Atlas of Procedures in Neonatology, 4th Edition
Kathleen A. Marinelli
Acute Peritoneal Dialysis (1,2,3,4, and 5)
In neonates, acute peritoneal dialysis (PD) is frequently preferred over hemodialysis (HD), continuous arteriovenous hemofiltration with or without dialysis (CAVH/D), and continuous venovenous hemofiltration with or without dialysis (CVVH/D) because it is technically easier. Because peritoneal surface area per kilogram of body weight is relatively larger in newborns and children than in adults, peritoneal dialysis usually allows adequate clearance and removal of excess fluid (6); in addition, it avoids the need for anticoagulation and maintenance of adequate vascular access (7).
- Renal failure, when conservative management has failed to adequately control any of the following conditions (8,9):
- Refractory metabolic acidosis
- Additional fluid space needed for delivering drugs and/or nutrition
- Inherited disorders of organic and amino acid metabolism when HD or CVVH/D is unavailable (10,11)
- In hyperammonemic metabolic crisis, evidence suggests that ammonia is more efficiently removed by extracorporeal techniques than by PD (12).
- In babies with imminent or current intracranial hemorrhage, PD is considered the therapeutic option of choice, especially in nonhyperammonemic disorders (12).
- Relative Contraindications
- Acute abdomen
- Abdominal adhesions
- Immediately after abdominal surgery (13)
- Diaphragmatic or abdominal wall disruptions
- Equipment (Figs. 50.1, 50.2 and 50.3)
- Masks, sterile drapes, gowns, and gloves
- 1% xylocaine without epinephrine
- 3-mL syringe with 25-gauge needle
- Intravenous cutdown tray with no. 11 surgical blade
- Waterproof tape
- 22-gauge angiocatheter
- A temporary catheter such as a 14-gauge angiocatheter or one of the commercially available temporary dialysis catheters, e.g., a Trocath (Trocath Peritoneal Dialysis Center, Kendall McGaw Laboratories, Sabana Grande, Puerto Rico)
- Dialysis solution (1.5, 2.5, or 4.25%)
- Other concentrations can be made by manual mixing of standard solutions
- Home Choice Automated PD System (Fig. 50.2) or any other reliable fluid warmer
- IV pole
- Inline burette set
- Ultra Set CAPD Disposable Disconnect Y-Set
- MiniCap Extended Life PD Transfer Set With Twist Cap
- FlexiCap Disconnect Cap with povidone–iodine solution
- Medicap with povidone–iodine solution
- Baby weigh scale with low resolution (Medela, which has a resolution of 2 g from 0 to 6,000 g) (Fig. 50.2)
An alternative approach is to utilize a pediatric cycler set. Experience in using this equipment is necessary. We recommend a commercially available cycler that provides a minimum fill volume of 50 mL with 10-mL increments.
FIG. 50.1. A, IV pole (Fig. 50.3); B, Dianeal PD-2 Peritoneal Dialysis Solution (Baxter Healthcare Corporation, Deerfield, IL, USA); C, Inline Burette Set 150 mL (Abbott Laboratories, North Chicago, IL, USA); D, Ultraset CAPD Disposable Disconnect Y-Set (Baxter Healthcare Corporation, Deerfield, IL, USA); E, MiniCap Extended Life PD Transfer Set With Twist Clamp (Baxter Healthcare Corporation, Deerfield, IL, USA); F, Flexicap Disconnect Cap with Povidone–Iodine Solution (Baxter Healthcare Coporation, Deerfield, IL, USA); G, Minicap with Povidone–Iodine Solution (Baxter Healthcare Corporation, Deerfield, IL, USA).
- Preprocedure Care
- Obtain informed consent.
- Check body weight and abdominal girth.
- Check for infection at the insertion site.
- Decompress the stomach.
- Catheterize the bladder.
- Place preweighed diaper under the patient.
Before assembly of system, wash hands and put on a mask. All connections should be made using sterile technique. Universal precautions should be observed (Chapter 4). Keep all tubing clamped. See Fig. 50.3 for connections.
