Peritoneal Dialysis at Home How to Contact Your Peritoneal Dialysis Team
The PD Unit is on level 4 of the River zone, section B, at the main hospital campus. The PD Unit is open Monday through Friday from 8 a.m. to 8 p.m. We are closed on weekends, Thanksgiving, Christmas and New Year’s Day.
Address 4800 Sand Point Way N.E. Seattle, WA 98105
Phone numbers Main hospital 206-987-2000
PD Unit 206-987-1310
PD Unit dietitian 206-987-6358 or 206-987-5538
PD Unit social worker 206-987-9584 or 206-987-9876
After hours, weekends, and holidays: If you have an urgent dialysis-related concern that cannot wait until the PD Unit is open, please call the main hospital at 206-987-2000. Calls will be forwarded to an operator who can help you to reach the on-call dialysis nurse.
For all other medical problems, please contact your primary care provider, kidney doctor or family doctor.
For any PD Cycler equipment related concern, please call Baxter Technical Support at 1-800-553-6898.
For life threatening emergencies dial 911.
2 Peritoneal Dialysis at Home Table of Contents
Starting Peritoneal Dialysis...... 5
Hand Hygiene...... 17
Caring for Your Catheter...... 29
Safe Treatment...... 53
PD Problem-Solving...... 69
Balancing Fluids...... 101
Dialysis Medicines...... 119
Caregivers...... 141
Automatic Dialysis with a Cycler Machine Versus Manual Dialysis...... 153
Seattle Children’s Hospital 3 4 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 1
Starting Peritoneal Dialysis
In this lesson you will learn: • What healthy kidneys do for your child’s body • The condition of uremia and its symptoms • All about peritoneal dialysis (PD) and a process called Automated Peritoneal Dialysis (APD) • The steps of a peritoneal dialysis cycler or exchange • Lifestyle benefits of APD
Seattle Children’s Hospital 5 Lesson 1: Starting Peritoneal Dialysis
Words to know
APD Automated Peritoneal Dialysis, sometimes called CCPD. CAPD Continuous Ambulatory Peritoneal Dialysis (also known as manual PD). This type of dialysis is done manually. Gravity is used to drain and fill your peritoneal cavity with dialysis solution. Catheter A tube that carries the dialysate into and out of your body. CCPD (APD) Continuous Cyclic Peritoneal Dialysis. This type of dialysis is done with a machine called a cycler. The cycler will automatically drain, fill and dwell the dialysis solution from your peritoneal cavity. Cycler Machine used to do peritoneal dialysis. Dialysate A liquid that has a sugar called dextrose in it to help pull waste and extra fluid into the peritoneal cavity. Dialysis The process of removing waste products and excess fluid from the body. Dwell time The time the dialysis solution sits in your peritoneal cavity. Exchange or cycle The process of draining, filling, and dwelling the dialysis solution from your peritoneal cavity. Peritoneum A layer of tissue covering the wall of the abdominal cavity. The peritoneum is a natural filter and lets waste product and fluid pass from your blood into the dialysis “sugar” solution. Transfer set A 4- or 6-inch length of tubing that attaches to the PD catheter. The transfer set lets the catheter open and close. Ultrafiltrate The fluid that is removed from the bloodstream during dialysis. Uremia Occurs when the kidneys don’t work like they should. The toxins or “waste” build up in the body.
6 Peritoneal Dialysis at Home Lesson 1: Starting Peritoneal Dialysis
What do healthy kidneys do?
Remove waste Waste products, such as blood urea nitrogen (BUN) and creatinine, are made by the body during normal daily functions. These products are removed from the blood by healthy kidneys. Balance fluid Healthy kidneys know when there is too much or too little fluid in the body. When kidneys are working, they make urine to remove extra fluid your child drinks. If your child has too little fluid in their body from sweating, throwing up, or having diarrhea, the kidneys keep fluid and make less urine. More on this in Lesson 6. Control blood pressure Healthy kidneys help keep the blood pressure in a safe range. They release a signal that tells the body when to raise or lower blood pressure. They also help control blood pressure by balancing the fluid in the body. More on this in Lessons 6 and 7. Make red blood cells Healthy kidneys release a signal that tells the body when to make more red blood cells. More on this in Lesson 7. Balance electrolytes Kidneys play an important role in the regulation (balance) of fluids and electrolytes. When they malfunction it often leads to an electrolyte imbalance. Electrolytes are charged particles involved in sending impulses to nerves and muscles. Excessive amounts of electrolytes are removed from the blood by healthy kidneys. Maintain healthy bones Healthy kidneys remove extra phosphorus (foss-for-us) from the blood and take it out of the body in the urine. Too much phosphorus causes low calcium. Low calcium leads to weak, brittle bones. Keeping phosphorus levels normal keeps calcium levels normal, so bones stay strong and healthy. Kidneys also make vitamin D, which helps your body to absorb calcium from food. Growth and development Many things in the body affect your child’s growth and development. These include acids, bases, minerals, hormones and proteins. Healthy kidneys make sure these stay balanced so that children can grow and develop normally.
Seattle Children’s Hospital 7 Lesson 1: Starting Peritoneal Dialysis
What is uremia?
The kidneys filter waste from the blood. When the kidneys are not working well, they do not filter the blood and wastes build up in the blood causing a condition called uremia.
Symptoms of uremia are:
Tiredness/ Loss of appetite weakness
Difficulty Bad taste in mouth concentrating in school
Nausea/vomiting (throwing up)
Dialysis will help relieve the symptoms of urea.
What is peritoneal dialysis?
During peritoneal dialysis (PD) your child’s blood is filtered and extra fluid is removed. During PD, a cleansing fluid called dialysate is circulated through a tube (catheter) inside part of your abdominal cavity (peritoneal cavity). The dialysate absorbs waste products from the blood vessels in your abdominal lining (peritoneum) and then is drawn back out of your body and discarded.
Imagine watching a teabag as the tea particles spread out through the water. A teabag steeping in water is like what happens during PD. The tea bag is the peritoneal membrane, the tea leaves are the blood vessels, the tea color that makes the tea is the waste in the blood vessels, and the water is the dialysate solution. This process is called diffusion.
8 Peritoneal Dialysis at Home Lesson 1: Starting Peritoneal Dialysis
Tea leaves inside the tea bag (blood vessels)
Tea bag steeping in water (peritoneal membrane)
Water (dialysate Tea color (waste in solution) the blood vessels)
You will hear some medical terms used when learning how dialysis works. These are some of the medical terms the team may use:
Peritoneal membrane • The lining on the inside of your child’s abdomen between the abdominal wall and internal organs. It contains a lot of blood vessels. • Acts as a natural filter. • Allows waste products and excess fluid to pass into the dialysate solution.
Osmosis • The movement of extra fluid from the bloodstream, across the peritoneal membrane, and into the dialysate solution to be drained. • The fluid that is removed is called ultrafiltrate (UF). • The amount of ultrafiltrate (UF) is determined by the concentration of the dialysate solution used. • PD does not remove a set amount of fluid each treatment.
Diffusion • The movement of waste products from the bloodstream, across the peritoneal membrane, and into the dialysate fluid to be removed. • The waste moves from the bloodstream where there is a high concentration of particles to the dialysate solution where there is a low concentration of particles.
It is through osmosis and diffusion using the peritoneal membrane and dialysate solution that dialysis removes wastes and fluids. Osmosis and diffusion are slow, gentle processes that your child will not feel. The processes stop on their own when each side of the peritoneal membrane is balanced.
Seattle Children’s Hospital 9 Lesson 1: Starting Peritoneal Dialysis
What is a peritoneal dialysis catheter?
