Access Care Guide: Noninfectious Complications

Noninfectious Complications

Pericatheter and Subcutaneous Leaks
Introduction

Pericatheter and subcutaneous leaks are often related to poor catheter implantation technique, anatomical abnormalities, utilizing the catheter prior to healing or trauma.12 Leakage occurring in the first 30 days following catheter implantation is usually external in nature and is evident at the catheter exit or incision site.1 Subcutaneous leaks may resolve with a prolonged rest period or dry day. Subcutaneous leakage involving the genital region or abdominal wall usually indicates a larger leak requiring exploration of the incision site or evaluation for an anatomical defect.

Delaying peritoneal dialysis for 14 days following catheter insertion is a useful preventative measure in order to avoid early leakage.12 Attention to surgical recommendations on insertion location (paramedian approach) and positioning of internal cuff reduce the risk of leakage.

Key Assessments
Patients at risk:

  • Patients with poor tissue healing (diabetics, elderly, malnourished, and those taking corticosteroids)
  • Patients with increased intra-abdominal pressure12

Findings that require evaluation for leaks:12

  • External fluid at wound or exit site
  • Reduced exchange outflow volume
  • Weight gain
  • Abdominal swelling and edema/increased girth
  • Scrotal, penile or labial edema
  • Peripheral edema
  • Unilateral pleural effusion with or without volume overload (see Noninfectious Complications-Hydrothorax)
Key Activities
External leaks:

  • Verify that clear fluid at incision or exit site contains glucose, using glucose test strip12
  • Document condition of exit site, subcutaneous cuff, tunnel and/or wound
  • Alter dressing change procedure to accommodate increased fluid drainage
  • Reduce leak by use of a dry day or suspension of PD to be considered
  • These leaks increase the risk of peritonitis and consideration should be given to prophylactic antibiotic administration12

Subcutaneous leaks:

  • Monitor girth
  • Examine flank and back for subcutaneous fluid
  • Examine for scrotal, penile or labial swelling
  • Order/review abdominal computerized tomography (CT) with intraperitoneal (IP) contrast or magnetic resonance imaging (MRI) without gadolinium (see imaging techniques)13, 14
  • Increase clinic visits as needed for observation

 

IMAGING TECHNIQUES

  • CT peritoneography (see Appendix)13
  • Abdominal fluoroscopy with contrast
  • Peritoneal scintigraphy (see Appendix)15
  • Peritoneal MRI with dialysate as “contrast medium”14

Pericatheter Leak
CT without IP contrast revealing a pericatheter leak in a patient with improper placement of the catheter. White arrows indicate catheter and leak area identified by different contrast to other subcutaneous tissue.

Radiographs courtesy of Ali Abu-Alfa, MD

 

CT Peritoneography
CT peritoneography with IP contrast showing dye around the cord structures in the upper scrotum on the right side (arrow) at the level of the root of the penis.

Radiographs courtesy of John Crabtree, MD

 

Peritoneal Scintigraphy
Peritoneal scintigraphy postdrain image demonstrating right inguino-scrotal fluid collection.

Radiographs courtesy of John Crabtree, MD

 

CLINICAL APPROACH TO LEAKS

Dialysis therapy:

  • Initiate PD or APD in supine position, using low volume exchanges (500 to 1500 mL) until leak has sealed.11 Keep abdomen dry when not in supine position
  • If required, use HD backup for 1 to 2 weeks1

In new patients in whom dialysis is not urgently required:

  • Delay use of PD for up to 3 weeks if necessary until leakage subsides12
  • Reinitiate PD in presence of trained staff to assess for recurrence

Invasive steps:

  • Persistent leak may require surgical repair12
  • Provide HD backup if needed during healing in patients with no residual renal function if low volume APD is not feasible or does not adequately control azotemia
  • Recurrent pericatheter leaks may require catheter replacement12
Patient Education
  • Monitor for signs and symptoms of exit-site infection and peritonitis in presence of leaks
  • Alter dressing change procedure and frequency to accommodate increased drainage
  • Report physical examination changes indicating potential leak
  • Alter dialysis regimen if required to minimize intra-abdominal pressure following surgical correction
  • Reduce activities that increase intra-abdominal pressure such as lifting, coughing or straining
Outcomes Evaluation
Collect data to include:

