Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures

50

Peritoneal Dialysis

Kathleen A. Marinelli

Majid Rasoulpour

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).

  1. Indications
  2. Renal failure, when conservative management has failed to adequately control any of the following conditions (8,9):
  3. Hypervolemia
  4. Hyperkalemia
  5. Hyponatremia
  6. Refractory metabolic acidosis
  7. Hyperphosphatemia
  8. Azotemia
  9. Additional fluid space needed for delivering drugs and/or nutrition
  10. Inherited disorders of organic and amino acid metabolism when HD or CVVH/D is unavailable (10,11)
  11. In hyperammonemic metabolic crisis, evidence suggests that ammonia is more efficiently removed by extracorporeal techniques than by PD (12).
  12. In babies with imminent or current intracranial hemorrhage, PD is considered the therapeutic option of choice, especially in nonhyperammonemic disorders (12).
  13. Relative Contraindications
  14. Acute abdomen
  15. Abdominal adhesions
  16. Immediately after abdominal surgery (13)
  17. Diaphragmatic or abdominal wall disruptions
  18. Equipment (Figs. 50.1, 50.2 and 50.3)
  19. Masks, sterile drapes, gowns, and gloves
  20. Povidone–iodine
  21. 1% xylocaine without epinephrine
  22. 3-mL syringe with 25-gauge needle
  23. Intravenous cutdown tray with no. 11 surgical blade
  24. Waterproof tape
  25. 22-gauge angiocatheter
  26. 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)
  27. Dialysis solution (1.5, 2.5, or 4.25%)
  28. Other concentrations can be made by manual mixing of standard solutions
  29. Heparin
  30. Home Choice Automated PD System (Fig. 50.2) or any other reliable fluid warmer
  31. IV pole
  32. Inline burette set
  33. Ultra Set CAPD Disposable Disconnect Y-Set
  34. MiniCap Extended Life PD Transfer Set With Twist Cap
  35. FlexiCap Disconnect Cap with povidone–iodine solution
  36. Medicap with povidone–iodine solution
  37. 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.

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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).

  1. Preprocedure Care
  2. Obtain informed consent.
  3. Check body weight and abdominal girth.
  4. Check for infection at the insertion site.
  5. Decompress the stomach.
  6. Catheterize the bladder.
  7. 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).

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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.

  1. Add 500 U of heparin to each 1 L of the dialysis solution. Start with 1.5% dialysate.
  2. 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).
  3. 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.
  4. Connect the outlet of the burette set to the inflow line of the Ultra Set CAPD Disposable Disconnect Y-Set.
  5. 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.
  6. Prime the circuit in a sterile fashion, clamp, and cap the end of the transfer set, or the short limb of the Y-Set.
  7. 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).

  1. Monitor vital signs.
  2. Restrain infant in supine position.
  3. Scrub.
  4. Prepare the skin of the abdomen (Chapter 4).
  5. 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.

  1. Infuse approximately 0.5 mL of xylocaine around the insertion point.

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  1. Select either a 14-gauge angiocatheter or a temporary dialysis catheter.
  2. If you elect to use a 14-gauge angiocatheter:
  3. Insert the angiocatheter at the insertion site.
  4. Remove the stylet.
  5. Infuse ~20 mL of normal saline to confirm a free flow. Clamp.
  6. Proceed to Step 10 (Section E).
  7. 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).
  8. Test patency.
  9. Temporary catheter:
  10. May observe flow of a few drops of saline. Connect the free end of the Transfer Set to the catheter.
  11. Allow approximately 30 mL of dialysis solution to enter peritoneal cavity by gravity.
  12. Clamp the short arm of the Y-Set (inflow).
  13. Unclamp the long arm of the Y-Set (outflow).
  14. Repeat steps a(2) through a(4) several times.
  15. Secure the temporary catheter with a purse-string suture and tape if inflow and outflow occur readily.
  16. Tenkhoff catheter:
  17. 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.
  18. 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.