• The catheter is a small, flexible tube. It is surgically placed through the wall of the belly area (abdomen) into a space called the peritoneal cavity. The peritoneal cavity holds the abdominal organs. • The lining of the peritoneal cavity is called the peritoneal membrane. • Many blood vessels run throughout this peritoneal membrane. • PD uses the peritoneal membrane, along with dialysate fluid, to filter and clean waste products and extra fluid from the blood. The blood is from the blood vessels along the peritoneal membrane wall. • The catheter allows dialysate fluid to go in and out of the peritoneal cavity during a PD exchange. • A peritoneal dialysis catheter is your child’s permanent access for PD treatments.
Internal organs
Peritoneal catheter
Peritoneal cavity
10 Peritoneal Dialysis at Home Lesson 1: Starting Peritoneal Dialysis
What is a transfer set?
• Attached to your PD catheter is a transfer set that allows you to connect to your APD machine. • The transfer set is attachments that make it easy to connect the tubing for dialysis to the machine and close off the tubes when they are not being used. • The transfer set always stays connected to your catheter. It should only be changed by your PD nurse every 6 months or if there is a problem with the transfer set.
Transfer set PD catheter
What is a PD cycle or exchange?
A PD exchange is a cyclical process that removes waste products and fluid from your child’s body and replaces it with new dialysate solution.
Seattle Children’s Hospital 11 Lesson 1: Starting Peritoneal Dialysis
There are three steps to each PD exchange:
1. Drain Removes old dialysate solution, along with waste products and extra body fluid.
2. Fill Replaces old dialysate solution in the peritoneal cavity with new dialysate solution.
3. Dwell The time when dialysate solution is in the peritoneal cavity. This is when dialysis takes place. Dwell time is set by your kidney doctor.
12 Peritoneal Dialysis at Home Lesson 1: Starting Peritoneal Dialysis
Automated peritoneal dialysis
Automated Peritoneal Dialysis (APD) is sometimes called CCPD (continuous cyclic peritoneal dialysis). This is a kind of peritoneal dialysis (PD) that uses a machine called a cycler.
• APD works during the night while your child sleeps. • The cycler is set up to automatically do PD exchanges. • Your nurse will tell you if your child needs a PD exchange during the day (in addition to or in place of nighttime exchange). Sometimes you will need to close off the APD with a manual exchange — see Lesson 9.
Below are some pictures of cycler machines used at Seattle Children’s. Your nurse will help decide which cycler is best for your child.
HomeChoice Pro Cycler AMIA Cycler (typically for babies (typically for older kids and toddlers) and teenagers)
The name of the cycler I will be using at home is:
.
Seattle Children’s Hospital 13 Lesson 1: Starting Peritoneal Dialysis
APD offers you some nice lifestyle benefits
• It is done in the comfort of your own home, while your child sleeps. • With guidance from your PD team, your child’s schedule can be personalized to match your family’s lifestyle. • Unlike hemodialysis, your child’s dialysis treatment does not involve blood or needles. However, needles may be needed for medicines such as Epogen or growth hormones. • It is easier for your family to travel. You can take the APD equipment with you when you travel to visit friends and relatives, stay in a hotel or go camping in a recreational vehicle.
Key points
• Healthy kidneys remove waste products, balance fluids, control blood pressure and make red blood cells. • Symptoms of uremia are relieved by dialysis. • The peritoneal membrane is used as the filter in peritoneal dialysis. • The transfer set attaches to the peritoneal catheter using an adapter. • The transfer set allows the catheter to connect to the cycler. • There are 3 steps to a peritoneal dialysis exchange or cycle: drain, fill and dwell. • Automated Peritoneal Dialysis (APD) is peritoneal dialysis using a cycler that automatically drains dialysis solution from the patient, fills the patient with dialysis solution, and allows the dialysis solution to dwell for the ordered amount of time.
14 Peritoneal Dialysis at Home Lesson 1: Starting Peritoneal Dialysis
Teach-back moment
What does PD do?
Where is the PD catheter placed?
What are symptoms of uremia?
What happens during each of the 3 steps of peritoneal dialysis cycle or exchange?
Seattle Children’s Hospital 15 Lesson 1: Starting Peritoneal Dialysis
Notes
My questions:
My notes:
Important information from this lesson:
16 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 2
Hand Hygiene
In this lesson you will learn: • The importance of hand hygiene • The difference between sterile, clean and dirty • How to perform proper hand hygiene based on the World Health Organization (WHO) guidelines • How proper hand hygiene may help protect against infection
Seattle Children’s Hospital 17 Lesson 2: Hand Hygiene
Words to know
Aseptic technique The way to make sure clean items stay “clean” and sterile items stay “sterile.” The goals of aseptic technique are to protect your child from infection and to prevent the spread of germs.
Clean Most germs have been removed, but not all of them. For example, washing your hands makes them clean, not sterile.
Contaminated An item that was sterile that touches something that is either clean or dirty. It is no longer sterile.
Dirty Not clean or sterile.
Exit site Area where the PD catheter comes out of the skin.
Peritoneal cavity The space between the abdomen wall and the organs in the abdomen.
Peritoneal dialysis (PD) catheter Flexible plastic tube inserted into the peritoneal cavity by a surgical procedure.
Peritoneum A layer of tissue covering the inside wall of the abdominal cavity that contains a lot of blood vessels. Acts as a natural filter and lets waste product and fluid pass from your bloodstream into the dialysis “sugar” solution.
Peritonitis A serious infection of the peritoneum.
Sterile Free from bacteria and other germs. For example: supplies in sterile packaging.
Tunnel area The space under the skin surrounding the PD catheter.
18 Peritoneal Dialysis at Home Lesson 2: Hand Hygiene
Germs are everywhere
Germs, sometimes called “bugs,” are bacteria, viruses and fungi that are too small to see without a microscope. Germs are everywhere around us. We come into contact with millions of germs every day. Germs live on work surfaces, equipment and skin, and in the nose and the gut, even when there is no visible dirt or someone is healthy.
Not to worry! Most bugs are harmless, and some even help to keep your child healthy. But some can make your child very sick. Germs can spread to others when people touch things that others touch (like door handles, keyboards, phones and TV remote controls).
When these germs get on your hands, they can spread to other parts of your body when you touch your eyes, ears, nose or mouth. And they don’t stop there — you spread germs every time you touch something or someone else!
Seattle Children’s Hospital 19 Lesson 2: Hand Hygiene
You should perform hand hygiene before:
Handling food Performing peritoneal dialysis care:
• Cycler setup
Eating • Connecting to or disconnecting the catheter to the cycler lines Putting in or taking out • Exit site dressing contact lenses changes
You should perform hand hygiene after:
Eating Coughing or sneezing
Handling dirty dishes or utensils, or touching Being around someone countertops where who is sick food is prepared
Going to the bathroom Playing with pets or or helping someone animals go to the bathroom
Completing peritoneal dialysis care, such as Blowing or wiping your throwing away used nose peritoneal dialysis lines, drainage bags and soiled supplies
20 Peritoneal Dialysis at Home Lesson 2: Hand Hygiene
How to perform hand hygiene
You cannot rub your dirty hands on your clothes or rinse them with water to get rid of germs.
Water by itself is not enough to get rid of all germs. You need to use soap! Germs can stick to the oils that your skin naturally produces. Soap helps to break down that oil, making it harder for germs to stay on your hands. Then the germs can be rinsed away by water.
