Peritoneal Dialysis Catheter Placement. Peritoneal Dialysis Catheter Placement. Peritoneal Dialysis Catheter Placement

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1 ASDIN Advanced Techniques Pre-course Feb. 24, 2012 New Orleans, La Randall L. Rasmussen, MD Special thank you to Drs. Rajeev Narayan, San Antonio, Tx and Hemant Dhingra, Fresno Ca for lending me slides from their teaching files to use for this talk. Permanent CAPD catheters straight or arcuate inter-cuff segment two cuffs deep cuff that is implanted in the rectus muscle superficial cuff that is positioned two cm from the exit site variable length from the deep cuff to the coil a coiled distal end Four placement techniques: Peritoneoscopic Fluoroscopic Surgical Laparoscopic Blind technique - abandoned are favored by interventional doctors - but placing these catheters requires a different skill set than those interventional doctors are use to There are advantages to both the peritoneoscopic and the fluoroscopic technique - peritoneoscopic procedure offers visualization of the peritoneal cavity which is important in patients with a history of extensive surgery or adhesions - fluoroscopic placement is the least invasive

2 Pre-procedure assessment History meds, allergies, previous surgery regular bowel pattern and not constipated Physical exam obesity, hernias Laboratory coagulation profile Evaluation by CAPD nurse assess the patient s s ability to learn Immediately pre-procedure procedure document emptied bladder mark the belt line with the patient sitting start prophylactic antibiotics Cefazolin 1 gram IVPB Vancomycin 1 gram IVPB administer IV sedation - demonstrated in workshops Both peritoneoscopic and fluoroscopic techniques start with an abdominal US both require: abdominal ultrasound incision to expose the anterior sheath on the lateral border of the rectus muscle gain entry into the peritoneal cavity confirm entry into the peritoneal cavity insert the catheter check catheter function and close the incision Sub Q fat Ant rectus sheath Rectus muscle Post rectus sheath Peritoneal cavity Measure distance skin to rectus Measure thickness of rectus Document free movement US is used to identify any major vascular structure The second step is an incision, ½ distance between the ASIS and normal location of the umbilicus, to expose the anterior sheath on the lateral border of the rectus muscle. Inferior epigastric artery arises from the external iliac artery and courses cephalad along with the inferior epigastric vein between the posterior wall of the rectus muscle and the posterior rectus sheath The incision should be: - off the belt line - as long as it is deep Expose an area the size of a half dollar (3 cm in diameter) > to get good visualization of the rectus sheath

3 The third step is to gain entry into the peritoneal space access to the peritoneal cavity can be visualized with real time ultrasound need to avoid the pre-peritoneal space an incision is made to expose the anterior sheath on the lateral border of the rectus muscle ligate or bovie any bleeders Need to avoid the pre-peritoneal space Need to avoid the pre-peritoneal space Parietal peritoneum Pre-peritoneal space Posterior rectus sheath Rectus muscle Pre-peritoneal space Parietal peritoneum The pre-peritoneal space is the space between the posterior rectus sheath and parietal peritoneum The pre-peritoneal space is less likely to be entered if an insertion site is selected above the level of the anterior superior iliac spine. Peritoneoscopic technique entrance to the peritoneal cavity is done using a quill guide assembly set Quill guide assembly set Quill guide, cannula & trocar are inserted through the rectus at a angle directed towards the coccyx Fluoroscopic technique(s) entrance to the peritoneal cavity is done using a Veress needle Veress needle Rectus Rectus muscle Pops can be felt when the Veress needle pierces the anterior and posterior rectus sheath. Note that saline will run freely once the peritoneal cavity is entered.

4 The fourth step is to confirm peritoneal location using the peritoneosope the white-pink appearance of the peritoneum can be directly visualized and moves with respiration a white appearance means pre-peritoneal location both techniques can confirm the location by performing a peritoneogram a.035 guidewire that easily curls across the midline is good evidence of intraperitoneal location saline runs wide open Peritoneogram usually requires 10cc of ½ strength contrast contrast can be injected through the cannula during the peritoneoscopic approach contrast can be injected through a sheath or dilator inserted over a guidewire during the fluoroscopic technique Peritoneogram with free flow of contrast in the peritoneum.035 Guidewire easily curls across the midline with minimal resistance Peritoneogram demonstrates contrast trapped in the pre-peritoneal space.035 Guidewire in the pre-peritoneal space meets resistance and does not cross the midline Complications of peritoneoscopic and fluoroscopic CAPD catheter insertion occur with entry into the peritoneal cavity * perforation of bowel, bladder or a vessel * can usually be taken care of with minimal adverse outcomes as long as the complication is recognized. * aspirate after gaining entry to the peritoneal cavity for blood, urine or bowel contents Interpret this peritoneogram done at the time of CAPD catheter insertion.

5 The fifth step is to insert the catheter in both techniques, a small volume of NS is first instilled into the peritoneal cavity Interpret this peritoneogram done at the time of CAPD catheter insertion. Abdel-Aal A K et al. AJR 2009;192: Peritoneoscopic technique Insufflation of the peritoneal cavity with room air Peritoneoscopic technique the CAPD catheter is mounted on a lubricated stylet for insertion the catheter is inserted over the quill guide into the clear space Peritoneoscopy allows the quill guide assembly to be advanced into a clear space under direct visualization using the peritoneoscope. note that during catheter insertion, the stylet should be inserted the minimal distance into the peritoneal cavity Peritoneoscopic technique Fluoroscopic techniques a peel-away sheath is advanced over a.035 guidewire then the guidewire is removed the CAPD catheter is mounted on a lubricated stylet for insertion the CAPD catheter is inserted into the peritoneal cavity through the peel-away catheter Quill guide Dilate Cath insertion Tunnel

6 Fluoroscopic techniques After insertion of the catheter into the peritoneal cavity: the deep cuff is anchored in the rectus muscle using an implanter device a tunnel is created for the exit so that the catheter is off the belt line and oriented lateral or inferior-lateral CAPD catheter uncoiling through 16 Fr peel-away sheath Note the stylet location CAPD catheter in position, with contrast freely flowing the superficial cuff is positioned 2 cm from the exit site Feet Head Lastly, check the catheter function and close the incision confirm catheter position by contrast injection check catheter function with 250 cc of dialysate or NS flush The deep cuff is implanted into the rectus muscle prior to tunneling the catheter to the exit site Head Feet The catheter is oriented inferior-lateral Post-procedure checklist Sutures absorbable subcutaneous sutures are used to close dead space only if it is excessive non-absorbable sutures are used to close the skin sutures are not usually placed at the exit site is the coil center no more than 5 cm cranial to the top of the symphysis pubis? is the angle of the intraperitoneal straight portion more than 15 degrees from the horizontal? is the coil of the catheter in its natural shape (meaning that no part appears to cross any other part)? are there any kinks in the catheter? was the deep cuff visible in the rectus? is the angle of the catheter at the exit site horizontal or downward (not upward)?

7 Post-procedure the patient must have a follow-up appointment for dressing change and flush consider Rx stool softeners postoperatively and analgesic medications that do not cause constipation patients should expect minimal post-operative operative discomfort and must be given instructions to call for any sign of symptom that requires medical attention