  1. Management
  2. 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.
  3. Establish a dialysis volume per pass. Starting volume is usually 20 to 30 mL/kg.
  4. Clamp the long arm of the Y-Set (outflow line).
  5. Unclamp the inflow line.
  6. Allow the dialysate to flow in as quickly as possible while carefully observing vital signs.
  7. Clamp the inflow line.
  8. Allow the fluid to dwell.
  9. Unclamp the outflow when dwell time is completed.
  10. Allow 5 to 10 minutes for draining.
  11. Clamp the outflow line.
  12. Repeat the cycle.
  13. Increase the volume by 5 mL/kg/cycle slowly. Maximum volume is 40 mL/kg if tolerated, attained over 12 to 24 hours.
  14. Continue to add 500 U of heparin/L of dialysate, until dialysate effluent return is clear, with no evidence of cloudiness.
  15. Add 3 mEq/L of K if serum K level is ≤4 mEq/L.
  16. Monitoring
  17. Maintain hourly PD flow sheet.
  18. Volume in
  19. Volume out
  20. Net/hr (+/-)
  21. Net over the course of dialysis (+/-)
  22. Intakes (enteral, parenteral)
  23. Outputs (urine, gastric, insensible water loss, etc.)
  24. Establish a desired fluid balance. Proceed gently if negative balance is required. Reassess the state of hydration frequently.
  25. 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.
  26. Obtain cell count, Gram stain, and culture of peritoneal effluent every 12 hours.
  27. Recognize that some drug dosages may need adjustments (18,19 and 20) (see Appendix E).
  28. Complications

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.

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TABLE 50.1 Complications of Peritoneal Dialysis

Problem (Risk)

What to Do

Perforation of bladder, bowel, or major vessels (3%–7%)

Surgical consultation

Puncture-site bleeding (3%–15%)

Apply pressure gently.
Purse-string suture.

Blood-stained dialysis maintained after several cycles

Check hematocrit frequently.
Continue heparin.
Rule out major-vessel bleeding.

Leakage from exit site (2%–20%)

Reduce dwell volume until leakage stops.

Extravasation of dialysate into the anterior abdominal wall

Replace with new catheter.

More than 10% of solution retained in each of several consecutive cycles (outflow obstruction) (15%–30%)

Reposition infant gently.
Reposition catheter by rotation and slight retraction. Do not advance.
Remove if unchanged.
Replace with new catheter.

Two-way obstruction (3%–20%)

Irrigate catheter with small amount of dialysate or saline aseptically.
Reposition.
Remove if unchanged.

Dislodgment of catheter (3%)

Replace with new catheter.

Hydrothorax (0%–10%)

Reposition infant, head and chest above level of abdomen.
Decrease dwell volume.

Hyperglycemia (10%–60%)

Avoid high concentrations of dialysate unless outflow is inadequate.
Low dose of insulin if needed.

Lactic acidosis

Use bicarbonate dialysatea

Hyponatremia

Reduce fluid intake. Aim to increase outflow if secondary to fluid overload.

Hypernatremia

Increase fluid intake if secondary to excessive ultrafiltrate.

Exit site infection (4%–30%)

Systemic antibiotics.

Peritonitis (0.5%–30%)

Several rapid flushing exchanges.
Blood culture. Systemic vancomycin plus ceftazidime or an aminoglycoside.
For fungal peritonitis, systemic therapy is needed and catheter should be removed.

Hernia (inguinal or umbilical) (2%–13%)

Possible need for future repair.

Small bowel herniation and gangrene at catheter exit site (1 case report)

Surgical consultation

Removal of therapeutic drugs

See Appendix E.

a1.5% bicarbonate dialysis solution: 140 mEq/L Na, 110 mEq/L Cl, 30 mEq/L HCO3, 15 g of glucose; add sterile water to 1,000 mL.
Data from refs. (4,15,16,21,22,23,24,25,26,27,28,29,30,31).

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).

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FIG. 50.4. A continuous arteriovenous hemofiltration circuit.