When washing with soap and water, a quick rinse is not effective. Don’t just wipe those wet hands on your clothes! Drying hands thoroughly after each washing is important. If you have a choice, use a paper towel instead of a cloth to prevent the spread of germs to others who might use the same towel. Throw away the paper towel once you’re done drying your hands. If you’re using a cloth towel, use a new clean towel. Do not use an already used towel, because it could have germs on it.
Time must be spent cleaning all areas of the hands. This includes the back of hands, between the fingers and even the fingernails. Dirt and germs can easily get stuck underneath your fingernails. This is the area that contains the highest number of germs on the hand. Keep fingernails short and clean. Several studies show that long fingernails or artificial nails are linked to infections with a very serious bug named Pseudomonas aeruginosa. These infections are very hard to treat and are a common reason why PD catheters need to be replaced.
If soap and water is not available, use an alcohol-based hand sanitizer gel. Alcohol-based sanitizer gel must contain at least 60% alcohol to kill germs. It is really important when using alcohol-based sanitizer gel to make sure that your hands are completely dry before handling your child’s PD catheter. Alcohol that is left on your hands from the gel may lead to holes or leaks in the catheter.
Seattle Children’s Hospital 21 Lesson 2: Hand Hygiene
Sterile, clean or dirty?
Aseptic technique means the use of practices to prevent contamination with germs to keep an object or area clean. We use these words when talking about aseptic technique:
Sterile means completely free of all germs. The peritoneum is sterile.
Clean means free of dirt. Hands are clean after a 1-minute scrubbing.
Dirty means not clean or sterile. Dirty objects should not be used in dialysis procedures where clean or sterile items are needed.
Contaminated means a sterile item has been touched by something that is not sterile. Germs are now on the sterile item.
Follow these guidelines when using this method: • Before handling packages of sterile items, wash your hands! • Do not put packages on wet surfaces or let them get wet. The wetness lets germs into the wrapper. This will contaminate the item. • Do not use contaminated items! • Prepackaged sterile items are sterile only if the package is not opened and not damaged. Remember, only the inside of the packaging is sterile. • Once sterile solutions are opened, they are exposed to germs in the air. Open sterile solutions just before use. • When in doubt, throw it out!
Hand hygiene information from the World Health Organization
• Hand hygiene is the best, most simple and effective way to stop the spread of germs and prevent infection. • Good hand hygiene takes 40 to 60 seconds when washing your hands with soap and water. • Good hand hygiene takes 20 to 30 seconds when using alcohol-based gel.
22 Peritoneal Dialysis at Home Lesson 2: Hand Hygiene
Wash your hands! Stop germs!
Keeping hands clean is one of the most important things we can do to prevent peritonitis.
Steps for using soap and water
Seattle Children’s Hospital 23 Lesson 2: Hand Hygiene
Clean your hands! Stop germs!
Keeping hands clean is one of the most important things we can do to prevent peritonitis.
Steps for using hand sanitizer
24 Peritoneal Dialysis at Home Lesson 2: Hand Hygiene
Peritonitis
The peritoneal cavity (the space between the abdominal wall and the organs in the abdomen) is sterile, meaning it is free from germs. It is very important to keep germs from getting inside your child’s peritoneal cavity where they can cause a serious infection called peritonitis. Most germs that cause peritonitis are bacteria, tiny invisible organisms that are always in our environment.
Common causes of peritonitis include:
• Bacteria directly entering the body through the dialysis catheter because of mistakes with connections or disconnections or a problem with the catheter itself. Common problems include: • The open ends of the catheter or dialysis lines are touched during connections. • The lines are accidentally disconnected during treatment. • A hole or crack develops in the catheter.
• An infection of the tunnel area around the catheter that spreads to the peritoneal cavity. • An infection of the exit site where the dialysis catheter leaves the abdomen, allowing germs to enter the peritoneal cavity through the tunnel area. • Issues with the bowels that allow bowel bacteria to cross into the peritoneal cavity, such as: • Constipation • Diarrhea • Surgical procedures
Hand hygiene is the #1 way to prevent peritonitis!
Resources
https://www.cdc.gov/cdctv/healthyliving/hygiene/fight-germs-wash-hands.html
https://www.cdc.gov/cdctv/healthyliving/hygiene/wash-your-hands.html
Seattle Children’s Hospital 25 Lesson 2: Hand Hygiene
Key points
• Because of the risk and seriousness of infection, everything that comes in contact with your child’s peritoneal cavity or the open ends of the dialysis catheter or dialysis lines must be sterile or germ-free. • Germs are everywhere! You never know when you may come into contact with a bug that can cause illness. Most often bugs are spread into our bodies by our hands!
Teach-back moment
What is the most important thing you can do to protect your child from germs?
What is the difference betweenclean and sterile?
Should you use towels hanging in the bathroom or kitchen to dry your hands after washing prior to dialysis care?
True/False: When washing hands or using alcohol-based gel, it is important to clean under the fingernails, front and back of hands, between fingers and around thumbs.
What is the best way to prevent peritonitis?
According to the World Health Organization (WHO) guidelines, how long should hand washing take when done correctly with soap and water?
What do you need to do if you touch something that is not clean with your freshly washed hands, such as putting on your mask or scratching an itch?
26 Peritoneal Dialysis at Home Lesson 2: Hand Hygiene
Notes
My questions:
My notes:
Important information from this lesson:
Seattle Children’s Hospital 27 Lesson 2: Hand Hygiene
28 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 3
Caring for Your Catheter
In this lesson you will learn: • All about your peritoneal dialysis (PD) catheter • How to keep your PD catheter safe after surgery • How to care for your PD catheter at home
Seattle Children’s Hospital 29 Lesson 3: Caring for Your Catheter
Words to know
Adapter Small metal or plastic piece connecting the PD catheter to the transfer set.
Antibiotic A prescribed medicine to treat bacterial infections.
Antifungal A prescribed medicine to treat or prevent fungal (yeast) infections.
Antiseptic Prescribed cleaning solution (for example, ExSept Plus).
Culture Lab test to determine the type of infection.
Cuff (deep) Fabric piece around the catheter deep under the muscle.
Cuff (subcutaneous) Fabric piece around the catheter just under the skin.
Dressing Bandage with padding and adhesive to cover the exit site.
Exit site Place on the stomach area where the catheter comes out of the skin.
Fibrin Whitish strings or strands of protein seen in the drain bags.
MiniCap/Stay-Safe cap Iodine-filled cap that protects the end of the transfer set.
Omentum Fatty layer of peritoneum that can clog up the catheter.
Peritoneal dialysis (PD) catheter Flexible plastic tube inserted into the peritoneal cavity by a surgical procedure.
Peritoneal membrane or peritoneum Semipermeable membrane that lines the abdominal cavity and covers abdominal organs; it is a stretchy sac filled with many tiny blood vessels.
30 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Peritoneal cavity The space between the abdomen wall and the organs in the abdomen where PD solution dwells.
Transfer set A 4- to 6-inch length of tubing that attaches to the PD catheter. The transfer set lets the catheter open and close.
True catheter A soft plastic tube that is surgically implanted in the peritoneal cavity. It is permanent unless removed in surgery.
Tunnel area The space between where the catheter exits the skin (exit site) and where it enters the muscle layers of the abdomen and into the peritoneum. The catheter can usually be felt under the skin in the tunnel area.
Seattle Children’s Hospital 31 Lesson 3: Caring for Your Catheter
What is a peritoneal dialysis (PD) catheter?
Your child’s catheter is their lifeline, because without the catheter you cannot perform PD exchanges. The exit site and catheter tunnel must be free of germs. If an infection happens, the catheter may have to be removed. Look at the exit site every day and call the dialysis nurse if you think your child has an infection.
