Access Care Guide: Appendix

It is essential to establish appropriate communication between the surgeon and the nephrology/dialysis clinic during preparation and follow-up to PD catheter placement.A variety of procedures exist for catheter insertion. Your patient should always consult your individual healthcare practitioner for his or her specific recommendations.

The instructions below may offer your patient guidance during the process of planning, PD catheter placement and follow-up with their healthcare team in order to assure both patient education and successful outcomes during initial access placement.

Before Surgery

The catheter placement procedure will be thoroughly explained. Marking of the catheter site (determination of the optimal location, i.e., away from the belt line, within easy reach and sight, right or left side) may be completed at this time. Questions and concerns will be addressed.

Shower with a disinfectant soap, as directed: _________

Do not eat or drink after: _________

Bowel preparation (if required): _________

Alert the surgeon/doctor of any known hernias: _________

Medication

Take: _________

Do not take (hold): _________

Adjust dosage: _________

Antibiotics: _________

Report any unusual cough, fever, chills or ill feelings prior to surgery.

Date of catheter placement: _________

Report to (location): _________

Please notify the dialysis clinic when your catheter surgery has been scheduled.

Additional instructions/notes: _________

After Surgery

• Report any of the following to your surgeon/doctor:
• Bleeding
• Fever
• Vomiting
• Severe cough
• Severe pain
• Wet or dirty/soiled dressing
• Dressing falls off

Emergency Contact: _________

• The surgical dressing SHOULD BE LEFT IN PLACE FOR AT LEAST SEVEN DAYS
• The dressing should only be changed by your doctor or nurse at the dialysis clinic
• Do not shower or bathe until advised by the dialysis clinic that the exit site is healed*
• Avoid heavy lifting, stair climbing, straining and constipation. Your activities for the next few weeks should be light
• Resume all routine medications and diet as instructed by your doctor
• Talk with the surgeon about the need for pain medication
• If antibiotics are ordered, take as directed until they are gone
• Call your dialysis clinic to schedule your follow-up appointment

The telephone number is: _________

CT peritoneography and peritoneal scintigraphy are suggested when there is suspected dialysis fluid leakage in the abdominal wall, genital region, or pleural space. This information is important in order to localize the leakage site and to assist the surgeon if surgical intervention is necessary. Peritoneal imaging can also be used to identify fluid loculation, a result of peritoneal adhesions.^{13, 15}Note: Communicate the purpose of the test to the radiologist and review radiographs personally. It is advisable to coordinate the diagnostic study with the PD nursing staff to perform the addition of the imaging marker to the dialysate and to make the tubing connections to prevent contamination of the catheter by healthcare personnel who may be unfamiliar with dialysis technique.

CT Peritoneography:¹³

Procedure:

• Add 80 mL of water soluble contrast media (80 mL OMNIPAQUE 350) to 1.5 L of dialysis solution
• Infuse dialysis solution with radiocontrast into supine patient
• Instruct patient to move and walk to promote intraperitoneal mixing and to raise intra-abdominal pressure to drive the contrast into the source of the leak

If pleuroperitoneal fistula is suspected, CT should include the chest. If scrotal swelling has been noted, the examination should include this area, otherwise avoid radiation of the testes.

Peritoneal Scintigraphy:¹⁶

Procedure:

• Add 2 mCi of technetium-99m sulfur colloid to 2 L of dialysis solution
• Infuse radionucleotide-containing dialysate into supine patient with anterior dynamic images obtained at one frame per minute for 15 minutes
• Instruct patient to move and walk for 30-60 minutes to promote intraperitoneal mixing and to raise intra-abdominal pressure to drive the radiotracer into the source of the leak
• Obtain 5-minute postambulatory static images in anterior, posterior, and both lateral views
• Drain dialysate from peritoneal cavity and repeat 5-minute static images in anterior, posterior, and bothlateral views

Include chest if pleuroperitoneal fistula is suspected. Include inguinal region if scrotal swelling has been noted.