  • Type of catheter and insertion technique
  • Condition of exit site/wound
  • Condition of subcutaneous cuff and tunnel
  • Type of leak
  • Diagnostic testing and results
  • Dialysis prescription alterations

Enter data into catheter management database

Peritoneal Catheter Obstruction
Introduction
Inflow and outflow obstruction occur more commonly as early complications but can also occur at any time, especially during or following episodes of peritonitis.1 Ascertaining the cause of obstruction will assist in determining the appropriate intervention.
Key Assessments
Inflow obstruction may be due to:1

  • Mechanical blockage such as clamps or kinks in transfer set, tubing or catheter including segment under the dressing
  • Postimplantation blood clot or fibrin
  • Fibrin, particularly with peritonitis

Outflow obstruction may be due to:1

  • Mechanical blockage of transfer set or catheter
  • Postimplantation blood clot or fibrin
  • Fibrin, particularly with peritonitis
  • Constipation
  • Extrinsic bladder compression due to urinary retention
  • Catheter tip migration out of pelvis
  • Catheter entrapment
    • Omental wrap
    • Epiploic appendices of colon
    • Fallopian tubes
    • Adhesions
Key Activities
Conservative noninvasive steps:1

  • Eliminate kinks or remove clamps on transfer set, tubing and catheter. Examine portions hidden by clothing and dressings
  • Change body position
  • Dislodge blockage (by experienced PD personnel)
    • Infuse dialysate or normal saline with a 50 mL syringe using moderate pressure (“push and pull” maneuver). Discontinue procedure if patient notes pain or cramping
  • Correct constipation
  • Obtain flat plate of abdomen to visualize catheter position, a lateral view may be necessary to identify a subcutaneous and intraperitoneal catheter kink

Invasive steps:

  • Laparoscopy1
  • Open surgical repositioning of catheter or replacement1
  • Partial omentectomy or omentopexy3
  • Adhesiolysis if indicated
  • Fluoroscopically guided stiff wires or stylet manipulation1
  • Fogarty catheter manipulation1

 

CLINICAL APPROACH TO CATHETER OBSTRUCTION

In case of fibrin-related obstruction:

  • Add heparin 500 U/L to dialysate each exchange1
  • Instill recombinant tissue plasminogen activator (tPA)

Administration of tPA16

Prepare a solution of sterile water that has tPA 1 mg/mL. Instill up to 8 mLs (1-8 mg) after the filling of the abdomen with dialysis solution and allow to dwell for 1-2 hours. If the dialysate does not drain adequately, ensure that there is enough dialysate in the abdomen and re-instill the tPA at the same dose and allow to remain for an additional 90 minutes. Upon clearance of catheter, allow effluent to drain by gravity. Prior to initiating dialysis, the catheter may be flushed with sterile heparinized solution. Add antibiotics (first-generation cephalosporin preferred) to dialysate in following exchange.

Patient Education
  • Tape catheter and transfer set to avoid kinking
  • Position tubing to prevent kinking while asleep if using APD
  • Prevent constipation with diet, exercise and stool softeners
  • Patient to report reduced drain volume
Outcomes Evaluation
Collect data to include:

  • Type of obstruction (inflow/outflow)
  • Etiology
  • Results of diagnostic testing
  • Findings and responses to interventions

Enter data into catheter management database

Hernia
Introduction

Significant abdominal wall hernias should be surgically repaired prior to the initiation of peritoneal dialysis. Enlargement of the herniation may occur as a result of increased abdominal wall pressure from intraperitoneal dialysate. Significant hernias left untreated increase the risk of further enlargement, pain, bowel entrapment and subsequent discontinuation of peritoneal dialysis.1