A PD catheter is a flexible plastic tube that allows dialysate to enter and exit your child’s peritoneal cavity.
• The catheter is surgically placed in the body. • The catheter passes through the skin layers before it enters the peritoneal cavity. This is called the tunnel area. • There are usually two small fabric cuffs on the catheter. As the catheter heals, your child’s skin will grow into the cuffs. This prevents the catheter from slipping out and keeps germs out of the peritoneal cavity. • The internal end of the catheter has many small holes. These holes allow the fluid to flow into and drain out of the peritoneal cavity.
Exit site Skin Tunnel area
Catheter in peritoneal cavity
32 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Care of the peritoneal dialysis catheter exit site dressing after surgery
• Ensure the dressing is secured on all four sides. Use surgical tape or Tegaderm as needed to keep the dressing in place. • The catheter must be prevented from moving for proper healing to occur at the exit site. Secure the catheter to the dressing with tape. • The clamp of the transfer set must remain closed at all times with a MiniCap or disconnect cap in place. • No showering or tub baths are allowed until the site is totally healed. Only sponge baths are allowed. Keep the dressing covering the peritoneal dialysis catheter dry at all times. Do not submerge any part of the catheter or dressing in water.
A PD exit site with gauze dressing and a Tegaderm covering
• Until the exit site is healed completely, you will need to go to the dialysis center weekly so the dialysis nurse can do a sterile dressing change. You may also need to come in if the dressing becomes wet, soiled or is removed.
Seattle Children’s Hospital 33 Lesson 3: Caring for Your Catheter
Activity after surgery
Try to have your child rest as much as possible for the first 48 hours after the peritoneal dialysis catheter placement.
• Your child should not return to school until . • Do not allow your older child to carry anything weighing more than 10 pounds for the 3 to 6 weeks after catheter placement. Your younger child should not carry anything weighing more than 5 pounds for 3 to 6 weeks after catheter placement. • Your doctor and nurse will let you know when the exit site is healed enough for your child to return to normal exercise and activities. • Your nurse will let you know if you need to continue using a dressing or not.
When to call the unit
Call the Dialysis Unit if:
• The dressing becomes wet, soiled or falls off. • There is any kind of break or hole in the catheter. If you discover a hole or break, place a clamp between the break or hole and your child’s abdomen first and then call the Dialysis Unit.
• Your child has a temperature over 100.5 degrees Fahrenheit.
• The MiniCap falls off the transfer set. MiniCap
• Your child is not having daily bowel movements. Pain medicines and immobility can cause constipation.
34 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
What is a transfer set?
The transfer set is a small segment of tubing with a clamping device. It is placed on the end of the PD catheter by a trained professional, using sterile techniques.
A transfer set right out of the package
Checking your child’s catheter and transfer set
Check your child’s catheter, transfer set and exit site before and after every treatment.
• The exit site is where the catheter exits your child’s body (see pages 10 and 11). • The skin around the catheter and tunnel area should not be red, painful, or swollen. It should not have any drainage or pus. • The transfer set and catheter should be free of tears, cracks, slits and holes. • The connection between the true catheter and the transfer set should be secure. • The transfer set cap (MiniCap) should be in place and secured tightly. • Your child’s transfer set needs be changed every 6 months or if the PD nurse has concerns. You don’t change the transfer set. The dialysis nurse will change the transfer set as needed.
Seattle Children’s Hospital 35 Lesson 3: Caring for Your Catheter
Taking good care of your child’s catheter
The catheter should be secured and unable to move at all times to prevent pulling and injury or damage at the exit site. Tape the true catheter to your child’s skin to prevent tugging and possible injury. We may recommend a PD belt (not pictured).
Transfer set
True PD catheter
The skin around the exit site will take up to 6 weeks to fully heal. Until the exit site is healed, it must stay completely dry and covered with a dressing. This means absolutely no showers or swimming. Sponge baths only are allowed during this time.
A dressing must always cover the exit site until it heals.
Once healed, your child may not need a dressing; your nurse will discuss with you the need for a dressing. If your child needs dressings, your child’s nurse will teach you how to perform a dressing change.
• Once the exit site is fully healed, your child may take a daily shower. No baths! (Bath water is considered dirty.) • If your child is old enough to shower on their own, your PD nurse will teach them the best way to safely take a shower. • Never apply lotion, oil or powder to the exit site. • Never use scissors, pins or other sharp objects near the catheter. For example, do not use scissors to cut the dressing off. Any defect in your child’s catheter can cause an infection. This may lead to more surgeries to replace the catheter. • No swimming or bathing is allowed in rivers, • Swimming is allowed lakes, streams, baths, hot tubs or hot springs. once the catheter is The International Society of Peritoneal healed, but only in Dialysis does not recommend salt pools; chlorinated pools or only chlorinated pools. the ocean.
36 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
When to call the unit
Call the dialysis nurse:
• If you notice any tears, cracks or openings in your child’s catheter. Do not start dialysis. Clamp the catheter as you were taught and call the dialysis nurse.
• If your child develops a fever or stomach pain.
• If there are warning signs of infection, such as pain, redness, swelling or pus along the tunnel area or exit site.
Seattle Children’s Hospital 37 Lesson 3: Caring for Your Catheter
Changing the dressing
Your dialysis nurse will teach you how to change the peritoneal dialysis catheter dressing using the steps below. The dressing should be changed as directed by your dialysis nurse, as well as any time it gets wet or dirty or is coming off.
1. Gather supplies. • Antibacterial soap or ExSept solution • Antibiotic cream • Gauze • Cotton-tip applicator (Q-tip) • New dressing or tape • Tegaderm (if needed to protect from soiling) • Masks
2. Maintain a safe environment. • Pets should remain outside of the room. • Everyone in the room should wear a mask. • Close doors and windows, and turn off fans. • Wash hands.
3. Remove the old dressing. Never use scissors, pins or any other sharp objects to remove the dressing. When you pull off the dressing, make sure to support the catheter so it does not get pulled on.
4. Clean the site using cleanser as you were taught. Leave crusts or scabs in place to heal. Allow them to fall off naturally, as part of the normal healing process. 5. Apply a pea-sized drop of antibiotic cream to the exit site using the corner of clean gauze or a Q-tip.
Look at your exit site. Wash. Apply cream and secure the catheter.
38 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
6. Place a new dressing as you were taught. Make sure that the edges of the dressing stick securely to the skin. If the dressing is coming off, start over with a new dressing. 7. Secure the transfer set in a PD belt.
Troubleshooting catheter problems
Any child can have problems with the dialysis catheter, even if extra caution is used. Your child’s nurse will help you to understand common problems to watch out for and what actions to take.
Catheter trauma (rips, tears or comes out)
Cause • Not properly secured • Pulling, rough-housing or contact sports
Symptoms • Pain at the exit site • Skin tear near the exit site • Blood draining from the exit site • The catheter has migrated outward and the cuff has become visible
Action • Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.
Seattle Children’s Hospital 39 Lesson 3: Caring for Your Catheter
Exit site infection
Cause • Despite extra caution, some kids will still get germs into the exit site. These germs can cause a bad infection that will need to be treated with antibiotics.
Symptoms • Redness (irregular pattern) • Swelling • Pain at the exit site • Drainage or pus from the exit site
Action 1. Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call. 2. Obtain a culture if instructed by your nurse. 3. Start antibiotics and antifungal medication as instructed by the dialysis nurse and ordered by the dialysis doctor. 4. Clean the exit site carefully as instructed while it heals from the infection. During the early stages of the infection, it may be appropriate to cleanse the exit site and change the dressing more than once each day.