Identifying appropriate antibiotic therapy is dependent on accurate specimen collection and microbiological diagnosis of peritonitis.Key Points for Specimen Processing:

• Culture should be obtained as early as possible
• The first bag of cloudy solution is the best specimen, as the probability of a positive diagnostic culture is the greatest
• Patients or PD staff should send the first cloudy bag or an aliquot thereof to the laborAtory as quickly as possible
• While delay of several hours from time of collection to time of culture does not decrease accuracy of bacteriological diagnosis, it is preferable to expedite this process
• As large a volume (20 to 100 mL) as possible should be cultured or concentrated to maxImize bacterial recovery rates
• Draw fluid from medication port
• Blood culture techniques are considered most optimal
• Inject fluid into standard blood culture medium (5-10 mLs required per bottle)
• The collection and processing of specimens require meticulous care in order to avoid contamination of the fluid
• Laboratory should be notified of specimens obtained from patients receiving antibiotic therapy, as they may require special handling
• Identification and sensitivity testing should be expedited to facilitate initiation of specific antibiotic therapy

Sterile or Culture-negative Peritonitis:

• Incidence of sterile peritonitis varies from 2% to 20% and is more common when the laboratory facility does not have experience in processing peritoneal dialysis effluent
• Other factors contributing to a high incidence of sterile peritonitis include:
• Insufficient culture sample volume
• Causative organism difficult to culture
• Causative organism requiring specialized culture media (i.e., mycobacteria)
• Patient may not have informed PD center of current antibiotic treatment
• Patient’s signs and symptoms related to other medical condition (i.e. pancreatitis)

The correct microbiological culturing of peritoneal effluent is of utmost importance to establish the microorganism responsible. Identification of the organism and subsequent antibiotic sensitivities will not only help guide antibiotic selection but, in addition, the type of organism can indicate the possible source of infection. Culture-negative peritonitis should not be greater than 20% of episodes. Standard culture technique is the use of blood-culture bottles, but culturing the sediment after centrifuging 50 mL of effluent is ideal for low culture-negative results.Procedure:

• Centrifuge 50 mL of peritoneal effluent at 3000 g for 15 minutes
• Follow with resuspension of the sediment in 3-5 mL of sterile saline
• Inoculate this material both on solid culture media and into a standard blood-culture medium (method most likely to identify the causative organisms. With this method, less than 5% will be culture negative)
• The solid media should be incubated in aerobic, microaerophilic and anaerobic environments
• Blood-culture bottles can be directly injected with 5-10 mL of effluent if equipment for centrifuging large amounts of fluid is not available (this method generally results in a culture-negative rate of 20%)
• The removal of antibiotics present in the specimen may increase the isolation rate if the patient is already on antibiotics

Important Points:

• The speed with which bacteriological diagnosis can be established is very important
• Concentration methods not only facilitate correct microbial identification, but also reduce the time necessary for bacteriological cultures to turn positive
• Rapid blood-culture techniques (e.g., BACTEC, SEPTI-CHEK, BacT/ALERT) may further speed up isolation and identification. A resin culture bottle should be used if patient is on antibiotics or antibiotics were discontinued less than 24 hours prior to culture
• The majority of cultures will become positive after the first 24 hours and, in over 75% of cases, diagnosis can be established in less than 3 days

Mycobacterium Examination:

• Examine smear of the peritoneal effluent with the Ziehl-Neelsen stain (“smear negative” disease is common)
• The sensitivity of the smear examination by the Ziehl-Neelsen technique can be enhanced by centrifuging 100-150 mL of the dialysate sample
• Prepare smear from the pellet
• A specific diagnosis can be made by culturing the sediment, after centrifugation of a large volume of effluent (50-100 mL), using a solid medium (such as Lowenstein-Jensen agar) and a fluid medium (Septi-Chek, BACTEC; Becton Dickinson; etc.)
• The time of detection for growth of mycobacteria is decreased considerably in fluid medium
• Repeat microscopic smear examination and culture of dialysis effluent is mandatory for better yield in suspected cases of mycobacterial peritonitis

The most accurate peritonitis rate is one that is cumulative over a period of 12 months. Measuring peritonitis rates both for the individual patient and PD facility provides insight into the peritoneal dialysis outcomes leading to interventions that may improve results. Knowing peritonitis rates also allows for intercenter comparisons at different time points.

