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Acute peritoneal dialysis (PD) in the PICU

Acute peritoneal dialysis (PD) in the PICU. Constantinos J. Stefanidis. “P. & A. Kyriakou” Children's Hospital, Athens, Greece. HD. CRRT. or. ARF. Neonates and infants. Early referral. PD. Choice of dialysis in ARF. Late referral life-threatening hyperkalemia or severe volume overload.

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Acute peritoneal dialysis (PD) in the PICU

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  1. Acute peritoneal dialysis (PD) in the PICU Constantinos J. Stefanidis “P. & A. Kyriakou” Children's Hospital, Athens, Greece

  2. HD CRRT or ARF Neonates and infants Early referral PD Choice of dialysis in ARF Late referral life-threatening hyperkalemia or severe volume overload C J Stefanidis 2002

  3. Were used as the primary means of acute renal replacement therapy in a nearly equal percentage of centers Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3 Choice of dialysis in ARF PD HD CRRT C J Stefanidis 2002

  4. Preferential use of PD and CRRT PD CRRT Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3 C J Stefanidis 2002

  5. When to start PD in ARF ? • Symptomatic uraemia • Hyperkalaemia • Volume overload • Severe metabolic acidosis • ( refractory to medical treatment) Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831 C J Stefanidis 2002

  6. When to start PD in ARF ? S. creatinine and blood urea are not primary indications for dialysis unless they relate to mental status changes Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54: 1817-1831 C J Stefanidis 2002

  7. When to start PD in ARF ? There are essentially no data In the absence of data it is advisable to start dialysis at the earliest sign that it may be needed Flynn JT. Pediatr Nephrol 2002;17(1):61-9 C J Stefanidis 2002

  8. Benefits of PD PD still remains the modality of renal replacement therapy of choice in many pediatric nephrology centers, because: 1. it requires minimal equipment and infrastructure 2. it is fairly inexpensive compared with other modalities 3. it is relatively easy to perform and does not require additional nursing personnel. Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9 C J Stefanidis 2002

  9. Benefits of PD 1. Less haemodynamic instability Children with ARF who are hypotensive, requiring vasopressor support and children with multiple organ failure are successfully managed with PD 2. Avoidance of systemic anticoagulation 3. Avoidance of angioaccess Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9 C J Stefanidis 2002

  10. Disadvantages of PD 1. Slower correction of metabolic parameters lower urea clearances 2. Lower ultrafiltration 3. Risk of peritonitis Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9 C J Stefanidis 2002

  11. Efficiency Volume Anticoa- Use in hy- control gulation potension Moderate Moderate No Yes HD Moderate High No Yes CAVH Moderate Low and Good No Yes variable CVVH Moderate High Good Yes Yes CVVHD High High Good Yes Yes Choice of dialysis in ARF Complexity PD Low Intermittent Thadhani R et al Acute renal failure. N Engl J Med 1996; 334: 1448-1460 C J Stefanidis 2002

  12. Acute PD in the PICU Choice of dialysis treatment PD catheters for ARF Prescription of PD in ARF C J Stefanidis 2002

  13. Trocath catheters • Their prolonged use (> 3 days) was associated with a significant risk of: • leakage • malfunction • peritonitis A major complication was viscus perforation. In our days very few centers use these catheters C J Stefanidis 2002

  14. Acute PD catheters Trocath catheters Percutaneus guidewire inserted catheters Tenckhoff catheters implanted under general anesthesia C J Stefanidis 2002

  15. Percutaneus guidewire inserted catheters Site of introduction: Level of umbilicus lateral to the rectus sheath (newborns) or any where along a line parallel to the rectus sheath. Local anesthetic C J Stefanidis 2002

  16. Angiocath 18 G Insertion of Angiocath 18 G Flushed with 5 ml of N/S and aspirated to ensure bowel content is not retrieved Percutaneus guidewire inserted catheters C J Stefanidis 2002

  17. The Angiocath 18 G is removed Priming of the abdomen is not essential Percutaneus guidewire inserted catheters The wire is advanced through the needle in the peritoneal cavity (3-4 cm) Seldinger (Acta Radiologica, 38, [1953], 368-376) C J Stefanidis 2002

  18. The catheter is threaded around the wire and is forced in the peritoneal cavity with a «screwing action» Percutaneus guidewire inserted catheters 3-4 mm incision around the wire. In newborns is not recommended ` The wire is removed The catheter is taped to the skin Seldinger (Acta Radiologica, 38, [1953], 368-376) C J Stefanidis 2002

  19. It was used in 10 neonates. Intraperitoneal bleed : 1 neonate Dialysate leak: 1 Catheter blockade: 4 Incidence of peritonitis: 1 Kohli HS et al Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol 1999 Apr;13(3):241-4 Femoral vein catheter for neonates Guide wire-inserted femoral vein polyurethane catheter (Medcomp-pediatric) 14 G 13.5 cm 3 sideports C J Stefanidis 2002

  20. Percutaneus guidewire inserted catheter Cook catheter 8.5 French 8 cm 44 sideports http://www.cookgroup.com/cook_incorporated/pdf/CDB11.pdf C J Stefanidis 2002