40 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Tunnel area or cuff infection
Cause • Germs get into the tunnel area. Tunnel area infections can be very difficult to treat and clear.
Symptoms • Redness along the tunnel area or at the cuff may look streaky • Swelling along the tunnel area or at the cuff • Pain or tenderness along the tunnel area, especially when touching the tunnel area • Rash or “pimples” along the tunnel area • May or may not have drainage
Action 1. Call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call. 2. You may need to come to the hospital to have cultures drawn. 3. Start medicines (antibiotics) as instructed by the dialysis nurse and nephrologist. Children with tunnel area or cuff infections need treatment with antibiotics.
Seattle Children’s Hospital 41 Lesson 3: Caring for Your Catheter
Other catheter complications
A clog or clot in the catheter
Problem Fibrin or blood can collect in the tiny holes at the end of the catheter. The catheter may need to be manually flushed by a medical professional if the dialysis fluid cannot flow in and out.
Action Check the fluid for fibrin and blood and add a medicine called heparin to the dialysis fluid as needed.
Improper position of the catheter (migration)
Problem The end of the true catheter should be located in the lower abdominal cavity. Problems with the fill or drain can occur if the catheter tip has moved away from this area.
The image shows proper placement of the catheter inside the abdomen.
Action The doctor may order an X-ray to look at the location of the catheter tip. If the dialysis treatment is not working, or if your child is having severe discomfort with fills or drains, surgery may be required to move the catheter back into position.
Obstruction of the catheter
Problem The catheter shares the peritoneal cavity with many other organs, including a special tissue called omentum. The catheter can become wrapped in and obstructed by the omentum and stop working.
Action Surgery is usually required to relieve this type of obstruction.
42 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Constipation
Problem Constipation can be a problem for peritoneal dialysis patients. If constipation occurs, your child may have some stomach pain and hard stools. Even if stools appear soft or runny, constipation may still be present as softer stool passes around harder stool. Severe constipation can cause the bowel to press on the catheter and block it or keep the catheter from moving. In severe cases, constipation can cause peritonitis as bacteria from the bowel crosses over into the sterile peritoneal cavity.
Constipation can be caused from medicines, diet restrictions and lack of exercise.
Action To prevent constipation from becoming a problem, your child should: • Exercise each day. • Eat fresh fruit and vegetables (as allowed). • Eat high-fiber foods each day.
Your child may need to take medicine daily to help with constipation. The use of MiraLAX and/or stool softeners is common with peritoneal dialysis. If your child has not had a bowel movement within 2 days, you need to call your dialysis nurse or doctor. It is important to keep track of your child’s bowel habits and to call the doctor if constipation develops.
Exit site leak
Problem Dialysis fluid is coming out of the exit site, causing the dressing to become very wet with clear or yellow liquid. This may be due to incomplete healing around the deep cuff and tunnel area, and increases the risk for infection.
Action Stop dialysis and call the PD nurse immediately. If it is a night, weekend or holiday, call the hospital at 206-987-2000 and ask for the dialysis nurse or doctor on call.
Seattle Children’s Hospital 43 Lesson 3: Caring for Your Catheter
Remember
Peritoneal dialysis will not work without a functioning catheter. As caregiver, it is important to follow the guidelines below to ensure that it continues to work properly.
Wash hands often. Wash hands with liquid antibacterial soap (a pump bottle) and warm running water before cleaning the exit site, before connecting or disconnecting your child and before connecting any dialysis solution bags.
Secure the catheter. Always secure and stabilize the catheter to the skin to prevent tension or tugging. Your nurse will have suggestions for you on how to stabilize the catheter.
Keep sharp objects away from the tube. Never use sharp objects anywhere near the catheter. No scissors or knives should be used to remove tape or dressings.
Inspect daily. Inspect the exit site daily for signs of infections and the catheter for wear, cracks or tears. Ensure that the transfer set is securely connected to the true catheter.
Keep good care of the exit site. Carefully remove the old PD dressing, taking care not to disrupt the catheter exit site. Perform exit site care. It is important that the exit site be completely dry before placing a new dressing on it. Bacteria love moist, warm and dark places to grow.
Use good overall hygiene. Shower daily (after the exit site has healed), wear clean clothes and keep bedding clean.
44 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Infants and young children
Infants and young children have a higher risk of infection and catheter breaks or holes. This is because:
• Their immune system is not as well developed as that of an older child. • The catheter exit site is close to the diaper area. • Infants and children who are crawling or scooting with their belly toward the ground are at high risk for injury to the catheter and exit site. • Small children do not understand the importance of their catheter. You need to monitor their catheter for them. • Young children are naturally curious and may want to play with or pull at the catheter. To prevent infection and help keep your child’s catheter protected, all infants and young children must:
• Wear a dressing. • Secure and immobilize the catheter against their tummy wall. • Contain their entire catheter and transfer set beneath their clothing, preferably with a snug-fitting onesie. • Do not tuck the catheter or transfer set into the diaper. • If the transfer set gets any stool on it, immediately perform a cleaning procedure or transfer set change, as directed by your individual center. • If the exit site is near a stoma or diaper, consider using a bio-occlusive dressing such as Tegaderm as a barrier. There are many ways to help you immobilize the catheter. Mesh fabric called BandNet works well for many families. There are also several companies that offer PD catheter belts or other immobilizing products. Your child’s nurse can help connect you with the resources or share other ideas.
Seattle Children’s Hospital 45 Lesson 3: Caring for Your Catheter
Key points
• Peritoneal dialysis requires a soft plastic tube to be surgically implanted in the peritoneal cavity. This is called the “true catheter” because it is permanent unless removed in surgery. • Some activity restrictions are required while a peritoneal dialysis catheter is in place. This might include handling pets. (Speak to your PD nurse about this.) • Inspect the exit site and catheter with each dressing change. • Your child’s exit site should not appear red, swollen, tender or be draining. Any of these could mean there’s an infection at the exit site. Call your nurse immediately if you suspect an infection. • Inspect the catheter and transfer set daily. They should be free from cracks, tears or debris. • Gently feel the catheter tunnel area and cuff daily. Note any swelling or tenderness. Secure the catheter to avoid tension or tugging. • General hygiene is a very important part of your child’s catheter care. • Never put anything on your child’s exit site such as lotion, powder or Vaseline. Only use approved gentamicin cream and antiseptic as directed by your PD nurse. • Do not pick at or remove scabs from the exit site.
46 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Teach-back moment
What is the most important step you do to prevent exit site infections?
When should you call the Dialysis Unit or your peritoneal dialysis nurse?
What are the signs of an exit site infection?
What are the signs of a tunnel area infection?
Point out the:
• Peritoneal catheter • Adapter • Transfer set • Minicap/Stay-Safe cap
Practice a dressing change.
