesothelium from the peritoneal surface reflects along the surface of the catheter to reach the deep cuff Bottom The extension of the peritoneal lining above the muscle layer c
62. o the therapy OUTCOMES EVALUATION Identifies data required for tracking trending and comparative benchmarking through a Clinical monitoring system and for analysis by the continuous quality improvement CQI team to improve clinical outcomes CLINICAL PROCESS FOR OPTIMAL OUTCOMES section Catheter Insertion and Care Baxter Preoperative Management Optimal timing for peritoneal catheter insertion should take place 2 weeks prior to use of the catheter This is to ensure anchoring of the internal and external cuffs and healing of the exit site KEY ASSESSMENTS e Determine factors that may impair initial wound healing and exit site management Clinical status chronic cough steroids use edema Nutritional status malnutrition impairs healing Obesity pannus location Presence of colostomy gastrostomy or ureterostomy Use of adult diapers e Evaluate for Abdominal wall for rash and evidence of infection Pre existing abdominal scars Chronic intertrigo under abdominal skin folds Abdominal wall hernias that require repair KEY ACTIVITIES we e Set up appropriate communication plan with surgeon for catheter placement enh a and patient follow up see Appendix two cuff straight intercutt e Confirm catheter placement date segment coiled tip e Determine exit site location that optimizes longevity and patient satisfaction iiia rij Patient preference should be considered in determining exit site place Tenckhoff two
63. occur more commonly as early complications but can also occur at any time especially during or following episodes of peritonitis Ascertaining the cause of obstruction will assist in determining the appropriate intervention KEY ASSESSMENTS Inflow obstruction may be due to e Mechanical blockage such as clamps or kinks in transfer set tubing or catheter including segment under the dressing e Postimplantation blood clot or fibrin e Fibrin particularly with peritonitis Outflow obstruction may be due to e Mechanical blockage of transfer set or catheter e Postimplantation blood clot or fibrin e Fibrin particularly with peritonitis Constipation e Extrinsic bladder compression due to urinary retention e Catheter tip migration out of pelvis e Catheter entrapment Omental wrap Epiploic appendices of colon Fallopian tubes Adhesions KEY ACTIVITIES Conservative noninvasive steps Eliminate kinks or remove clamps on transfer set tubing and catheter Examine portions hidden by clothing and dressings Change body position e Dislodge blockage by experienced PD personnel Infuse dialysate or normal saline with a 50 mL syringe using moderate pressure push and pull maneuver Discontinue procedure if patient notes pain or cramping e Correct constipation e Obtain flat plate of abdomen to visualize catheter position a lateral view may be necessary to identify a subcutaneous and intraperitoneal catheter kink The
64. of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications PATIENT EDUCATION e Minimize intra abdominal pressure by avoiding e Straining e Coughing e Constipation Stair climbing e Lifting e Report increase in size of hernia or pain e Following surgical repair instruct patient to maintain separation of exit site and operative wound dressings to prevent cross contamination e Observe for recurrence e Use velcro abdominal binder during ambulatory periods following repair of umbilical and midline hernias is suggested e Instruct in use of alternative perioperative dialysis regimen e Supine position during dialysis therapy e Initial low volume intermittent dialysis Dry abdomen during ambulatory periods during first two weeks Volume graduated incrementally over two weeks to usual regimen OUTCOMES EVALUATION Collect data to include Type of hernia e Interventions utilized e Results e Dialysis prescription alterations Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and wa
65. of dialysis solution KEY ASSESSMENTS e Evaluate degree and duration of shoulder pain e Interview patient regarding recent infusion of air during exchange procedure e Rule out pain of cardiac origin e Assess for bowel perforation KEY ACTIVITIES Send effluent sample for cell count and culture to rule out potential contamination Prime PD system according to manufacturer s instructions e Observe patient caregiver s exchange procedure to verify adherence to adequate tubing priming e Perform upright abdominal X ray to identify PD catheter position and identify subdiaphragmatic free air in the peritoneal cavity Intervention infuse full exchange volume then drain dialysate with patient in knee chest or Trendelenburg position PATIENT EDUCATION Proper priming flushing procedure for PD system For manual systems always close clamps after infusion of solution OUTCOMES EVALUATION Collect data to include e Diagnostic testing and results e Interventions Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfecti
66. ora of the Human Body Nose Mouth amp Upper Respiratory Tract Staphylococcus aureus Gram positive Staphylococcus epidermidis Gram positive Streptococcus species Gram positive Fusobacterium species Gram negative e Actinomyces species Gram positive Corynebacterium diphtheriae Gram positive Haemophilus species Gram negative Non pathogenic Neisseria species Gram negative Skin e Staphylococcus aureus Gram positive Staphylococcus epidermidis Gram positive e Acinetobacter species Gram negative Pseudomonas aeruginosa Gram negative Candida species Fungi Corynebacterium diphtheriae Gram positive Genitalia Corynebacterium species Gram positive Lactobacillus species Gram positive e Alpha hemolytic and non hemolytic streptococci Gram positive Non pathogenic Neisseria species Gram negative Candida albicans Fungi 31 33 Intestinal Tract Escherichia coli Gram negative e Proteus species Gram negative Enterococci Gram positive Klebsiella Gram negative e Alpha hemolytic and nonhemolytic streptococci Gram positive Candida species Fungi Clostridium species Gram positive Enterobacteriaceae Gram negative Pseudomonas aeruginosa Gram negative Potential Environmental Sources of Bacteria Pseudomonads Gram negative soil water plants and animals e Pseudomonas thrives in moist environments special attention should
67. orption may be reduced when given in combination with sevelamer hydrochloride calcium salts oral iron preparations magnesium aluminum containing antacids zinc sucralfate or milk Administration should be staggered as much as possible The quinolone should be administered first allowing at least 2 hours between each preparation The duration of antibiotic therapy following catheter removal and timing of resumption of PD may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES section Antibiotic Dosing Guidelines Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Antibiotic Dosing Guidelines Management of Exit Site Tunnel Infection Oral Antibiotics Used in Exit Site and Tunnel Infections Amoxicillin 250 500 mg b i d Cephalexin 500 mg b i d to t i d Ciprofloxacin 250 mg b i d Clarithromycin 500 mg loading dose then 250 mg b i d or q d Dicloxacillin 500 mg q i d Erythromycin 500 mg q i d Fluconazole 200 mg q d for 2 days then 100 mg q d Flucytosine 0 5b 1g q d t
68. ous Complications Hemoperitoneum Blood loss into the peritoneal cavity will produce cloudy bloody effluent As little as a few drops of blood will produce grossly bloody dialysate The most common cause of hemoperitoneum in women includes retrograde menstruation and ovulation 22 Mild bleeding can be caused by catheter induced trauma strenuous exercise and the formation of abdominal adhesions Any bleeding however needs to be carefully monitored for severity and potential serious causation 22 KEY ASSESSMENTS e Observe dialysis exchange drain fluid for color and clarity Rule out peritonitis e Obtain patient history investigate potential causes including 2 22 e Status post peritoneal catheter placement Retrograde menstruation ovulation in females Note interval and length of occurrence e Surgical causes such as cholecystitis rupture of the spleen or pancreatitis Medical causes such as coagulation disorders polycystic kidney disease leakage of hematoma outside of peritoneal cavity post extracorporeal lithotripsy for kidney stones rupture of ovarian or hepatic cysts encapsulating peritoneal sclerosis Recent enema sigmoidoscopy colonoscopy episode of abdominal trauma or abdominal disease Recent use of intraperitoneal tPA KEY ACTIVITIES CLINICAL APPROACH TO HEMOPERITONEUM For postcatheter insertion blood tinged effluent e 200 1500 mL volume flush with heparinized dialysis fluid or saline until drain is
69. p evaluate STEP No clinical improvement by 5 days on appropriate antibiotics remove catheter The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal dialysis may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Other Single Gram Negative Organism Peritonitis Single Gram Negative Organism on Culture STEP Other E coli Proteus Klebsiella etc Stenotrophomonas Adjust antibiotics to sensitivity pattern Cephalosporin ceftazidime or cefepime may be indicated Treat with 2 drugs with differing mechanisms based on sensitivity pattern oral trimethoprim sulfamethoxazole is preferred STEP Assess clinical improvement repeat dialysis effluent cell count and culture at days 3 5 Assess clinical improvement repeat dialysis effluent cell count and culture at days 3 5 Clinical improvement Clinical improvem
70. py according to Clinical improvement No clinical improvement STEP sensitivity patterns Continue antibiotic after 5 days Duration of therapy based on Duration of therapy 14 days Remove catheter organism identified E See Continue antibiotics for at least 14 days after catheter removal The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal dialysis PD may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Fungal Peritonitis Fungal Species on Gram stain microscopy or culture STEP Remove catheter ISPD Guidelines 2010 Alternative Therapies 7 Flucytosine 500 mg po bid Fluconazole 100 200 mg po or IV and Amphotericin B daily or 200 mg IP in one exchange certain candida species q 24 48 hrs either alone or with Flucytosine 500 mg po bid W l i STEP Re evaluate for species and Minimal Re evaluate for species and Minimal
