Access Care Guide: Catheter Insertion and Care

Optimal timing for peritoneal catheter insertion should take place 2 weeks prior to use of the catheter. This is to ensure anchoring of the internal and external cuffs and healing of the exit site.¹

• Determine factors that may impair initial wound healing and exit-site management
• Clinical status (chronic cough, steroids use, edema)
• Nutritional status (malnutrition impairs healing)
• Obesity-pannus location
• Presence of colostomy, gastrostomy or ureterostomy
• Use of adult diapers
• Evaluate for:
• Abdominal wall for rash and evidence of infection
• Pre-existing abdominal scars
• Chronic intertrigo under abdominal skin folds
• Abdominal wall hernias that require repair²

• Set up appropriate communication plan with surgeon for catheter placement and patient follow-up (see Appendix)
• Confirm catheter placement date
• Determine exit-site location that optimizes longevity and patient satisfaction
• Patient preference should be considered in determining exit-site placement unless there is a strong clinical indication that precludes choice
• Locate exit site to maximize self-care skills (vision, handedness, strength and motor skills).³ Patient should be able to look down and easily visualize the proposed exit site
• Evaluate patient while dressed and in the sitting position to determine belt-line location and other anatomical features that will influence selection of catheter type, insertion site, and exit-site location
• Avoid scars, belt line, fat and skin folds, moist areas due to perspiration, pressure points from clothing or areas that cannot be sufficiently visualized during exit-site care³
• Determine whether midabdominal, high abdominal or presternal location is most appropriate for individual patient (see fig. 4 and 5)
• Mark exit-site location with indelible ink using stencils or actual catheter³
• Choose appropriate catheter configuration and operative methodology
• Despite innovative attempts to design peritoneal catheters to overcome problems with flow function, none of these devices have been shown to outperform the standard Tenckhoff-style catheter with or without a swan neck bend (see fig. 1)^{2, 3}

• Choice of catheter type may be impacted by belt-line location and body habitus³
• Patients with belt lines below the umbilicus may require a Tenckhoff style catheter that produces a laterally directed exit site above the belt (see fig. 2)³
• Patients with belt lines above the level of the umbilicus may require a catheter that is bent or manufactured with a preformed bend, so called swan neck design, that results in a downwardly directed exit site (see fig. 3)³

Indications for Presternal/Upper Abdominal Peritoneal Dialysis Catheter

• Morbid obesity
• Multiple loose skin folds, scars or other abdominal wall deformities
• Chronic abdominal wall intertrigo
• Abdominal stomas (colostomy, ileostomy, urostomy)
• Urinary or fecal incontinence
• Desire to be able to take deep tub bath
• Patient preference

Contraindications for Presternal/Upper Abdominal Peritoneal Dialysis Catheter

• Body image issues
• Breast implants (presternal)
• Requires surgical expertise

• Patients for whom dialysis initiation is not anticipated until at least 3 to 5 weeks after catheter implantation may benefit from having the catheter embedded (Moncrief technique) (see figs. 6A and 6B)⁴
• Catheter embedding procedure can be performed with any catheter type, i.e., upper abdominal catheter and presternal catheter³

Advantages of Embedded Peritoneal Dialysis Catheter³

• Catheter heals in environment without exposure to contamination from exit site
• Greater patient acceptance for earlier catheter implantation:
• No catheter maintenance until dialysis started
• Avoids urgent temporary hemodialysis
• Start full-dose peritoneal dialysis without break-in period after exteriorization

Ensure PD education program is underway including the following topics:

• Home dialysis concept
• Basics of PD therapy
• Permanency of catheter until transplantation
• Self-care concept
• Postoperative catheter care
• Dressing changes following implantation should be restricted to experienced PD staff or trained patients
• Provide postoperative care instructions and if applicable supplies including: soap/alcohol-based hand disinfectants, masks, absorbent dressing (e.g., gauze), tape, and exit-site cleansing agent/skin disinfectant