Seattle Children’s Hospital 47 Lesson 3: Caring for Your Catheter
Notes
My questions:
My notes:
Important information from this lesson:
48 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
PD catheter dressing change
Supplies ExSept or liquid antibacterial soap (Dial soap) 4" x 4" gauze Dressing (Oasis or Island) Tegaderm (if needed to protect from soiling) Cotton tip applicator (Q-tip) Masks (if instructed to use) Antibiotic cream Hand sanitizer
Seattle Children’s Hospital 49 Lesson 3: Caring for Your Catheter
Nonshowering procedure 1. Gather supplies. 2. Wash your hands. 3. Open the 4" x 4" gauze packages to have ready for the dressing change. 4. Put on clean gloves. This is to protect you – not your child. 5. Remove the old dressing and assess the exit site for redness, swelling, drainage, crusts and pain on pressure. Do this each time the dressing is changed. 6. Remove gloves and gel your hands. 7. Put on new clean gloves. 8. Soak the 4" x 4" gauze with liquid antibacterial soap and water or ExSept. 9. Place the 4" x 4" gauze (soaked with ExSept) on the catheter site. Leave on for about 1 to 2 minutes. 10. Using a new clean soaked 4" x 4" gauze, gently clean the skin at the catheter site. • Begin cleaning at the catheter and work outwards using a circular pattern. • Do not forcibly remove crusts or scabs. • Crusts and scabs act as a natural barrier and should not be removed. Aggressive exit site cleansing should be avoided to minimize trauma to the exit site. • Never go back to the catheter with this gauze. 11. Repeat as needed, usually 2 to 3 times. Let it dry completely. 12. Using a cotton tip applicator (Q-tip) or corner of clean gauze, apply antibiotic cream to the skin at the catheter site. 13. Put the dressing on over the catheter site. 14. Secure the catheter with tape or tuck into Flexinet or PD belt. • Catheters should not hang freely. • Ensure that the catheter is lying within the tract.
50 Peritoneal Dialysis at Home Lesson 3: Caring for Your Catheter
Full showering procedure 1. Gather supplies. Leave dry supplies for dressing in a dry area to prevent them from getting wet. 2. Before showering, support the catheter by securing it to the abdomen above the belly button with tape or Tegaderm to prevent dangling of the catheter. 3. Begin showering by washing the hair and body. 4. Remove the old dressing and assess the exit site for redness, swelling, drainage, crusts and pain on pressure. Do this each time the dressing is changed. 5. Cleanse the area around the exit site and under the catheter with antibacterial liquid soap or ExSept on a clean washcloth (you will need a new washcloth for each shower) or use 4" x 4" gauze. • Begin cleaning at the catheter and work outwards using a circular pattern. Rinse in the shower and allow water to run over and off the exit site. • Do not forcibly remove crusts or scabs. • Crusts and scabs act as a natural barrier and should not be removed. Aggressive exit site cleansing should be avoided to minimize trauma to the exit site. • Never go back to catheter with this gauze. 6. After showering, thoroughly dry the exit site by patting with a clean, dry 4" x 4" gauze. 7. Dry the rest of the body with a towel. 8. Once the child is out of the shower, apply antibiotic cream or ointment sparingly to the exit site if ordered. 9. Allow the catheter to assume a natural lie on the abdomen, ensuring that there are no kinks in the tubing and that the connector/adapter is not lying on the exit site. 10. Cover the exit site with dressing. 11. Secure the catheter with tape or tuck into Flexinet or PD belt. • Catheters should not hang freely. • Ensure that the catheter is lying within the tract.
Seattle Children’s Hospital 51 Lesson 3: Caring for Your Catheter
52 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 4
Steps for a Safe Treatment
In this lesson you will learn: • The 3 “Rs” to help prevent infection • Clean versus sterile
Seattle Children’s Hospital 53 Lesson 4: Steps for a Safe Treatment
Words to know
Aseptic technique The way to make sure clean items stay “clean” and sterile items stay “sterile.” The goals of aseptic technique are to protect your child from infection and to prevent the spread of germs.
Clean Most germs have been removed, but not all of them. For example, washing your hands makes them clean, not sterile.
Contaminated An item that was sterile that touches something that is either clean or dirty. It is no longer sterile.
Dirty Not clean or sterile.
Sterile Free from bacteria and other germs. For example: supplies in sterile packaging.
Steps for a safe treatment
Congratulations! You have learned so much. This lesson reviews what you have learned to perform a safe treatment for your loved one.
Here are 3 “Rs” to help prevent infection: R ealize R ecognize R eact
R 54 Peritoneal Dialysis at Home R ealize R ecognize R eact Lesson 4: Steps for a Safe Treatment
R ealize
When germs get into the sterile area of the peritoneal cavity, they cause serious illness and injury to the peritoneal membrane. If the damage is severe enough, your child may not be able to continue PD.
Germs are invisible to the naked eye, but they live on everything! Your mouth, nose and skin have many germs.
The peritoneal cavity is the perfect breeding ground for germs! They love to grow in a dark, warm, moist, sugary environment.
Keeping things clean
Bed and clothing • Wash bed sheets and clothing, including sleepwear, regularly and whenever soiled. • If a sheet, bedding or clothing becomes wet, investigate to figure out where that liquid is coming from. It could be a loose connection of the PD catheter, disconnection or damage to catheter or tubing.
Bathing • Follow PD team instructions for how often your child can bathe. • Only use a sponge bath to keep your child clean in the beginning when the PD catheter is placed. Once approved by your dialysis team, your child can shower. • Secure the catheter to prevent pulling or tugging on it. • Exit site care is best done at bathing time for ease and timing. Perform exit site care if the bandage is wet or loose, using the techniques you have learned.
Treatment environment • Keep floors, storage areas, cycler and work surfaces clean. • Work surfaces must be large enough to perform dialysis tasks and store supplies. • Work surfaces must be washable, so they can be cleaned with a disinfectant like germicidal wipes, diluted bleach solution or mild household cleaning products.
Seattle Children’s Hospital 55 Lesson 4: Steps for a Safe Treatment
• Disinfect work surfaces before beginning tasks each day and any time they become soiled. • Keep windows, doors and vents closed and fans turned off to prevent air flow during setup, connection and disconnection. • Have masks (covering mouth and nose), hand sanitizer and emergency supplies readily available. • Keep pets away during the setup of the cycler, during connection and disconnection from tubing and during dressing changes. Be careful with all animals around sterile supplies. Germs from pets can cause serious infections. Try not to allow pets to sleep with your child, especially cats (they typically like to play with the tubing and can bite a hole in it).
Clean hands! Clean hands! Clean hands! Hand hygiene is the most important thing you can do to prevent infection. Performing thorough hand hygiene reduces the number of germs on your hands. This action is so simple yet so critical.
Wash your hands with running warm water, soap and single-use towels or use hand sanitizer before beginning any PD process. This includes:
• A dressing change • Cycler (APD) setup • CAPD (manual) setup • Connection process • Disconnection process
Remember to perform hand hygiene: Bacterial growth from dirty hands versus clean hands on a petri dish • After applying mask to self and child. • If you have touched anything other than PD supplies or setup. • Immediately before opening your child’s catheter cap. • Rewash using soap and water any time your hands have become visibly soiled.
Remove distractions Remove potential sources of distraction from the room:
• Turn off cell phone ringer, TV and radio. • Plan time to perform PD procedures when you will not feel rushed, distracted, too tired or hungry.
56 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
• Limit the number of people present. Everyone must wear masks and only those properly trained may perform PD processes. • Ensure the room has good lighting. • Wear your corrective lenses (contacts or eye glasses) if needed. • Do not eat or drink in the treatment environment during aseptic procedures.
Remain sterile Use aseptic techniques to remain sterile.
Areas and items that must remain sterile:
• Your child’s peritoneum • The transfer set tip (dark blue part) • The inside of the transfer set and catheter • The inside of the PD tubing and cassette • Dialysate fluid inside each bag • Dialysate connection under the cap or pull ring • Inside area of the MiniCap (catheter cap) • Inside area of the FlexiCap (tubing cap)
For items to remain sterile during setup:
• Perform hand hygiene at all appropriate times. • Mask (cover mouth and nose) all people present. • Decrease drafts and air flow by turning off fans and closing windows. • Remove pets from the room during these procedures. • Have needed and extra supplies handy. • Reduce distractions. • Prevent transfer of germs by touch with non-sterile things. • Perform hand hygiene when moving from one task to another, like from preparing the environment to preparing supplies, or from cycler setup to the connection with the catheter.