The most commonly seen hernias are incisional, umbilical and inguinal. Incisional hernias occur more often when the peritoneal catheter is placed through the midline instead of the paramedial approach through the rectus muscle.1

Key Assessments
  • Protrusion at umbilicus, inguinal area, genitalia or incision
  • Determine reducibility/pain/size
  • Evaluate for tenderness and inflammation
  • If incisional, review catheter placement procedure
Key Activities
  • Inspect and examine suspect sites
  • Refer to surgeon to determine intervention in symptomatic patients
  • Umbilical hernias may be asymptomatic and can be managed by avoiding large fill volumes
  • Schedule patient follow-up

THERAPEUTICS

  • Significant hernia requires surgical repair1
  • Hernias should be repaired with prosthetic mesh techniques to minimize the high risk of recurrence in patients on PD3, 17, 18
  • Appropriate surgical attention to details in producing a watertight peritoneal closure and the use of supine, low-volume intermittent PD permits immediate resumption of therapy after hernia repair and avoids the need for temporary hemodialysis1
  • Provide HD backup if needed in patients with no residual renal function in whom small volume frequent exchanges are insufficient to control azotemia
Patient Education
  • Minimize intra-abdominal pressure by avoiding:
    • Straining
    • Coughing
    • Constipation
    • Stair climbing
    • Lifting
  • Report increase in size of hernia or pain
  • Following surgical repair, instruct patient to maintain separation of exit-site and operative wound dressings to prevent cross-contamination
  • Observe for recurrence
  • Use velcro abdominal binder during ambulatory periods following repair of umbilical and midline hernias is suggested
  • Instruct in use of alternative perioperative dialysis regimen
    • Supine position during dialysis therapy1
    • Initial low-volume intermittent dialysis1
    • Dry abdomen during ambulatory periods during first two weeks
    • Volume graduated incrementally over two weeks to usual regimen
Outcomes Evaluation
Collect data to include:

  • Type of hernia
  • Interventions utilized
  • Results
  • Dialysis prescription alterations

Enter data into catheter management database

Abdominal Discomfort During Infusion and Drain
Key Assessments
Perform dialysis exchange, inflow and outflow:

  • Evaluate patient for the presence, frequency and degree of discomfort or pain and relation to inflow and outflow
  • Monitor dialysis outflow drainage (effluent) for timing, completeness of drain, color and clarity
  • Check dialysis solution temperature
  • Rule out peritonitis
Key Activities
Inflow pain can be due to mechanical causes or to the effects of solution temperature or pH. Inflow pain usually subsides gradually after filling is complete. For abdominal discomfort during inflow:19

  • Change position during infusion
  • In CAPD patients, reduce dialysis infusion rate by lowering the IV pole or partially closing the transfer set clamp. In APD patients, adjust fill rate or program cycler to deliver modified tidal (85-90%)
  • Ensure proper warming of dialysis solution
  • Investigate PD catheter position – flat plate of abdomen
  • Reposition PD catheter if unresolved as necessary
  • Check shelf life of used dialysis solution
  • For patients with significant discomfort: Manual addition of bicarbonate or xylocaine solution to dialysis solutions has been documented.11 Prior to adding any medication to dialysis solutions, be sure to confirm compatibility of the medication with the specific PD solution.

For abdominal discomfort during outflow:

  • Leave small amount of dialysate fluid in the peritoneal cavity in patients on CAPD. In APD patients, program cycler to deliver modified tidal PD (85-90%)20
Patient Education
Teach patient causes and interventions:19

  • Rapid inflow – reduce infusion rate
  • Too rapid a transition to larger dialysis fill volumes – slowly increase fill volumes
  • Dialysis solution too warm or too cold – warm to body temperature
  • Potential cause and interventions for PD catheter malposition
  • Peritonitis prevention
  • Medication administration
  • Training for APD
Outcomes Evaluation
Collect data to include:19

  • Duration and degree of discomfort
  • Interventions
  • Adjustments to dialysis prescription
  • Patient tolerance
  • Medications prescribed
  • Diagnostic tests and results

