|Year : 1994 | Volume
| Issue : 2 | Page : 184-189
|Acute Peritoneal Dialysis Using Stylet Catheter
T Timothy Paul, KS Ramprasad
Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
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|How to cite this article:|
Paul T T, Ramprasad K S. Acute Peritoneal Dialysis Using Stylet Catheter. Saudi J Kidney Dis Transpl 1994;5:184-9
| Introduction|| |
Ganter was the first to describe instillation of 1.5 liters of saline solution to the peritoneal cavity of a patient to treat uremia  . The true era of clinical peritoneal dialysis (PD) began in 1959 along with the availability of single catheter method and commercially available PD solutions  . Since then PD has become an established mode of treatment for renal failure. Although there have been further advances in the field of PD itself such as continuous ambulatory peritoneal dialysis (CAPD), continuous cyclic peritoneal dialysis (CCPD) etc, PD using stylet catheter continues to be an important mode of treating acute renal failure (ARF) particularly in small and peripheral hospitals. This technically simple method of treating renal failure has even survived the technologically advanced and more glamorous forms of treatment like haemodialysis (HD) and its other advanced modifications. The main advantages of PD lie in the fact that it is a simple procedure, can be performed at the bed side and without the need for any sophisticated equipment. It can be made available even in primary health care settings. In this paper, we describe some of the practical aspects of PD using a stylet catheter.
| Indications of PD|| |
Generally speaking the indications of PD using stylet catheter are by and large the same as that for HD and are as follows.
1. Acute Renal Failure
This is the major indication for this form of dialysis. Many nephrologists are of the opinion that the first dialysis in ARF probably can be PD although there is a shift towards continuous arteriovenous hemofiltration (CAVH) when facilities are available. In such situation PD using a stylet catheter can be started without delay and is technically quite simple. It can even be started on patients with bleeding diathesis as well as in post operative and post traumatic cases, since there is no need to use heparin or its use can be limited to minimum. Even in a patient who is hypotensive, PD may be used effectively despite reduced peritoneal clearance. In addition, invasive diagnostic procedures (e.g. a kidney biopsy) can be performed on a patient on PD with less risk than in a patient being treated with HD.
2. Chronic Renal Failure
Use of acute PD in patients with chronic renal failure is limited only to the situation where a life-saving dialysis is urgently needed while arranging for transfer to a center where facilities for long term dialysis like HD or CAPD exist and can be offered. It is worth remembering that acute PD should be avoided if some other form of treatment can be offered in a patient who is likely to benefit from CAPD in future.
3. Pediatric Dialysis
Haemodialysis units, particularly in the developing world, are primarily equipped for handling only adult patients. Thus, PD using a stylet catheter can be a life saving form of treatment for pediatric patients with ARF, poisoning etc.
PD is one of the accepted modalities of treatment for drug poisoning when other facilities are not available. However, the efficacy of removal of toxic substances is only 5 to 30% of HD. PD may be advantageous in patients with marked hypotension as well as in children.
| Procedure|| |
Access to the Peritoneal Cavity
Strict aseptic precautions should be followed while obtaining access to the peritoneal cavity since peritonitis is a potentially life threatening complication  . It should always be remembered that asepsis is the safest and the most cost effective approach for prophylaxis of infection  . Thus, the physician should ensure that strict aseptic techniques are followed by all personnel handling PD patients and equipment.
Iodine compounds are generally used for chemical 'sterilization' of the patient's abdominal wall, the equipment used as well as in all connect-disconnect procedures of PD. A five minute delay should be allowed for effective contact disinfection when povidone-iodine solutions are used.
Two main types of peritoneal catheters are currently available for use in acute PD. They are; the disposable stylet catheter (Trocath)  and the permanent silastic catheter  . The disposable stylet catheter consists of two parts; a plastic catheter of approximately 3 mm overall diameter and 20 to 30 cm length with multiple small holes on its distal 8 cm, and a metal stylet that protrudes from the end of the catheter providing a sharp cutting tip to penetrate the abdominal wall. The specific indications for the use of disposable catheters include acute poisoning when only one dialysis session is contemplated, in the setting of severe extra cellular volume overload and severe hyperkalemia when acute dialysis has to be considered, when there is one-way obstruction of a silastic catheter with abdominal distension (drainage of the peritoneal cavity can be accomplished through a style catheter), or during antibiotic treatment of a skin infection of the abdominal wall before implanting a permanent silastic catheter.
Permanent (indwelling) silastic catheters are bacteriologically safer when used with a closed dialysate delivery circuit  and have some advantages over disposable catheters. They include avoidance of repeated puncture, ease of instituting dialysis, excellent irrigation characteristics independent of the patient's position, and no pain during or between dialysis,  . Therefore, some centers prefer silastic indwelling peritoneal catheters. However, the insertion and maintenance is technically more difficult than stylet catheter.
| Preparation of the Patient and Placement of the Catheter|| |
1. Empty the bladder. If the patient cannot void, urethral catheterization should be done.
2. Prepare the abdominal wall by shaving from xiphoid to the symphysis pubis. Examine the patient's abdomen carefully for features which may cause difficulties to catheter insertion (e.g. skin infection, previous surgery, or organomegaly).