Seattle Children’s Hospital 57 R ealize R ecognize R eact Lesson 4: Steps for a Safe Treatment
R ecognize
Recognize when something has been contaminated.
Daily tasks with high risk for contamination:
Adding medicine into dialysate bag
Connecting dialysate bag(s) to cycler cassette tubing
Connecting to treatment
58 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
Disconnecting from treatment
Other ways contamination can occur:
• Accidental loosening Constipation or disconnecting of the tubing from the transfer set • Accidental loosening or disconnecting of the Cracks, tears or breaks in transfer set from the the catheter or transfer catheter set • Loosened or lost catheter cap (MiniCap)
Punctures or damage Pets playing with the to the dialysate bags or tubing tubing
Use of sharp objects (scissors) near catheter, tubing or dialysate bags
Seattle Children’s Hospital 59 R ealize R ecognize R eact Lesson 4: Steps for a Safe Treatment
R eact
React to contamination quickly.
Being disciplined means being alert, skipping no steps, and cutting no corners. Ignoring a contamination and failing to take action can result in peritonitis, a serious infection. Contaminations do happen. Always react on the side of caution.
When in doubt, throw it out.
• Expired product or supply. • Damaged or wet package. • Sterile item is dropped or touched. • PD fluid is contaminated when adding a medicine through the medication port. (The medication port is the shorter line located on the solution bag next to the where the cycler tubing is connected to the solution bag.) • You forgot to mask or perform hand hygiene before working with sterile supplies. • You forgot to close doors and windows or turn fans off.
60 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
“Stop, Clamp and Call”
This chart helps explain what to do if contamination occurs.
What if… What you need to do
Contamination of the patient • Place a clamp or close the white twist clamp on the line, transfer set, cycler tubing or transfer set between the contamination and the dialysate bags during dialysis. patient abdomen or exit site. • Call the dialysis nurse immediately for instructions. Follow the directions provided to you by your dialysis nurse.
Contamination of the end of the • Close the white twist clamp on the transfer set transfer set. between contamination and the patient abdomen or or exit site. The MiniCap falls off of the • Place the new MiniCap on the transfer set. transfer set. • Call the dialysis nurse immediately for instructions. • You may need to come to the Seattle Children’s for further treatment.
The exit site looks infected. • Call the dialysis nurse immediately for instructions. • You may need to come to Seattle Children’s for evaluation. • Increase the exit site care to twice a day. • Your child may need to start antibiotics.
Contamination of the dialysate • Throw away all of the contaminated supplies. Start bags or PD tubing before the over. patient is connected to dialysis.
The transfer set has fallen off or • Place a clamp or close the white twist clamp on the come apart from the catheter, or transfer set between the patient and the there is a hole in the PD catheter. hole/disconnection. • Call the dialysis nurse immediately for instructions. • You may need to come to Seattle Children’s for treatment.
Seattle Children’s Hospital 61 Lesson 4: Steps for a Safe Treatment
Preparing supplies for treatment Have everyone in the room put on a mask.
1. Perform hand hygiene.
2. Prepare workspace and environment. Expiration date • Clean the cycler and workspace. • Close the door to the room. • Turn off fans and close vents. • Do not allow pets in the room.
3. Gather supplies. Amount • Dialysis tubing/ Strength in mL cassette of solution concentration • Drain bag(s) % • Manifold if needed • Dialysate bag(s) • MiniCap • Mask(s)
4. Check each dialysate bag using SEAL (see the picture above): Strength of solution concentration is correct Check Expiration date and clarity for leaks of solution Amount or size of dialysate fluid Leaks from the dialysate fluid, or loose or missing pull tabs
5. Place dialysate bags properly for treatment.
6. Use the aseptic technique to connect dialysate bags to cycler tubing.
62 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
Connection process
Ready
• When the cycler is finished priming and ready to connect, check that the dialysate has reached the end of the patient line. • Close the door to the room. Turn off all fans and close vents. Have everyone in the room put on masks and perform hand hygiene.
Set
• Make sure the transfer set is closed or clamped.
Go
• Connect the transfer set to the patient line of the cycler using the method taught to you. • Make sure the clamps are open and the transfer set is open. • Start treatment. • When finished, remove mask(s) and perform hand hygiene. • Always be sure to have a disconnect cap or MiniCap in reach.
Seattle Children’s Hospital 63 Lesson 4: Steps for a Safe Treatment
Disconnection process
When the treatment is finished:
• Close the door to the room. Turn off all fans and close the vents. Have everyone in the room put on masks and perform hand hygiene. • Open the disconnect cap or MiniCap package. • Using the aseptic technique, disconnect your child from the cycler as you are taught by your nurse. • Apply the disconnect cap or the MiniCap to the transfer set. • Securely immobilize the catheter using a PD belt, tape, dressing, Grip-Lok or ElastiNet. • Measure vital signs, including blood pressure and weight, and record them as instructed.
64 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
Drain fluid appearance
Note the characteristic of the drain fluid.
Is it:
Clear like apple juice Cloudy like pineapple juice? (normal pee color)?
Colored or blood-tinged? Containing fibrin? (looks like jellyfish floating)
Seattle Children’s Hospital 65 Lesson 4: Steps for a Safe Treatment
Disposal
Tubing and bags • Empty all fluid in the toilet, tub or shower. The drain bags can be heavy and awkward if full. • Rinse in the shower or under the tub faucet for 1 minute. Place in the trash bag and tie off. • Remove mask and perform hand hygiene.
Resources
World Health Organization hygiene video https://youtu.be/3PmVJQUCm4E
Baxter HomeChoice Cycler training videos https://www.youtube.com/playlist?list=PLxOc1MKY05MODOAp8jxa1Bz_crk--b5IH
Key points
• When germs get into the sterile area of the peritoneal cavity, they cause serious illness and injury to the peritoneal membrane. • Hand hygiene is the most important thing you can do to prevent infection. • Remove all possible distractions. • Use the aseptic technique to keep things sterile. • Recognize when something has been contaminated. • When in doubt, throw it out. • Check each dialysate bag using SEAL. • Always check your drain fluid. Is it clear, cloudy, yellow, or pink, or does it have fibrin in it?
66 Peritoneal Dialysis at Home Lesson 4: Steps for a Safe Treatment
Teach-back moment
What do you do when you contaminate the dialysis tubing setup?
What do you do when you contaminate the transfer set?
What do you do when you contaminate a bag of dialysate?
Practice setting up the cycler and connecting it to the transfer set.
Practice disconnecting.
Seattle Children’s Hospital 67 Lesson 4: Steps for a Safe Treatment
Notes
My questions:
My notes:
Important information from this lesson:
68 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 5
PD Problem-Solving
In this lesson you will learn: • How to identify complications from infections and what to do • How to identify other noninfectious complications and troubleshooting chart
Seattle Children’s Hospital 69 Lesson 5: PD Problem-Solving
Complications from infection
Infection is always a concern of your child being on peritoneal dialysis because they have a foreign object (a PD catheter or central line) placed in their body. Germs can enter the inside of the body through the opening in the skin. It is very important to understand the signs and symptoms of an infection, and how to prevent an infection from happening.
Infections can be prevented! By washing your hands, using sterile connection and disconnection practices and being mindful of touch contaminations, you can greatly lessen the chance of infection. In the next few pages, you will find a list of signs and symptoms of trouble, possible causes and what to do if you are concerned your child might have an infection.
Note: A fever is always a sign to call the dialysis nurse. Be prepared to answer questions about your child that the nurse will ask to better understand the best next steps to keep your child healthy.