FIG. 50.2. Right: Home Choice Automated PD System (Baxter Healthcare Corporation, Deerfield, IL, USA). Left: Medela baby weigh scale (Medela, McHenry, IL, USA).
FIG. 50.3. An assembled peritoneal dialysis circuit illustrates an IV pole (A) and an in-line burette (C) that is connected to an Ultra Set CAPD Y-Set (D). The short limb of this Y-Set is connected to the transfer set (E), which is connected to a Tenckhoff catheter exiting from the abdominal cavity of a doll, and its long limb has a bag at its end that is located on the floor.
- Add 500 U of heparin to each 1 L of the dialysis solution. Start with 1.5% dialysate.
- Warm a liter bag of dialysate (Dianeal or other), or a larger bag if 1 L dialysate is not unavailable, by resting it on the heating surface of the Home Choice Automated PD System, or a reliable fluid warmer. The temperature can be set between 35°C and 37°C. For a newborn, keep the temperature at 37°C (in older pediatric patients, the temperature is usually set to 36°C, and occasionally to 35°C if the environmental temperature is high).
- Spike the in-line burette set (Abbott Laboratories, North Chicago, IL, USA) into the dialysate (Dianeal or other) when the ideal temperature has been achieved.
- Connect the outlet of the burette set to the inflow line of the Ultra Set CAPD Disposable Disconnect Y-Set.
- Connect the short arm end of the Y-Set to the twist clamp end of a MiniCap Extended Life PD Transfer Set with Twist Clamp (Baxter Healthcare Corporation, Deerfield, IL, USA). If the catheter is placed surgically, this Transfer Set is routinely connected by most surgeons to the Tenckhoff catheter, before assessment of patency, and you will be able to skip this step.
- Prime the circuit in a sterile fashion, clamp, and cap the end of the transfer set, or the short limb of the Y-Set.
- Procedure (Also Refer to Chapter 25, Abdominal Paracentesis, and Videos on Procedures DVD.)
The ideal technique is surgical insertion of a permanent peritoneal dialysis catheter, which can be placed in the neonatal intensive care unit (14). The catheter is tunneled from the peritoneum to an exit site on the skin; it usually works well and leaks infrequently (Quinton Pediatric Tenckhoff Neonatal 31 cm2 Cuff catheter. Kendall Healthcare, Mansfield, MA, USA). However, if surgical insertion of a permanent catheter is not possible, an alternative approach is to utilize an angiocatheter or a temporary PD catheter for no longer than a few days. Note that surgically inserted catheters are associated with fewer acute complications (15). With catheters inserted at the bedside, guidewire-inserted femoral catheters have shown the least mechanical complications; intravenous catheters produce more mechanical complications than femoral catheters, but less than stylet catheters (16,17).
- Monitor vital signs.
- Restrain infant in supine position.
- Prepare the skin of the abdomen (Chapter 4).
- Drape to expose the insertion site.
The choice of insertion site is influenced by the preference of the physician and/or the presence of postoperative wounds, abdominal wall infection, or organomegaly. A location one third the distance from the umbilicus to the symphysis pubis in the midline or a site lateral to the rectus sheath in either of the lower quadrants is preferred.
- Infuse approximately 0.5 mL of xylocaine around the insertion point.
- Select either a 14-gauge angiocatheter or a temporary dialysis catheter.
- If you elect to use a 14-gauge angiocatheter:
- Insert the angiocatheter at the insertion site.
- Remove the stylet.
- Infuse ~20 mL of normal saline to confirm a free flow. Clamp.
- Proceed to Step 10 (Section E).
- If using a soft and flexible temporary catheter, such as a Cook catheter (Cook Critical Care, Bloomington, IN, USA), follow the manufacturer's instructions. Then proceed to Step 10 (Section E).
- Test patency.
- Temporary catheter:
- May observe flow of a few drops of saline. Connect the free end of the Transfer Set to the catheter.
- Allow approximately 30 mL of dialysis solution to enter peritoneal cavity by gravity.
- Clamp the short arm of the Y-Set (inflow).