3. The physician carrying out the procedure should wear full sterile gown, gloves, mask and cap. All assistants and bystanders should also wear masks and caps.
4. The physician should describe the procedure to the patient. This will help in relieving the patient's anxiety and consequently obtain his/her co-operation.
5. Mild sedation might be required. Diazepam 10 mg IM, atropine 0.25 mg IM and local anesthesia (1% procaine) is adequate in most patients. However, general anesthesia may be required in children.
6. Fill the abdomen with pre-warmed dialysis solution. The fluid is infused through a large bore needle to distend the abdomen moderately. A spinal needle of 15 gauge is ideal. Alternatively, this can be done during the procedure itself after introducing the perforated segment of the catheter into the peritoneal cavity.
7. The catheter is usually inserted in the midline 3 to 6 cm below the umbilicus. The catheter may also be introduced in either iliac fossa but this is rarely done nowadays. Local anesthesia is administered in the selected area.
8. Make a skin incision with a pointed blade. Care should be taken not to make the incision too big since the catheter should fit snugly in the wound to prevent leakage and to reduce the risk of infection. Nicking the fascia of the linea alba with the blade reduces the force needed to carry the catheter through.
9. Insert the stylet catheter perpendicular to the abdominal wall, while the patient tightens his abdominal musculature; a sudden decrease in resistance occurs when the stylet catheter passes the parietal peritoneum and enters the peritoneal cavity. Withdraw the stylet about 2 cm to sheath its cutting tip.
10. If the abdomen has not been primed with fluid prior to the procedure, the catheter should be advanced until all perforations are within the peritoneal cavity; the stylet should then be withdrawn and 2,000 ml of dialysis fluid is instilled into the abdominal cavity.
After filling the abdomen, the catheter, with the reinserted stylet but with the cutting tip shielded is advanced at 45° into the true pelvis. Remove the stylet at this stage. Observe whether the dialysis fluid wells up into the catheter lumen. This confirms that the catheter is in the peritoneal space.
11. Connect the administration set to the catheter and allow the dialysate to drain out. If the patient complains of discomfort, the catheter tip may be readjusted.
12. Fix the catheter to the abdominal wall with a good surgical tape after covering the entry site with several sterile gauze squares. A purse string suture may be put to anchor the catheter. It is advisable to cut the gauze to facilitate fitting around the catheter. The exit site should be kept clean and dry at all times.
A schematic presentation of the PD procedure as well as a cross section of the abdomen showing the position of the PD catheter is depicted in [Figure 1].
| The Use of Heparin|| |
Conventionally it is advised to add heparin to dialysis solutions in the first four to six cycles after catheter implantation  . If there is any bleeding it is advisable to continue heparin till the returns are clear. If there is peritonitis one has to use heparin in all cycles  . The usual dose is 200 to 500 IU/L of PD fluid.
| Dialysis Solution|| |
There is a great variety of commercially available solutions with different formulae. The fluid used most commonly has the composition given in [Table 1]. Ready to use dialysis solutions are available in 1 or 2 liter glass bottles or 0.5, 1 and 2 liter plastic bags as well as 10 liter plastic containers. Glass bottles should be avoided as far as possible since they are likely to introduce bacteria with the replacement air that enters the bottles as the fluid drains from the bottle into the peritoneal cavity.
The dialysate dextrose concentration determines the amount of water that is removed by way of ultrafiltration. Hypertonic fluids containing 2.5 g/dl and 4.25 g/dl of dextrose are available for use in patients with volume overload who need removal of large amounts of water.
Potassium (K + ) is generally not added to PD fluid. However, in patients on digitalis therapy, it may be necessary to add K + .
| Peritoneal Irrigation and Dialysate Exchange Cycles|| |
During dialysis, irrigation of the peritoneal cavity by dialysis solution is carried out by exchange cycles comprising three phases; inflow, diffusion (dwell) and outflow. Fluid should be warmed to body temperature before infusion into the peritoneal cavity.
Most adults will tolerate an inflow volume of about two liters. The exchange volume can be adjusted, according to patient's size, the abdominal volume and cardiopulmonary tolerance  . The usual dwell time allowed is 20 minutes. In children and small sized adults, the amount of fluid instilled may be calculated using the formula; body weight x 40-50 ml/cycle. The inflow and outflow volume should be monitored on a sheet of paper in order to know the exact negative balance achieved.
| Closing Peritoneal Dialysis|| |
When dialysis is completed, the peritoneal cavity should be drained completely. The catheter is then removed, again under strict aseptic conditions. Occasionally, catheter withdrawal may be uncomfortable and painful due to the incarceration of omental fringes into the holes in the distal segment of the catheter. Instilling local anesthesia to peritoneal cavity may alleviate this discomfort. The catheter then can be gently mobilized and freed by a slow axial rotation. After withdrawing the catheter, the abdominal wound should be preferably closed with one or two stitches.
| Complications of Peritoneal Dialysis|| |
The common complications associated with the use of the stylet catheter , are the following:
Mild bleeding is frequently observed after catheter insertion and clears spontaneously after a few dialysate exchanges. It is advisable to add heparin (500 IU) to the dialysis solution to prevent clotting in the catheter. Major bleeding is occasionally seen. In such situations, various measures are recommended such as pressure dressing, placement of a deep purse string around the catheter, injection of epinephrine solution in the tissues surrounding the catheter, and discontinuation of heparin in the dialysis fluid. In most instances bleeding clears spontaneously and blood transfusion seldom becomes necessary.