Enter data into catheter management database

Pneumoperitoneum (Shoulder Pain)
Introduction
Intraperitoneal air may lead to referred pain to the shoulder. Pneumoperitoneum typically occurs due to the inadvertent infusion of air during the instillation of dialysis solution.
Key Assessments
  • Evaluate degree and duration of shoulder pain
  • Interview patient regarding recent infusion of air during exchange procedure20
  • Rule out pain of cardiac origin
  • Assess for bowel perforation20
Key Activities
  • Send effluent sample for cell count and culture to rule out potential contamination
  • Prime PD system according to manufacturer’s instructions20
  • Observe patient/caregiver’s exchange procedure to verify adherence to adequate tubing priming
  • Perform upright abdominal X-ray to identify PD catheter position and identify subdiaphragmatic free air in the peritoneal cavity20
  • Intervention: infuse full exchange volume, then drain dialysate with patient in knee-chest or Trendelenburg position20
Patient Education
Proper priming/flushing procedure for PD system:

  • For manual systems, always close clamps after infusion of solution
Outcomes Evaluation
Collect data to include:

  • Diagnostic testing and results
  • Interventions

Enter data into catheter management database

Hemoperitoneum
Introduction

Blood loss into the peritoneal cavity will produce cloudy/bloody effluent. As little as a few drops of blood will produce grossly bloody dialysate. The most common cause of hemoperitoneum in women includes retrograde menstruation and ovulation.21, 22

Mild bleeding can be caused by catheter-induced trauma, strenuous exercise and the formation of abdominal adhesions. Any bleeding, however, needs to be carefully monitored for severity and potential serious causation.21, 22

Key Assessments
  • Observe dialysis exchange drain fluid for color and clarity
    • Rule out peritonitis
  • Obtain patient history, investigate potential causes including;21, 22
    • Status post peritoneal catheter placement
    • Retrograde menstruation/ovulation in females (Note interval and length of occurrence)
    • Surgical causes such as cholecystitis, rupture of the spleen or pancreatitis
    • Medical causes such as coagulation disorders, polycystic kidney disease, leakage of hematoma outside of peritoneal cavity, post extracorporeal lithotripsy for kidney stones, rupture of ovarian or hepatic cysts, encapsulating peritoneal sclerosis21
    • Recent enema, sigmoidoscopy, colonoscopy, episode of abdominal trauma or abdominal disease
    • Recent use of intraperitoneal tPA
Key Activities
CLINICAL APPROACH TO HEMOPERITONEUM
For postcatheter insertion blood-tinged effluent:
  • 200-1500 mL volume flush with heparinized dialysis fluid or saline until drain is clear1
  • Add heparin 500-1,000 U/L as long as the effluent has visible signs of blood or fibrin to maintain catheter patency21
  • Intraperitoneal instillation of heparin does not affect systemic coagulation parameters and does not increase the risk of bleeding.21 However, it has been reported that heparin may still reach the systemic circulation potentially via lymphatic absorption or with increased peritoneal membrane permeability with peritonitis. Hence, IP heparin is contraindicated in patients with heparin-induced thrombocytopenia (HIT)23
  • Observe drain fluid color with dialysis exchanges
  • Document duration of blood-tinged exchanges and progression (increase/decrease)
  • Check hematocrit (serum and dialysis) as needed
  • Consider investigating for peritonitis or other acute abdominal issue if prolonged

Other causation:21

  • Add heparin 500-1,000 U/L as long as the effluent has visible signs of blood or fibrin to maintain catheter patency
  • Perform rapid exchanges with dialysate at room temperature until effluent clears
  • Obtain imaging and surgical consultation as required
Patient Education
  • Instruct women of reproductive age about the potential for hemoperitoneum
  • Observe dialysis exchanges drain fluid for decreasing color and resolution

Teach patient to:

  • Avoid heavy lifting/trauma
  • Document frequency, duration and treatment of bloody effluent
  • Bleeding, typically minimal to moderate, may resolve spontaneously
Outcomes Evaluation
Collect data to include:

