Disclaimer. PD Catheter Placement in Urgent and Emergent Peritoneal Dialysis. Catheter design and outcomes CATHETER DESIGN AND OUTCOME

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1 ASDIN 2014 Scientific Meeting Disclaimer PD Catheter Placement in Urgent and Emergent Peritoneal Dialysis Bharat Sachdeva M.D. Associate Professor of Medicine/Nephrology Interventional Nephrology Division of Nephrology and Hypertension LSUHSC, Shreveport LA ASDIN 2014 My presentation does not include discussion of any commercial products or services used in an unapproved or off label way. I have no disclosures. CATHETER DESIGN AND OUTCOME ASAIO Trans 36:M497 M500, 1990 Perit Dial Int 10:63 66, 1990 Perit Dial Int 14:70 74, 1994 Perit Dial Int 14: , 1994 Perit Dial Int 15:18 21, 1995 Perit Dial Int 15: , 1995 Perit Dial Int 16:S333 S335, 1996 (suppl 1) Perit Dial Int 29:278 84, 2009 AJKD 58(6):946 55, 2011

2 Coiled Vs Straight tip Coiled catheter Allows for better flow Less inflow pain Less propensity for catheter migration? Less propensity for omental wrapping Less trauma to the viscera Perit Dial Int 12: , 1992 Perit Dial Int 25: , 2005 Cochrane Database Syst Rev Straight versus coiled PD catheter Risk of peritonitis (5 trials, 324 patients) RR 1.14; 95% CI 0.73 to 1.79 Peritonitis rate (4 trials, 2589) RR 0.89; 95% CI 0.63 to 1.26 Exit site/tunnel infection (6 trials, 332 patients) RR 1.26; 95% CI 0.73 to 1.47 Catheter removal/replacement (5 trials, 275 patients) RR 1.11, 95% CI 0.53 to 2.31 Cochrane Database Syst Rev Am J Kidney Dis. 2006;48(5): Time to Catheter Reposition 16% Vs 14% (P 0.77) Time to Catheter Associated Infection 47% Vs 53% (P 0.60) Technique Survival Inadequate small solute clearance (P < 0.05) 2 yr patient survival rates 79% Vs 88% Am J Kidney Dis. 2006;48(5): Am J Kidney Dis. 2011; 58(6):

3 Table 1 : Demographics Table 2 : Complications Table 3 : Procedure Success Rate ASDIN 2014 Scientific Meeting Placement techniques Open Surgical Laproscopic Fluroscopic Peritoneoscopic Techniques Cons FLUOROSCOPIC PERITONEAL DIALYSIS CATHETER PLACEMENT AN OUTPATIENT PROCEDURE Ishwinder Sidhu, M.D., Mukesh Sharma, M.D., Kenneth Abreo, M.D., Bharat Sachdeva, M.D. Louisiana State University Health Sciences Center, Shreveport, LA Background Patients and Methods Results Timely placement of Peritoneal Dialysis Retrospective review of medical charts of 89 patients with catheter (PDC) remains a major hurdle for fluoscopic placement of peritoneal dialysis catheters from patients starting Peritoneal Dialysis (PD) 2000 to 2012 to review intraoperative and immediate and has spurred the growth of non-surgical postoperative complications. All patients with Fluoroscopic PD catheter placement. Techniques of PDC placement were included in the study. Patients with catheter placement differ in required prior extensive abdominal surgery, bowel resection and resources, selection criteria, procedure morbid obesity were excluded from the study. Intraoperative complications were defined as bowel/bladder anesthesia, procedure complications, postoperative recovery time, and cost perforation, bleeding/ hematoma, acute abdomen, amongst others. Fluoroscopic PDC procedure abandonment, any complication requiring placement have equivalent outcomes and higher level of care or surgical intervention, and death. has been increasingly used. A single Immediate postoperative complications were defined as center review of immediate complications those occurring within 24 hours after PDC placement. of Fluoroscopic PDC placement is presented here. Procedure Purpose of the Study To assess the risk of immediate complications associated with fluoroscopic placement of peritoneal dialysis catheters with an aim to evaluate if this procedure can be safely performed in an out patient setting. Definitions Intra-operative complications: bowel/bladder perforation, intra-peritoneal/abdominal hematoma, acute abdomen, procedure failure from any cause, any complication requiring higher level of care, and death. Immediate post-op complications: those occurring within 24 hours after PDC placement and included catheter flow dysfunction, fluid leak, acute abdomen, or any complication necessitating open laparotomy or surgical laparoscopic intervention, and death. Number of patients 89 Mean Age, years 46.5 Gender, N (%) M-52, F-46 Race, N (%) African American AA-54,C-46 Mean egfr, ml/min ± 4.7 Mean Se. Creatinine, mg/dl 7.55 COMPLICATION INTRA-OP n (%) IMMEDIATE POST OP (%) Bowel Puncture 2 (2.2) 0 Bladder Perforation 0 (0.0) 0 Bleeding/Hematoma 1 (1.1) 0 Failure of placement of 4 (4.5) PDC under fluro Total PD Catheter Attempted 89 Succesfully Placement 85 Success Rate (%) 95.5 Conclusions Fluoroscopic Peritoneal Dialysis Catheter placement is a safe procedure and has a high technical success rate. Intra-Op complications are minimal; bowel puncture can be prevented using a blunt tip needle for peritoneal entry. Patients can be discharged once recovered from procedure sedation analgesia.

4 LSU Shreveport Experience Fluoroscopy (NKF 2012) Fluroscopic vs surgical Peritoneoscopic vs surgical 13% Comparison of Outcomes of Peritoneal Dialysis Catheters Placed by the Fluoroscopically Guided Percutaneous Method versus Directly Visualized Surgical Method J Vasc Interv Radiol 2008; 19: Peritoneoscopic Versus Surgical Placement of Peritoneal Dialysis Catheters: A Prospective Randomized Study on Outcome AJKD. 1999, 33;1: Recommendations Guideline 4: Implantation technique Guideline 4.1 Local expertise at individual centers should govern the choice of method of PD catheter insertion (1B) Guideline 4.2 Each PD unit should have the ability to manipulate or reimplant PD catheters when necessary (1B) Guideline 4.3 Urgent removal of PD catheters should be available where necessary (1A) Guideline 4.4 Timely surgical support should be available for the review of PD patients (1A).

5 Guideline 5: Facilities Guideline 5.1 Dedicated area be used for catheter insertion with appropriate staffing and patient monitoring facilities (1A) Guideline 5.2 No particular catheter type is proven to be better than another (2C) Guideline 5.3 Catheter of a suitable size should be used (2C) Guideline 5.4 PD catheters should be inserted as day case procedures as long as this does not compromise the quality of care (2C) Guideline 6 7: Training audit Guideline 6.1 Training should be available to all trainees with an interest (1C) Guideline 6.2 PD catheter insertion should not be delegated to inexperienced unsupervised operators (1A) Guideline 7.1 Regular audit at not less than 12 month intervals of the outcome of catheter insertion as part of multidisciplinary meetings of the PD team and the access operators (1B). Need more level 1 evidence Conclusions Fluoroscopic and peritoneoscopic techniques are fairly straightforward with minimal complications Local expertise at individual centers should govern the choice of method of PD catheter insertion Modality of placement should be individualized for each patient