Important points:

• Include hospital days (once home therapy begins) in total days at risk
• Include hospital acquired peritonitis (once home therapy begins) in total peritonitis rate
• Relapsing episodes of peritonitis are counted as a single episode of peritonitis
• Recurrent peritonitis is a new episode of peritonitis and should be counted as an individual occurrence
• Peritonitis rates should be no more than 1 episode every 18 months or 0.67 episodes per patient year per ISPD
• Programs should also be aware of the percentage of patients who are peritonitis free to include in unit’s quality management programs.
• Exit-site infection rates are calculated in the same manner as above

Prevention of exit-site infections and peritonitis requires that both clinicians and patients understand and practice aseptic technique. In the course of daily practice, staff must demonstrate and teach patients how to recognize the potential sources of contamination and to practice measures that will decrease the risk of infection. These preventative measures will reduce complications and promote positive patient outcomes.Recommendations for a Safe and Clean Environment:²⁰

• Prior to each exchange, clean the work area
• The exchange area must:
• Be well-lit and private
• Have no open windows or doors
• Have fans and air conditioners turned off
• Be free of pets
• For handwashing, use soap and/or alcohol-based products, followed by thorough drying with paper towels
• The patient and partner or nurse, must wear a face mask when performing exit-site care and dialysis exchange procedures
• Do not touch STERILE areas of the PD system including:
• Open solution port of the new bag
• Tip of the exposed transfer set
• Connections of the twin bag/“Y” set/cycler set
• Interior of the minicap or connection shield
• Encourage the patient to practice good hygiene
• Perform connections of PD/APD sets to solution bags and transfer sets using aseptic technique each time an exchange is performed
• Use only clean and dry port clamps. Wash clamps with soap and water. Let outlet port clamps dry with open end facing downward

Nose, Mouth, & Upper Respiratory Tract

• Staphylococcus aureus (Gram-positive)
• Staphylococcus epidermis (Gram-positive)
• Streptococcus species (Gram-positive)
• Fusobacterium species (Gram-negative)
• Actinomyces species (Gram-positive)
• Corynebacterium diptheriae (Gram-positive)
• Haemophilus species (Gram-negative)
• Non-pathogenic Neisseria species (Gram-negative)

Skin

• Staphylococcus aureus (Gram-positive)
• Staphylococcus epidermis (Gram-positive)
• Acinetobacter species (Gram-negative)
• Pseudomonas aeruginosa (Gram-negative)
• Candida species (Fungi)
• Corynebacterium diptheriae (Gram-positive)

Genitalia

• Corynebacterium species (Gram-positive)
• Lactobacillus species (Gram-positive)
• Alpha-hemolytic and non-hemolytic streptococci (Gram-positive)
• Non-pathogenic Neisseria species (Gram-negative)
• Candida albicans (Fungi)

Intestinal Tract

• Escherichia coli (Gram-negative)
• Proteus species (Gram-negative)
• Enterococci (Gram-positive)
• Klebsiella (Gram-negative)
• Alpha-hemolytic and nonhemolytic streptococci (Gram-positive)
• Candida species (Fungi)
• Clostridium species (Gram-positive)
• Enterobacteriaceae (Gram-negative)
• Pseudomonas aeruginosa (Gram-negative)

Potential Environmental Sources of Bacteria

• Pseudomonads (Gram-negative) — soil, water, plants, and animals
• Pseudomonas thrives in moist environments — special attention should be paid to sink, water baths, showers, hot tubs, and other wet areas.
• Acinetobacter species (Gram-negative) — soil and water
• Serratia marcescens (Gram-negative) — soil and water
• Pasteurella species (Gram-negative) — cats and dogs
• Mycobacteria (Gram-positive) — water and food