References

  1. Blatz S, Paes B, Steele B.Peritoneal dialysis in the neonate. Neonatal Network. 1990;8:41.
  2. Stapleton FB, Jones DP, Green RS.Acute renal failure in neonates: incidence, etiology and outcome. Pediatr Nephrol. 1987;1:1314.
  3. Meeks ACG, Sims DG.Treatment of renal failure in neonates. Arch Dis Child. 1988;63:1372.
  4. Matthews DE, West KW, Rescorla FJ, et al. Peritoneal dialysis in the first 60 days of life. J Pediatr Surg.1990;25:110.
  5. Fischbach M.Peritoneal dialysis prescription for neonates. Peritoneal Dial Int. 1996;16:S512.
  6. Esperanca MJ, Collins DL.Peritoneal dialysis efficiency relation to body weight. J Pediatr Surg. 1966;1:162.
  7. Chan KL, Ip P, Chiu CSW, Cheung Y.Peritoneal dialysis after surgery for congenital heart disease in infants and young children. Ann Thorac Surg. 2003;76:1443.
  8. Anand SK.Acute renal failure in the neonate. Pediatr Clin North Am. 1982;29:791.
  9. Moghal NE, Embleton ND.Management of acute renal failure in the newborn. Semin Fetal Neonatal Med. 2006;11:207.
  10. Batshaw ML, Brusilow SW.Treatment of hyperammonemic coma caused by inborn errors of urea synthesis. J Pediatr. 1980;97:893.
  11. Gartner L, Leupold D, Pohlandt F, et al. Peritoneal dialysis in the treatment of metabolic crises caused by inherited disorders of organic and amino acid metabolism. Acta Paediatr Scand.1989;78:706.
  12. Daschner M, Schaefer F.Emergency dialysis in neonatal metabolic crises. Adv Renal Replace Ther. 2002;9:63.
  13. Mattoo TK, Ahmad GS.Peritoneal dialysis in neonates after major abdominal surgery. Am J Nephrol. 1994;14:6.
  14. Chadha V, Warady BA, Blowey DL, et al. Tenckoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis.Am J Kidney Dis.2000;35:1111.
  15. Kohli HS, Barkataky A, Kumar RSV, et al. Peritoneal dialysis for acute renal failure in infants: a comparison of three types of peritoneal access. Renal Fail.1997;19:165.
  16. Kohli HS, Bhalla D, Sud K, et al. Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol.1999;13:241.
  17. Ronnholm KAR, Holmberg C.Peritoneal dialysis in infants. Pediatr Nephrol. 2006;21:751.
  18. Trompeter RS.A review of drug prescribing in children with end-stage renal failure. Pediatr Nephrol. 1987;1:183.
  19. Aandgil A, Srivastava RN.Drug prescribing in children with renal failure. Indian Pediatr. 1989;26:693.
  20. Bennett WM, Blyth WB.Use of drugs in patients with renal failure. In: Schrier RW, Gottschalk CW, eds. Disease of the Kidney. 4th ed. Boston: Little, Brown; 1988:3437.
  21. Kohli HS, Arora P, Kher V, et al. Daily peritoneal dialysis using a surgically placed Tenckhoff catheter for acute renal failure in children. Renal Fail.1995;17:51.
  22. Bunchman T.Acute peritoneal dialysis access in infant renal failure. Peritoneal Dial Int. 1996;16:S509.
  23. Walle JV, Raes A, Castillo D, et al. New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Peritoneal Dial.1997;13:190.
  24. Blowey DL, McFarland K, Alon U, et al. Peritoneal dialysis in the neonatal period: outcome data. J Perinatol.1993;13:59.
  25. Sizun J, Giroux JD, Rubio S, et al. Peritoneal dialysis in the very-low-birth-weight neonate (less than 1000g). Acta Paediatr.1993;82:488.
  26. Werner HA, Wensley DF, Lirenman DS, et al. Peritoneal dialysis in children after cardiopulmonary bypass. J Thorac Cardiovasc Surg.1997;113:64.
  27. Dittrich S, Dahnert I, Vogel M, et al. Peritoneal dialysis after infant open heart surgery: observations in 27 patients. Ann Thorac Surg.1999;68:160.
  28. Sorof JM, Stromberg D, Brewer ED, et al. Early initiation of peritoneal dialysis after surgical repair of congenital heart disease.Pediatr Nephrol.1999;13:641.
  29. Reznik VM, Griswold WR, Peterson BM, et al. Peritoneal dialysis for acute renal failure in children. Pediatr Nephrol.1991;5:715.
  30. Huber R, Fuchshuber A, Huber P.Acute peritoneal dialysis in preterm newborns and small infants: surgical management. J Pediatr Surg. 1994;29:400.
  31. Wong KKY, Lan LCL, Lin SCL, Tam PKH.Small bowel herniation and gangrene from peritoneal dialysis catheter exit site. Pediatr Nephrol. 2003;18:301.
  32. Menster M, Bunchman TE.Nephrology in pediatric intensive care unit. Semin Nephrol. 1998;18:330.