71. r forcibly remove crusts and scabs Apply new sterile dressing with each cleansing procedure until infection resolved even if not routinely used e Protect exit site from exposure to organisms and trauma e Review antibiotic antacid food interactions Note Quinolone absorption may be reduced when given in combination with sevelamer hydrochloride calcium salts oral iron preparations magnesium aluminum containing antacids zinc sucralfate or milk Administration should be staggered as much as possible The quinolone should be administered first allowing at least 2 hours between each preparation Rifampin can induce drug metabolizing enzymes reducing levels of medications ie anticonvulsants warfarin and statins OUTCOMES EVALUATION Collect data to include e Date of culture organism identified drug therapy used e Date infection resolved e Recurrent organisms date of drug therapy e Date of reeducation training e Antibiotic prophylaxis regimen used Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complication
72. r patients on peritoneal dialysis ASA O J 1993 39 62 65 Markowitz G Stokes MB Radhakrishnan J V Agati VD Acute phosphate nephropathy following oral sodium phosphate bowel purgative An unrecognized cause of chronic renal failure J Am Soc Nephrol 2005 16 3389 3396 Piraino B Bailie G Bernardini J Boeschoten E Gupta A Holmes C et al Peritoneal dialysis related infections recommendations 2005 update Perit Dial Int 2005 25 107 131 Gadallah MF Ramdeen G Mignone J Patel D Mitchell L Tatro S Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters Am J Kidney Dis 2000 36 1014 1019 Twardowski ZJ History of peritoneal access development nt J Artif Organs 2006 29 2 40 Prowant BF Twardowski ZJ Recommendations for exit site care Perit Dial Int 1996 16 S94 S99 Twardowski ZJ Prowant BF Classification of normal and diseased exit sites Perit Dial Int1996 16 532 550 Twardowski ZJ Nichols WK Peritoneal dialysis access and exit site care including surgical aspects In Gokal R Khanna R Krediet R Nolph K Textbook of peritoneal dialysis 2nd ed Dordrecht Netherlands Kluwer Academic Publishers 2000 307 362 Leblanc M Ouimet D Pichette V Dialysate leaks in peritoneal dialysis Sem Dial 2001 14 50 54 Litherland J Lupton EW Ackrill PA Venning M Sambrook P Computed tomographic peritoneography CT manifestations in the investigation of
73. reates the potential for a pseudohernia and pericatheter leak If the abdominal wall is weak the tract may dilate and develop a true hernia Illustrations courtesy of John Crabtree MD The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 8 Perioperative and Intraoperative WETE Te 33a e Catheter tip should have deep pelvic location e Close peritoneum below level of deep cuff with purse string absorbable sutures e Position subcutaneous cuff no closer than 2 cm from exit site 6 e Sinus tract is too long gt 2 3 cm the epithelium will not reach the cuff and granulation tissue may develop deeper in the tract As a result may see drainage or serous weeping Sinus tract is too short lt 2 cm the epidermis may be irritated by the cuff resulting in redness and irritation with eventual cuff extrusion e Subcutaneous tunneling instruments should not exceed the diameter of the dialysis catheter e Straight catheters should not be sharply arched as the catheter has memory e Sharply arching a straight catheter may encourage migration and cuff extrusion see figs
74. representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix After Surgery e Report any of the following to your surgeon doctor Bleeding e Fever e Vomiting Severe cough e Severe pain e Wet or dirty soiled dressing e Dressing falls off Emergency Contact e The surgical dressing SHOULD BE LEFT IN PLACE FOR AT LEAST SEVEN DAYS e The dressing should only be changed by your doctor or nurse at the dialysis clinic Do not shower or bathe until advised by the dialysis clinic that the exit site is healed e Avoid heavy lifting stair climbing straining and constipation Your activities for the next few weeks should be light e Resume all routine medications and diet as instructed by your doctor e Talk with the surgeon about the need for pain medication e If antibiotics are ordered take as directed until they are gone e Call your dialysis clinic to schedule your follow up appointment The telephone number is The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Peritoneal Imaging CT peritoneography an
75. rranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Abdominal Discomfort During Infusion and Drain KEY ASSESSMENTS Perform dialysis exchange inflow and outflow e Evaluate patient for the presence frequency and degree of discomfort or pain and relation to inflow and outflow e Monitor dialysis outflow drainage effluent for timing completeness of drain color and clarity e Check dialysis solution temperature e Rule out peritonitis KEY ACTIVITIES Inflow pain can be due to mechanical causes or to the effects of solution temperature or pH Inflow pain usually subsides gradually after filling is complete For abdominal discomfort during inflow 9 Change position during infusion e In CAPD patients reduce dialysis infusion rate by lowering the IV pole or partially closing the transfer set clamp In APD patients adjust fill rate or program cycler to deliver modified tidal 85 90 Ensure proper warming of dialysis solution e Investigate PD catheter position flat plate of abdomen e Reposition PD catheter if unresolved as necessary e Check shelf life of used dialysis solution For patients with significant discomfort Manual addition of bicarbonate or xylocaine solution to dialysis solutions has been documented Prior to adding any medication to dialysis solutions be sure to confirm compatibility of the medication with the specific PD solution For abdominal di
76. s CoNS can sometimes lead to relapsing peritonitis presumably due to biofilm involvement The duration of antibiotic therapy following catheter removal and timing of resumption of peritoneal dialysis may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Pseudomonas aeruginosa Peritonitis Pseudomonas Species on Culture Without catheter infection With catheter infection exit site tunnel exit site tunnel current or prior to peritonitis STEP Use 2 antibiotics with differing Catheter removal mechanisms oral quinolone ceftazidime gy cefepime tobramycin piperacillin based on sensitivities Continue oral and or systemic Repeat cell count and culture at days 3 5 antibiotics for at least 2 weeks Clinical improvement symptoms resolve bags clear e Continue antibiotics e Duration of therapy at least 21 days No clinical improvement symptoms persist effluent remains cloudy e Reculture am
77. s Management of Exit Site Tunnel Infection Diagnosis and Management of Exit Site Tunnel Infection Assessment Purulent drainage from exit site STEP Do culture Gram stain Gram positive organism Gram negative organism Include S aureus coverage STEP Penicillinase 2 resistant penicillin PO PO quinolones or first generation cephalosporin PO Adjust antibiotics to Adjust antibiotics to culture and sensitivity culture and sensitivity If slow improvement or severe cases If pseudomonas and no improvement add STEP add rifampin PO second antipseudomonal drug e 450 mg day lt 50 kg e g IP ceftazidime 600 mg day gt 50 kg Avoid use of Vancomycin for gram positive Exit site infection should be reserved for S aureus Exit site infection Re evaluate Re evaluate l l STEP Infection resolving Infection unresolved Infection resolving Infection unresolved a continue therapy 3 4 weeks continue therapy 3 4 weeks for minimum 2 weeks consider catheter for 3 weeks and consider catheter and re evaluate revision removal re evaluate revision removal 7 In areas where tuberculosis is endemic rifampin used for treatment of Staphylococcus aureus should be restricted Rifampin can induce drug metabolizing enzymes reducing levels of medications ie anticonvulsants warfarin and statins Quinolone abs
78. scomfort during outflow e Leave small amount of dialysate fluid in the peritoneal cavity in patients on CAPD In APD patients program cycler to deliver modified tidal PD 85 90 PATIENT EDUCATION OUTCOMES EVALUATION Teach patient causes and interventions 9 Collect data to include e Rapid inflow reduce infusion rate e Duration and degree of discomfort Too rapid a transition to larger dialysis fill e Interventions volumes slowly increase fill volumes e Adjustments to dialysis prescription e Dialysis solution too warm or too cold e Patient tolerance warm to body temperature e Medications prescribed Potential cause and interventions for PD e Diagnostic tests and results catheter malposition Enter data into catheter management database e Peritonitis prevention e Medication administration e Training for APD The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Pneumoperitoneum Intraperitoneal air may lead to referred pain to the shoulder Pneumoperitoneum typically occurs due to the inadvertent infusion of air during the instillation
79. te into supine patient with anterior dynamic images obtained at one frame per minute for 15 minutes Instruct patient to move and walk for 30 60 minutes to promote intraperitoneal mixing and to raise intra abdominal pressure to drive the radiotracer into the source of the leak e Obtain 5 minute postambulatory static images in anterior posterior and both lateral views e Drain dialysate from peritoneal cavity and repeat 5 minute static images in anterior posterior and both lateral views Include chest if pleuroperitoneal fistula is suspected Include inguinal region if scrotal swelling has been noted The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Principles of Accurate Peritoneal Dialysis Effluent Sampling and Culturing Identifying appropriate antibiotic therapy is dependent on accurate specimen collection and microbiological diagnosis of peritonitis Key Points for Specimen Processing e Culture should be obtained as early as possible The first bag of cloudy solution is the best specimen as the probability of a positive diagnostic culture is the great