- Unclamp the long arm of the Y-Set (outflow).
- Repeat steps a(2) through a(4) several times.
- Secure the temporary catheter with a purse-string suture and tape if inflow and outflow occur readily.
- Tenkhoff catheter:
- Unclamp the Transfer Set. Will observe either saline or dialysis fluid, which was instilled at surgery, draining. Allow to drain to completion. Connect the short arm of the Y-Set to the Transfer Set.
- Follow steps a(2) through a(5) of Step 10 above.
This procedure (Step 10) usually results in a positive fluid balance (the volume drained is less than the volume infused). This retention is acceptable.
- Establish a cycle time. This is usually about 60 minutes and consists of a fill by gravity, dwell time of 45 minutes, and drain by gravity.
- Establish a dialysis volume per pass. Starting volume is usually 20 to 30 mL/kg.
- Clamp the long arm of the Y-Set (outflow line).
- Unclamp the inflow line.
- Allow the dialysate to flow in as quickly as possible while carefully observing vital signs.
- Clamp the inflow line.
- Allow the fluid to dwell.
- Unclamp the outflow when dwell time is completed.
- Allow 5 to 10 minutes for draining.
- Clamp the outflow line.
- Repeat the cycle.
- Increase the volume by 5 mL/kg/cycle slowly. Maximum volume is 40 mL/kg if tolerated, attained over 12 to 24 hours.
- Continue to add 500 U of heparin/L of dialysate, until dialysate effluent return is clear, with no evidence of cloudiness.
- Add 3 mEq/L of K if serum K level is ≤4 mEq/L.
- Maintain hourly PD flow sheet.
- Volume in
- Volume out
- Net/hr (+/-)
- Net over the course of dialysis (+/-)
- Intakes (enteral, parenteral)
- Outputs (urine, gastric, insensible water loss, etc.)
- Establish a desired fluid balance. Proceed gently if negative balance is required. Reassess the state of hydration frequently.
- Measure serum glucose and potassium every 4 hours for the first 24 hours or until stable, then twice a day. Obtain other serum electrolyte levels twice daily. Check blood urea nitrogen, serum creatinine, serum calcium, serum phosphorus, and serum magnesium once a day.
- Obtain cell count, Gram stain, and culture of peritoneal effluent every 12 hours.
- Recognize that some drug dosages may need adjustments (18,19 and 20) (see Appendix E).
See Table 50.1.
Continuous Arteriovenous Hemofiltration in Newborns
A short discussion of CAVH and CVVH is included for completeness. However, use of these modalities should be limited to regional centers and performed by those with the required expertise.
TABLE 50.1 Complications of Peritoneal Dialysis
CAVH is an extracorporeal technique for removing plasma water and its dissolved solutes of less than 50,000 Da over an extended period of time. With use of an arterial access line of the largest possible diameter and a venous access line, blood enters the extracorporeal circuit (arterial tubing, hemofilter, and venous tubing) by way of the arterial line and returns to the patient by way of the venous line (Fig. 50.4). The arteriovenous pressure gradient frequently produces adequate blood flow through the circuit; however, the addition of a blood pump may be necessary. As blood flows through the extracorporeal device, plasma water and dissolved solutes are filtered out (ultrafiltered) through the pores of a hemofilter. A hemofilter is composed of many fine capillaries of highly water-permeable membranes located within a cylindric case. The filtered-off fluid (ultrafiltrate) is drained out by way of an exit incorporated on the surface of the hemofilter. The fluid removed has all the characteristics of an ultrafiltrate of plasma water.
Within the past few years, except when it is incorporated in an extracorporeal membrane oxygenation circuit for ultrafiltration, CAVH has been widely replaced by CVVH. Two single-lumen catheters (or one double-lumen venous catheter) are used for vascular access in CVVH. Blood flow is maintained by a pump and is therefore independent of the patient's systemic blood pressure. Several brands of CVVH machines are currently available in many pediatric centers for CVVH/D (32).
FIG. 50.4. A continuous arteriovenous hemofiltration circuit.
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