Review written operative instructions with patient/caregiver:

Preoperative:

• Review catheter placement procedure
• Fast after midnight or at least 8 hours prior to catheter insertion (essential medications are permitted with a sip of water)
• Empty bladder^{1, 2}
• Bowel preparation in case of previous history of constipation (e.g. mineral oil, enema, or a stimulant suppository is administered on the evening before surgery to evacuate the lower colon)^{1, 2}
• Avoid using sodium phosphate bowel preps⁵
• Shower or bathe with disinfectant soap on the day of surgery^{1, 2}

Postoperative:

• Keep sterile dressing clean, dry, securely taped for one week unless there is excess drainage or bleeding¹
• Report bleeding, pain or tenderness immediately
• Report severe cough
• Avoid high intra-abdominal pressure until healed (2 to 6 weeks):
• Heavy lifting
• Straining and constipation
• Pulling with upper extremities during stair climbing
• No showers or baths until completely healed up to two weeks except in case of buried catheter (after one week of surgery)^{3, 4}

Collect patient information to include:

• Patient demographics
• ESRD diagnosis
• Comorbid conditions
• Date of referral

Enter data into catheter management database

Peritoneal catheter implantation must be performed by a competent and experienced surgeon, interventional radiologist or nephrologist. Optimal long-term peritoneal catheter function and exit-site healing are directly related to the skills and competence of the catheter insertion team. Proper catheter insertion technique is one of the most important aspects in preventing catheter exit-site and/or tunnel infections. Attention to detail and commitment to excellence should be foremost in goals for success. Peritoneal catheter insertion procedures should meet the standards of any surgical procedure and inclusive of known best- demonstrated practice, whether performed by a surgeon in the operating room, the nephrologist at the bedside or interventionalist at an access center.¹

• Verify completion of preoperative activities:
• Fasting state maintained
• Shower on day of surgery with antibacterial soap^{1, 2}
• Bladder emptied or Foley catheter as needed^{1, 2}
• Bowel preparation complete^{1, 2}
• Verify exit site marked appropriately

Prepare patient:

• Administer antistaphylococcal antibiotic preoperatively⁶
• First-generation cephalosporin 1000 mg intravenously, 1 to 3 hours preoperatively

OR

• Vancomycin 1000 mg intravenously, administered approximately 12 hours preoperatively ^7*
• A prospective randomized trial determined that vancomycin was superior to cephalosporin or no treatment in reducing post-operative peritonitis ^7*
• If vancomycin is used, weigh potential benefits versus risk of resistant organisms^**
• If vancomycin is used, weigh potential benefits versus risk of resistant organisms
• Perform surgical skin prep (use electric clipper to avoid skin nicks)²

Prepare catheter:

• Eliminate air from catheter cuffs prior to implantation by soaking and gently squeezing cuffs in saline solution

Insert catheter:

Several methods of catheter implantation have been developed including open dissection, simple laparoscopic, modified advanced laparoscopic, blind techniques, ultrasound or flouroscopically assisted percutaneous techniques. The following general guidelines should be adhered to irrespective of implantation technique chosen.

• Preoperative determination of most appropriate catheter type, insertion site, and exit-site location
• Use of double cuff catheter preferred.⁶ Curled compared with straight intraperitoneal segment associated with less infusion pain⁸
• Paramedian insertion with deep cuff resting within the muscle (see fig. 7)¹

• Position deep cuff in rectus sheath of abdominal wall)
• Implanting the cuff superficial to the rectus fascia can lead to the formation of a hernia or pseudohernia and late pericatheter leak (see fig. 8 )¹

