Apd

1. Acute P.D. catheter
insertion
Hafez M. Bazaraa
MMXVI

2. PATIENT BLOOD
DIALYZATE
Membrane
Solute diffusion
UF
UF ΔP

3. PATIENT BLOOD
DIALYZATE
Membrane
Solute diffusion
UF
UF ΔP
HD
dialyzer
Concentrate + HCO3 + Treated water
Mechanical
TMP

4. PATIENT BLOOD
DIALYZATE
Membrane
Solute diffusion
UF
UF ΔP
PD
peritoneum
IP via catheter
Osmosis
DIALYZATE EXCHANGES THROUGH PERITONEUM
•I.P. catheter
•Dialyzate
•Exchange prescription & implementation

5. What we WON’T discuss
 Indications of dialysis
 P.D. vs H.D.?
 C.P.D.
 Catheter care
 Dialysis adequacy
 Detailed PD complications

6. Is there a role for APD catheter?
 APD IS a simple & useful mode of RRT
 Acute HD is sometimes not feasible/
available
 Patient may be unfit for HD & CRRT is not
always available
 Vs long-term PD catheters; short-term
indications & not always available

7. Contraindications
 Omphalocoele or Gastroschisis
 Diaphragmatic Hernia
 Bladder extrophy
 Obliterated Peritoneal Cavity
 Recent abdominal Surgery*
 Abdominal Malignancy*
* Relative

8. Before insertion
 Who should do it?
 Patient examined
 Determine site of entry
 Consent
 Ensure empty bladder
 I.V. access
 Assemble dialyzate & lines
 Sedation/ Anesthesia
 Patient monitoring
 Asepsis

9. Entry device

10. Entry site

11. •MIDLINE is safest
•Skin puncture (near) vertical; NEVER < 60-70°
•Towards pelvis generally preferable
•A lateral-directed entry may NOT be attempted or
unintentionally allowed until IP

13. Entry site

14. Fluid-filled peritoneum
 Facilitates entry
 Reduces visceral injury
 May facilitate U/S guided entry
 Usually requires initial puncture for prefilling
(unless ascites)
 When prefilling, don’t advance further once
IP. FIX POSITION DURING FILLING
 10-40 mL/Kg ( 2L)

15. Recognition of I.P. entry
DRY ABDOMEN
(before infusion or direct entry)
 Release of resistance
 Drip release
 Test flush
 Realtime U/S visualization
 Free flow (! bladder ! intestine)
 Respiratory fluctuation
FLUID FILLED PERITONEUM
 Release of resistance
 Realtime U/S visualization
 Free outflow
 Respiratory fluctuation

16. Catheter Entry
 Adequate (NOT EXCESSIVE) incision
skin ± deeper NOT peritoneal
 Avoid false abd wall track
 ALL side holes must be IP
 Entry may be made
– With trocar-catheter
(sheath trocar tip once IP)
– Seldinger technique
 Suture MAY be needed

17. Saudi J Kidney Dis Transplant 1994;5(2):184-189
IMMEDIATE fill-drain flush cycle

22. Balance

23. TROUBLESHOOTING
 Closed 3-way, kinked line, air in line
 No run in
 Underfilling (↑ volume, insert catheter deeper,
reposition patient, install 2nd
“only!” dwell)
 Circuit leak (external or abd. wall)
 Partial obstruction
- Blood clots, fibrin  attempt relief using trocar
- Catheter kink  trocar may relieve
- Intraabdominal: adhesions, omentum
 catheter repositioning

24. TROUBLESHOOTING
 Closed 3-way, kinked line, air in line
 Inadequate gravity drive (height of bag)
 Poor venting of non-collapsible bags
 Catheter tip position
(reposition patient or catheter)
 Obstruction
- Blood clots, fibrin  attempt relief using trocar
- Catheter kink  trocar may relieve
- Intraabdominal: adhesions, omentum
 catheter repositioning

25. TROUBLESHOOTING