  21. 5 French 5.5 cm 5 French Cook PD catheter • 29 infants • age 4.5 +/- 1.3 months • weight 4.8 +/- 0.5 kg • Complications: • inadequate inflow in one case • bleeding in one case • accidental removal in one case Duration of the placed catheters was 9.9 +/- 2.7 days, without the problems associated with the use of a stiff catheter Bunchman TE. Acute peritoneal dialysis access in infant renal failure Perit Dial Int 1996;16 Suppl 1:S509-11. C J Stefanidis 2002

  22. Cook (pleuropericardial) pig tail catheter 8.5 French 15 cm 6 sideports http://www.cookgroup.com/cook_incorporated/pdf/CADB14.pdf C J Stefanidis 2002

  23. Cook (pleuropericardial) pig tail catheter Retrospective study (1992-1995) in 46 patientsComplications of the Seldinger-placed Cook (pleuropericard) catheter were limited: leakage (1/44) bleeding: n = 0 obstruction or dislocation: n = 4 peritonitis: n = 1 (Candida) Vande Walle J et al New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Perit Dial 1997;13:190-4 C J Stefanidis 2002

  24. Introducer 11 French Tenckhoff catheters 9.5 French Lewis MA, Nycyk JA.Practical peritoneal dialysis--the Tenckhoff catheter in acute renal failure. Pediatr Nephrol 1992 Sep;6(5):470-5 C J Stefanidis 2002

  25. Tenckhoff catheters implanted under general anesthesia 16 French C J Stefanidis 2002

  26. Tenckhoff catheters (TC) implanted under general anesthesia compaired with Cook catheters (CC) TC in 22 patients and a CC in 37 patients The duration of use of TCs (16 days) was significantly greater than the duration of CC use (5 days; P < 0.001). By day 6 of dialysis, 90% of TCs were functioning without complications compared with 46% of CCs Only 2 patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%). • Chadha V et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis. 2000;35(6):1111-6. C J Stefanidis 2002

  27. Laparoscopic Tenckhoff catheter implantation In 25 children laparoscopic TCIs and in 23 conventional TCIs The inner cuff was placed adjacent to the peritoneum, without sutures leakage: n =1, bleeding: n = 0 ,obstruction : n = 2 Laparoscopic TCI is feasible in children of all age groups, with equivalent functional results compared to conventional TCI An additional advantage is the option to identify and eliminate anatomical risk factors, such as intra-abdominal adhesions or preformed inguinal hernias in male infants Daschner M et al Perit Dial Int 2002 Jan-Feb;22(1):22-6 C J Stefanidis 2002

  28. Acute PD catheters A Tenckhoff catheter implanted under general anesthesia is recommended If the patient can not undergo surgery, a percutaneus guidewire inserted PD catheter should be placed C J Stefanidis 2002

  29. Acute PD in the PICU Choice of dialysis treatment PD catheters for ARF Prescription of PD in ARF C J Stefanidis 2002

  30. Prescription of acute PD The patient should be connected and start automated PD immediately after surgical catheter implantation. Complications (peritonitis and hypothermia) are significantly reduced with the use of a cycler compared with the manual method. Kohli HS et al Ren Fail 1995 If APD is not available a closed-drainage system PD system with disconnection should be used. The use of a closed-drainage system reduced the incidence of system-related peritonitis Valeri A et al Am J Kidney Dis 1993 C J Stefanidis 2002

  31. Initial prescription of acute PD Cefazoline (250 mg/liter) and Heparin 500 U/liter should be added to the dialysis solution for first two days Dialysate with a glucose concentration of 1.36% for volume of urine > 1.5 ml/kg/hr and UF is not required Otherwise a dialysate with a higher glucose concentration 2.27% (or even higher) should be prescribed For children with severe lactic acidosis or hepatic failure a bicarbonate-based dialysate can be prepared in the hospital pharmacy C J Stefanidis 2002

  32. Initial prescription of acute PD Initially the exchange volume is kept low (20 ml/kg, 100-200 ml/m²) to reduce the risk of dialysate leakage After 24 hours the volume is increased by 100-200 ml/m²/day up to 800-1000 ml/m² as tolerated by the patient The first day one-hour dwells are prescribed and usually two-hour dwells are recommended on the second day C J Stefanidis 2002

  33. Adapted prescription of acute PD Prescription of PD should be individually adjusted in the next days according to the needs of ultrafiltration and the parameters of adequacy (bl. urea and s. creatinine levels) Usually after the stabilization period 5 to 8 exchanges daily are effective in most children with ARF. The aim is to deliver a maximum clearance to compensate the catabolic stress C J Stefanidis 2002

  34. Messages to take home 1. Early referral and early initiation of PD is very important for the outcome of children with ARF 2. PD should not be used in children with severe life-threatening hyperkalemia or with severe volume overload C J Stefanidis 2002

  35. Messages to take home 3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD 4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time C J Stefanidis 2002

  36. Messages to take home 3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD 4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time C J Stefanidis 2002

  37. Messages to take home 5. The perscription of PD treatment should be optimized in critically ill children with ARF in order to achieve the goal of controlling uremia and fluid overload, and giving appropriate nutritional support C J Stefanidis 2002

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