• Catheter tip should have deep pelvic location¹
• Close peritoneum below level of deep cuff with purse-string absorbable sutures¹
• Position subcutaneous cuff no closer than 2 cm from exit site^{1, 6}
• Sinus tract is too long (>2-3 cm)-the epithelium will not reach the cuff and granulation tissue may develop deeper in the tract. As a result, may see drainage or serous weeping
• Sinus tract is too short (< 2 cm)-the epidermis may be irritated by the cuff resulting in redness and irritation with eventual cuff extrusion²
• Subcutaneous tunneling instruments should not exceed the diameter of the dialysis catheter
• Straight catheters should not be sharply arched as the catheter has memory
• Sharply arching a straight catheter may encourage migration and cuff extrusion (see figs. 9-10)²

• Position exit site downward or lateral^{1, 6}
• Create the smallest skin hole possible to provide for catheter exit site⁶
• Immobilze catheter with medical adhesive tincture (if available) and sterile adhesive strips³
• Do not utilize catheter anchoring sutures at the exit site due to risk of infection⁶
• Perform adjunctive procedures to catheter implantation such as hernia repair, omentopexy, omentectomy and adhesiolysis as needed

Verify function:

• Catheter patency and flow must be tested during surgical procedure prior to final closure¹
• Catheter position should be revised until satisfactory flow function is achieved before procedure end
• A trial irrigation of the catheter is performed to identify potential problems with flow. With the patient in reverse Trendelenburg position, infuse a standard one-liter bag of normal saline with heparin (1000 U per liter) and observe for unimpeded inflow and drainage by gravity
• A residual volume of 250 to 300 mL is left in the abdomen to reduce the likelihood of intraperitoneal structures being drawn into catheter tip and side holes toward the end of the drainage phase
• With nonlaparoscopic implantation methods, it is advisable to check for catheter patency and flow prior to exteriorizing the catheter through the exit site. This will prevent unnecessary tunnel tract and exit-site trauma in the event that catheter repositioning is required.

Final catheter preparation:

• Place catheter adapter
• Attach catheter cap or transfer set with cap (as per individual center policy)
• Make sure transfer set is in closed position
• Apply sterile gauze or other absorbent dressing and tape securely^{1, 9}
• Tape catheter securely to abdomen in several places
• Transparent occlusive dressings alone are not recommended^{1, 9}

• Review postoperative instructions prior to patient discharge
• Provide written instructions regarding follow-up care (see Appendix)
• Review postoperative medications
• Review postoperative pain management
• Schedule return appointment for postoperative evaluation and ideally for weekly dressing changes by experienced staff

Review operative report for baseline catheter data:

• Date, surgeon, inpatient/outpatient placement surgical approach, special procedures
• Catheter type, catheter material, position of cuffs, direction of exit site
• Catheter function

Enter data into catheter management database

Optimal postoperative care promotes healing of the exit-site wound and the catheter tract including immobilization of the catheter to prevent trauma to the exit site and cuffs, and minimizing exposure to bacteria and prevent colonization.8 If possible, implantation should be timed to allow 2 weeks for healing prior to initiation of dialysis. If dialysis is required early, small volume exchanges in the supine position may be performed with frequent checks for leakage. Postoperative assessment and dressing changes should be performed weekly by experienced staff only using aseptic technique with mask and gloves until healed.¹

• Assess exit-site and wound healing for:
• Absence of bleeding, drainage or leakage
• Absence of pain or tenderness on palpation

• Inspect and change dressing weekly or more frequently in the presence of:
• Delayed healing
• Infection¹
• Gross contamination
• Wetness
• Maintain clean, dry, intact dressings¹
• Utilize aseptic technique using mask and gloves¹
• Exit-site care:
• Minimize manipulation of catheter
• Use aseptic technique, including masking and wearing sterile gloves for postoperative dressing changes until healed⁹
• Inspect and classify exit site^{1, 10}
• Palpate tunnel
• Clean with nonirritating solution (i.e., nonionic surfactant, normal saline, or chlorhexidine)^{1, 6}
• Protect sinus tract and wound from povidone iodine and hydrogen peroxide^{1, 10}
• Tape dressing securely¹
• Immobilize catheter
• If the catheter is not used for a period of time, it is not necessary to check catheter patency and function
• Catheters that are exteriorized secondarily (Moncrief technique) can be used immediately for full-volume peritoneal dialysis.⁴ Exit-site management for secondarily exteriorized catheters is the same as described for primary exteriorization