2. Bowel perforation
This is a rare complication and can be avoided by priming the abdomen with fluid prior to catheter insertion. Also, the use of excess force while advancing the catheter into the peritoneal cavity should be avoided. A perforation of the gut has to be suspected in case of failure of dialysate to drain, cloudy, malodorous or frankly feculent returning fluid or occurrence of watery diarrhoea. The stool will then test strongly positive for glucose. Two therapeutic approaches have been equally successful: firstly, conservative management with local and systemic antibiotics and continued peritoneal dialysis through another abdominal entry site, and secondly, laparotomy and surgical repair of the perforation, followed by continuous antibiotic lavage to prevent the formation of peritoneal adhesions.
3. Perforation of the urinary bladder
This is a rare complication. PD can be continued uneventfully by inserting a new peritoneal catheter after ensuring continuous drainage of the urinary bladder with a Foley's catheter.
4. Leakage of dialysis fluid around the catheter
This occurs when the skin and/or peritoneal opening made for the insertion of the stylet catheter is too large. This apparently benign complication, can become quite bothersome due to a constant seeping of fluid and it also adds to the chances of acquiring infection. Catheter re-insertion through a new small incision and avoidance of abdominal over distension with dialysis fluid may be needed to avoid seepage.
5. Inadequate drainage
The common causes of inadequate drainage are given in [Table 2]. Manipulating and/or flushing the catheter may restore a proper drainage; in case of failure, the catheter has to be replaced.
6. Pain in a localized area (rectum, vagina)
This occurs due to direct irritation of the area involved. Gentle withdrawal of the catheter usually provides relief.
7. Skin infection at the site of the stylet catheter.
This complication occurs fairly commonly and care should be taken to prevent this by proper cleansing of the skin and stab wound. If repeated catheter placements become necessary, puncture at the same site is best avoided.
Peritonitis is a frequently observed complication during acute PD. The main routes of contamination are: a) through the lumen of the peritoneal catheter, b) across the abdominal wall, c) from the blood stream, d) via the female genital tract and, e) through peritoneal lymphatics.
The diagnosis of peritonitis may be difficult and should be considered when the following are present.
a) Presence of symptoms and signs of peritonitis b) Occurrence of cloudy effluent and, c) Positive culture of the peritoneal fluid. The management of peritonitis should include continuation of PD which acts as a lavage, addition of heparin to the dialysate to prevent catheter clogging and usage of antibiotics that are administered either intraperitoneally or systemically or, both.
9. Metabolic complications
Hyperglycemia and hypernatemia can result from usage of hypertonic fluid. Protein loss up to 1 gram per liter of dialysate can occur during PD.
10. Respiratory complications
Hydrothorax is a rare but serious complication. Rarely atelectasis, pneumonia and purulent bronchitis have been reported. Exchange volume should be reduced in patients with respiratory disorders.
11. Miscellaneous complications
Complication such as loss of catheter into the peritoneal cavity, creation of a preperitoneal space due to not perforating the linea alba and pareital peritoneum with the stylet can occasionally occur. The other side effects encountered are gastrointestinal symptoms like nausea and vomiting and excessive thirst.
| Disadvantages of PD|| |
i) May be inadequate in hypercatabolic patients because of relatively low solute clearance.
ii) Technically may be difficult after recent abdominal surgery.
iii) Patients needing multiple dialysis, need to undergo catheter insertion several times.
iv) Many not be possible if patient is in left ventricular failure or severe obstructive lung disease since the distention of abdomen reduces lung volume making respiration more difficult.
v) Difficult to initiate on a non co-operative patient.
| Conclusions|| |
Acute PD is a very simple and life saving procedure that can be performed at the bedside. Its immediate efficacy remains unquestioned and side effects are minimal. Till today, it remains an important replacement therapy of ARF, particularly in children. Its importance gets magnified by the fact that this procedure can be performed without the need for any sophisticated equipment which could be beyond the reach of many hospitals particularly in the developing countries.
| Acknowledgements|| |
We would like to thank Mr. Pedly F. Atienza and Mr. S. Mohamedali of SCOT for their valuable secretarial assistance in preparing the manuscript.
| References|| |
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|8.||Tenckhoff H. Chronic peritoneal dialysis manual. Univ of Washington School of Medicine. Seattle WA, 1974. |
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|10.||Ribot S, Jacobs MG, Frankel HJ, Bernstein A. Complications of peritoneal dialysis. Am J Med Sci 1966;35:505. |
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T Timothy Paul
Consultant Nephrologist, Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
[Table 1], [Table 2]
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