80. ted Peritoneal Dialysis APD DRUG Cefazolin IP DOSE 20 mg kg IP every day in long dwell DRUG Cefepime IP DOSE 1g IP in one exchange per day DRUG Fluconazole IP DOSE 200 mg IP in one exchange per day every 24 48 hours DRUG Tobramycin IP DOSE Loading dose 1 5 mg kg IP in long dwell then 0 5 mg kg IP each day in long day dwell DRUG Vancomycin IP DOSE Loading dose 30 mg kg IP in long dwell repeat dosing 15 mg kg IP in long dwell every 3 5 days following levels keep trough levels gt 15 g mL IP intraperitoneal Table used adapted with permission MultiMed 2010 The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES section Appendix Baxter CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Preoperative and Postoperative PD Catheter Insertion Patient Instructions It is essential to establish appropriate communication between the surgeon and the nephrology dialysis clinic during preparation and follow up to PD catheter placement A variety of procedures exist for catheter insertion Your patient should always consult your
81. ther abdominal wall deformities Chronic abdominal wall intertrigo Abdominal stomas colostomy ileostomy urostomy e Urinary or fecal incontinence e Desire to be able to take deep tub bath e Patient preference Contraindications for Presternal Upper Abdominal Peritoneal Dialysis Catheter e Body image issues e Breast implants presternal e Requires surgical expertise SS SFG 5 P FIG 4 An extended catheter with an upper chest exit site can be utilized in patients with morbid obesity abdominal stomas or urinary fecal incontinence or per patient preference 2 An extended catheter for upper abdominal exit site may be useful for patients with obesity or floppy skin folds or per patient preference Illustrations courtesy of John Crabtree MD The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES 4 Preoperative Management e Patients for whom dialysis initiation is not anticipated until at least 3 to 5 weeks after catheter implantation may benefit from having the catheter embedded Moncrief technique see figs 6A and 6B e Catheter emb
82. tibacterial and in liquid form e Do not transfer cleansing agent between containers to avoid cross contamination 9 e Soften crusts and scabs with saline or soap and water Never forcibly remove crusts and scabs 9 Apply antibiotic cream or ointment for prophylaxis using a cotton swab Do not apply directly from tube e Avoid mupirocin ointment with polyurethane catheters e Immobilize catheter with tape or immobilization device at all times Apply dressing to protect from contamination Povidone iodine can be damaging to the peritoneal catheter over time e Healed site may be left uncovered but should be kept dry e In case of prophylactic antibiotics a nonocclusive dressing may be suitable Perform exit site care if exit site becomes wet or grossly contaminated e Report trauma of exit site or catheter e Maintain regular soft bowel movements CARE FOR PATIENTS WHO SWIM Exposure to water with high concentration of bacteria may lead to exit site infection and potential loss of the peritoneal catheter Swimming may be allowed for patients with fully healed exit site e Avoid swimming in the presence of exit site infection Apply waterproof occlusive dressing over exit site area e Avoid submersion of unprotected exit site in water particularly in a public pool hot tub or Jacuzzi Swimming in a private chlorinated pool or salt water may have less risk for contamination Perform exit site care immediately following sub
83. tion In case of laparotomy indicating na A STEP intra abdominal pathology abscess continue antibiotics remove catheter remove catheter cl Duration of therapy Continue antibiotics 14 days minimum 21 days based on clinical response The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal dialysis may be modified depending on clinical course GI gastrointestinal The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Culture Negative Peritonitis Culture Negative on Days 1 amp 2 STEP Continue initial therapy Day 3 culture still negative Clinical assessment Repeat PD fluid white cell count and differential St 2 Infection resolving Infection not resolving Patient improving clinically Special culture technique for unusual causes e g viral mycoplasma Continue initial therapy for 14 days mycobacteria Legionella Consider fungi Now culture positive Still culture negative Adjust thera
84. tion of PD may be modified depending on clinical course The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Infectious Complications Peritonitis Management Peritonitis Terminology Recurrent Peritonitis Defined as an episode of peritonitis that occurs within 4 weeks of completion of treatment for a preceding episode but with a different organism Relapsing Peritonitis Defined as an episode of peritonitis caused by the same genus and species of bacteria that caused the immediately preceding episode or 1 sterile episode and occurring within four weeks of completion of antibiotics see previous page Repeat Peritonitis Defined as an episode of peritonitis that occurs more than 4 weeks after completion of antibiotics for an infection with the same organism Refractory Peritonitis Defined as failure to observe clearing of the effluent after 5 days of appropriate antibiotics Catheter Related Peritonitis Peritonitis in conjunction with an exit site or tunnel infection with the same organism or 1 site sterile Relapsing peritonitis