• Review postoperative instructions with patient
• Maintain clean, dry, securely taped sterile dressing
• Protect site from gross contamination and wetness
• Immobilize catheter
• Practice good hygiene
• Take no shower or bath until healed^{6, 9}
• Avoid heavy lifting, stair climbing, straining and constipation until catheter healed (2 to 6 weeks)
• Notify PD unit in case of blood or other drainage, pain or tenderness, trauma to abdomen
• Restrict dressing changes following implantation to experienced PD staff or trained patients (if patient lives far from center)⁹
• Educate patients who perform postoperative dressing changes to:
• Recognize early signs of infection such as redness, tenderness and discharge
• Use aseptic technique with face mask and gloves
• Inspect exit site and palpate tunnel
• Maintain stability of catheter during inspection
• Cleanse with nonirritating solutions when instructed by nurse

Collect data to include:

• Exit-site classification

Enter data into catheter management database

Optimal long-term peritoneal catheter management focuses on maintaining a healthy exit site and catheter tract. Catheter survival of greater than 80% at one year is desired.^{1, 2} The primary preventative steps are: ongoing assessment of the exit site, institution of antibiotic prophylaxis, early identification and treatment of exit-site problems, prevention of contamination, and immobilization of the catheter to protect from trauma.

• Inspect exit site using magnifying glass as needed
• Evaluate exit site and sinus tract
• Classify exit-site appearance by checking for:¹⁰
• absence of drainage, erythema, crust, scab, granulation tissue, swelling and pain or tenderness on palpation
• Palpate tunnel
• Compare exit-site appearance on each clinic visit
• Verify function and assess integrity of peritoneal catheter by querying patients on CAPD for fill and drain duration, or by reviewing cycler logs for fill and drain profiles for APD patients
• Review chronic catheter care with patient
• Ensure compliance with topical antibiotic prophylaxis

• Document exit-site and tunnel appearance at each clinic visit
• Obtain exit-site culture if drainage or wetness noted
• Perform exit-site care as required
• Review and reinforce exit-site and catheter care plan

ANTIBIOTIC PROPHYLAXIS

Daily routine exit-site care:

• Wash and dry hands thoroughly^{1, 9}
• Inspect catheter, exit site and tunnel before catheter care¹
• Showers recommended; avoid immersion in tub
• Cleanse exit site every day, every other day or a minimum of two to three times per week⁹
• Cleanse exit site with liquid antibacterial soap or antiseptic (i.e. povidone iodine or chlorhexidine)⁶
• Cleansing agent should be nonirritating, nontoxic, antibacterial and in liquid form^{1, 9}
• Do not transfer cleansing agent between containers to avoid cross-contamination^{1, 9}
• Soften crusts and scabs with saline or soap and water. Never forcibly remove crusts and scabs^{1, 9}
• Apply antibiotic cream or ointment for prophylaxis using a cotton swab. Do not apply directly from tube
• Avoid mupirocin ointment with polyurethane catheters⁶
• Immobilize catheter with tape or immobilization device at all times
• Apply dressing to protect from contamination
• Povidone iodine can be damaging to the peritoneal catheter over time
• Healed site may be left uncovered but should be kept dry
• In case of prophylactic antibiotics, a nonocclusive dressing may be suitable
• Perform exit-site care if exit site becomes wet or grossly contaminated⁹
• Report trauma of exit site or catheter
• Maintain regular soft bowel movements⁶

Collect data to include:

• Exit-site classification/assessment
• Culture date, result and treatment
• Topical antibiotic regimen
• Evaluation of catheter outcomes
• Peritonitis rate
• Exit-site/tunnel infection rate
• Catheter survival

Enter data into catheter management database