  • Interventions including medications
  • Response to intervention
  • Alterations in dialysis prescription or schedule

Enter data into catheter management database

Hydrothorax
Introduction
Hydrothorax secondary to a pleuroperitoneal communication is an uncommon complication of peritoneal dialysis. The management of hydrothorax should begin with the temporary discontinuation of peritoneal dialysis to avoid aggravating pleural fluid accumulation and allowing the effusion to regress.24
Key Assessments
Signs and symptoms of pleural effusion:21

  • Cough or dyspnea
  • Chest pain
  • Weight gain
  • Decreased dialysis drain volumes
  • Small pleural effusion may be symptom free
  • Acute respiratory distress
Key Activities
Diagnostic:21

  • Assess for decreased lung sounds (pleural collection frequently on right side)
  • Observe for shortness of breath or cough especially when supine
  • Shortness of breath increasing with hypertonic exchanges, especially if drainage amount is decreased
  • Chest X-ray showing unilateral pleural effusion
  • Isotope scanning to identify pleural-peritoneal communication
  • High glucose, low protein, pleural fluid on thoracentesis

Radiograph courtesy of John Crabtree, MD

CLINICAL APPROACH TO HYDROTHORAX

  • Conservative management for pleural leakage in the form of peritoneal rest and intermittent low volume dialysis is rarely successful24
  • Temporary hemodialysis for 2-6 weeks usually required to allow pleuroperitoneal communication to seal, especially following surgical interventions24
  • Thoracentesis or chest tube drainage with chemical pleurodesis (talc slurry, autologous blood, OK-432 (Picibanil), minocycline) has been successful24
  • Video-assisted thorascopic surgery (VATS) may permit visualization of a pleuroperitoneal communication and direct surgical obliteration if appropriate24
  • Thoracoscopic pleurodesis with talc poudrage and/or mechanical rub produces 87-93% success rate in resolving pleural leaks25
  • Follow-up radiograph to establish closure of pleuroperitoneal communication may be utilized before restarting PD25
Patient Education
  • Report physical changes indicating potential leak
  • Alter dialysis regimen if required
  • Schedule more frequent clinic visits for observation
Outcomes Evaluation
Collect data to include:

  • Type of leak
  • Diagnostic testing and results
  • Interventions
  • Response to interventions

Enter data into catheter management database

Catheter Adapter Disconnect or Fracture of Peritoneal Catheter
Key Assessments
  • Observe for dialysis fluid leak from peritoneal catheter or transfer set
  • Obtain culture to rule out peritonitis
Key Activities
  • Initiate prophylactic antibiotics26

For adapter disconnect or catheter fracture:26

  • Stop dialysis
  • Clamp catheter proximal to damage
  • If catheter length is adequate, use sterile technique to:
    • Disinfect catheter proximal to damaged area
    • Trim catheter proximal to expanded area on catheter or fracture
    • Using sterile scissors, trim the catheter above area that is damaged or stretched
    • Fit a sterile, new adapter into the catheter
    • Attach transfer set to adapter

If catheter portion is marginal length:

  • Repair with appropriate manufacturer’s repair kit or catheter extension26
Patient Education
Instruct patient to:26

  • Stop dialysis
  • Clamp catheter proximal to damaged spot
  • Cover area with sterile dressing
  • Go to clinic or emergency room as soon as possible

Teach patient to:26

  • Secure catheter and transfer set under clothing, avoiding sharp bends in catheter
  • Keep sharp objects and tools away from catheter
    • Avoid using scissors to remove catheter dressing
  • Avoid using unsuitable disinfectants and soaps on catheter
  • Do not use toothed hemastat on catheter
  • Avoid using mupirocin cream if catheter is made of polyurethane
Outcomes Evaluation
Collect data to include:

  • Type of peritoneal catheter
  • Type of perforation
  • Intervention
  • Response to intervention
  • Patient outcome

Enter data into catheter management database

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