85. tive evaluation and ideally for weekly dressing changes by experienced staff OUTCOMES EVALUATION Review operative report for baseline catheter data e Date surgeon inpatient outpatient placement surgical approach special procedures e Catheter type catheter material position of cuffs direction of exit site e Catheter function Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Postoperative Management Optimal postoperative care promotes healing of the exit site wound and the catheter tract including immobilization of the catheter to prevent trauma to the exit site and cuffs and minimizing exposure to bacteria and prevent colonization If possible implantation should be timed to allow 2 weeks for healing prior to initiation of dialysis If dialysis is required early small volume exchanges in the supine position may be performed with frequent checks for leakage Postoperative assessment and dressing changes should be performed weekly by experienced staff only using aseptic technique with mask and gloves until healed KEY
86. treatment e Patient s signs and symptoms related to other medical condition i e pancreatitis The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Appendix Peritoneal Effluent Culture Laboratory Processing The correct microbiological culturing of peritoneal effluent is of utmost importance to establish the microorganism responsible Identification of the organism and subsequent antibiotic sensitivities will not only help guide antibiotic selection but in addition the type of organism can indicate the possible source of infection Culture negative peritonitis should not be greater than 20 of episodes Standard culture technique is the use of blood culture bottles but culturing the sediment after centrifuging 50 mL of effluent is ideal for low culture negative results Procedure e Centrifuge 50 mL of peritoneal effluent at 3000 g for 15 minutes e Follow with resuspension of the sediment in 3 5 mL of sterile saline e Inoculate this material both on solid culture media and into a standard blood culture medium method most likely to identify the causative organisms With this
87. until effluent clears e Obtain imaging and surgical consultation as required PATIENT EDUCATION Instruct women of reproductive age about the potential for hemoperitoneum e Observe dialysis exchanges drain fluid for decreasing color and resolution Teach patient to e Avoid heavy lifting trauma Document frequency duration and treatment of bloody effluent e Bleeding typically minimal to moderate may resolve spontaneously OUTCOMES EVALUATION Collect data to include e Interventions including medications e Response to intervention Alterations in dialysis prescription or schedule Enter data into catheter management database The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Noninfectious Complications Hydrothorax Hydrothorax secondary to a pleuroperitoneal communication is an uncommon complication of peritoneal dialysis The management of hydrothorax should begin with the temporary discontinuation of peritoneal dialysis to avoid aggravating pleural fluid accumulation and allowing the effusion to regress KEY ASSESSMENTS Signs and symptoms of pleural
88. xit site care as required e Review and reinforce exit site and catheter care plan ANTIBIOTIC PROPHYLAXIS ISPD recommends one of the following e Gentamicin 0 1 cream daily at exit site effective in reducing both gram positive and gram negative infections e Mupirocin cream or ointment daily at exit site effective in reduction of gram positive infections Note Avoid mupirocin ointment with polyurethane catheters e Mupirocin intranasal bid for 5 to 7 days every month if identified as nasal Staphylococcus aureus Carrier The information published in this update for general and educational purposes only This information is in no way meant to be a substitute for medical treatment and may not be construed as medical advice diagnosis or treatment Please refer to the front page of Access Guide for a full overview of Baxter s disclaimers representations and warranties associated with this guide CLINICAL PROCESS FOR OPTIMAL OUTCOMES Chronic Care of Peritoneal Dialysis Catheter PATIENT EDUCATION Daily routine exit site care e Wash and dry hands thoroughly e Inspect catheter exit site and tunnel before catheter care e Showers recommended avoid immersion in tub e Cleanse exit site every day every other day or a minimum of two to three times per week e Cleanse exit site with liquid antibacterial soap or antiseptic i e povidone iodine or chlorhexidine e Cleansing agent should be nonirritating nontoxic an

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