70 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms • Fever • Abdominal pain • Fussiness (infants) • Cloudy fluid (can you read writing clearly when you look through it?)
Possible Peritonitis. Germs have caused an infection in the peritoneal cause cavity.
• Possible contamination of sterile supplies or work area. • Can be from another infection (for example, a urinary tract infection or UTI).
Who • Call the on-call kidney doctor immediately. to call • Let the PD nurse know.
Treatment • Get the cell count and culture of the PD fluid from your plan child’s peritoneal effluent. • If your child still urinates, get a urinalysis and culture of their urine.
Your child will need:
• Antibiotics through an IV or through the peritoneum (IP) as soon as possible. • A meeting with your dialysis team to discuss probable causes of the infection. • Possible admission to the hospital for treatment.
Seattle Children’s Hospital 71 Lesson 5: PD Problem-Solving
My child has these symptoms • Pain at the exit site • Redness or swelling at the exit site • Pus or drainage at the exit site or on the dressing
Possible Exit site infection. Germs have caused an infection where the cause PD catheter exits the body.
Who • Call the on-call kidney doctor immediately. to call • Let the PD nurse know.
Treatment • Culture any pus or drainage. plan • Clean the exit site thoroughly and more often until it has improved. • Your child: • May be started on antibiotics, depending on the culture growth • Could be admitted to the hospital for treatment
72 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms • Pain along the tunnel area or at the cuff site • Redness or swelling along the catheter • Pus or drainage from the exit site or on the dressing
Possible Tunnel area infection. Germs have caused an infection along cause the tunnel area of the catheter. • Possible touch contamination or exit site infection may have introduced germs into the tunnel area.
Who • Call the on-call kidney doctor immediately. to call • Let the PD nurse know.
Treatment • Culture of any pus/drainage. plan • Possibly get an ultrasound to look for areas of fluid or pus collection near the tunnel area. • Your child: • May be started on antibiotics, depending on the culture growth • May be admitted to the hospital for treatment Note: Some germs are very hard to treat and may require catheter removal.
Seattle Children’s Hospital 73 Lesson 5: PD Problem-Solving
My child has these symptoms • Cloudy or foul-smelling urine • Fever • Abdominal pain • Pain with urination
Possible Urinary tract infection (UTI) cause • If your child pees, they are still at risk for a UTI due to poor wiping practices or urinary reflux (when urine doesn’t flow in the right direction). • A UTI can lead to infections, sepsis and secondary peritonitis in PD patients.
Who • Call the on-call kidney doctor immediately. to call • Call to schedule an appointment with your primary care provider. • Let the PD nurse know.
Treatment • You may need: plan • To come in for a visit and/or go to the emergency room • To have a urinalysis/urine culture • Treatment with antibiotics and may be admitted to the hospital If your child gets UTIs often, they may be prescribed an antibiotic to take regularly to prevent infection.
74 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms • Common cold symptoms (cough, congestion and nasal drainage) • Ear infection (ear tugging and drainage)
Possible Viral illness or ear infection cause
Who • Call to schedule an appointment with to call your primary care provider. • Let the PD nurse know.
Treatment • Your primary care provider (PCP) may prescribe antibiotics plan if it’s a bacterial infection or over-the-counter medicines. (Be sure to make sure they are on an approved list for dialysis patients.) • See the list of over-the-counter medications. • Call your PD nurse if your child is started on antibiotics. Ask for an antifungal medicine. (Antibiotics can destroy natural protective germs so fungus grows more easily.)
Key points
• Infections can happen when your child is on peritoneal dialysis. • Examples of PD-related infection are peritonitis, tunnel area infections and exit site infections. • If your child has fever, abdominal pain, cloudy fluid or redness/swelling around the catheter, you should call your kidney doctor and let the PD nurse know. • PD-related infection can be prevented by using good hand hygiene, using sterile connection/disconnection procedures and avoiding contaminations from touch.
Seattle Children’s Hospital 75 Lesson 5: PD Problem-Solving
Complications not caused by germs
Other problems may occur while your child is on peritoneal dialysis. Many of these are problems with the catheter tubing or equipment. They can lead to infection, but if you act quickly, you may be able to prevent infection or make it less severe.
Catheter malfunction The 3 main connection points of the catheter are pictured below.
Touch contamination or problems with connection/disconnection can happen. In the next few pages, you will find a list of possible problems or issues that might happen and what to do.
PD catheter Baxter MiniCap Baxter transfer set
76 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue The MiniCap cap accidentally came off.
Possible • The MiniCap cap was loose. cause • Your child may have removed it.
What • Ensure the transfer set is closed or clamped. to do • Replace with a new MiniCap immediately. • Call the PD nurse.
Treatment Remember the “3 Cs” (pictured below) plan • Clamp • Cover • Call
Clamp Cover Call
Seattle Children’s Hospital 77 Lesson 5: PD Problem-Solving
The issue My transfer set came apart from the catheter.
Possible • The child disconnected it. cause • The catheter got caught or pulled.
What • Place a clamp (pictured below) on the catheter to stop the to do drainage. • Cover the end of the catheter with gauze and secure with tape. • Do not complete any exchanges. • Call the PD nurse.
Treatment • You will need to come in for a visit. plan • Your child will need a new transfer set.
Clamp Cover Call
78 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue I accidentally touched or dropped the end of the transfer set when the cap was off during connection or disconnection.
Possible • Possible distractions cause • Hands slipped
What • Make sure the transfer set is closed or clamped. to do • Put on a new MiniCap. • Do not complete any exchanges. • Call the PD nurse.
Treatment • You may need to come in for a visit. plan • Your child may need to be treated with antibiotics.
The issue The dialysis tubing accidentally disconnected during treatment.
Possible • The connection wasn’t tight. cause • Your child disconnected it.
What • Clamp the catheter or close the clamp on the transfer set. to do • Do not start dialysis. • If dialysis is already in progress, press Stop. • Put on a new MiniCap as instructed by your PD nurse. • Call the PD nurse.
Treatment • You may need to come in to the PD Clinic or the hospital for plan treatment with antibiotics.
Seattle Children’s Hospital 79 Lesson 5: PD Problem-Solving
The issue There is a crack or hole in my child’s catheter or transfer set.
Possible • Your child may have chewed on or bitten the catheter. cause • The catheter may have been repetitively kinked when secured. • Pets could have bitten the catheter; this is why pets should not be allowed in the room where you do PD.
What • Clamp the catheter between your child and the crack or hole. to do • Cover the end of the catheter with gauze and secure with tape. • Do not start dialysis. • If dialysis was already in progress, press Stop. • Call the PD nurse.
Treatment • You will need to come in for a visit. plan • Your child will need a new transfer set. • Your child may need to be treated with antibiotics.
Clamp Cover Call
80 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue I accidentally touched the sterile connections when connecting the lines to my dialysate bags.
Possible • Possible distractions cause • Hands slipped
What • Throw away supplies. to do • Start with new sterile supplies.
Treatment • No concerns if you throw away the contaminated bags or plan cassette.
The issue There is fluid leaking from my child’s exit site.
Possible • Poor healing cause • Trauma or tugging on the catheter
What • Call the PD nurse. to do
Treatment • You may need to stop dialysis or change your fill volume. plan • You may need to come in for a visit.
Seattle Children’s Hospital 81 Lesson 5: PD Problem-Solving
The issue I can see the cuff at the exit site.
Possible • The catheter may have been pulled or tugged on. cause • Infection
What • Make sure the catheter to do is secured to the body. • Use the wrap you have been provided with or tape if the wrap is not available. • Call the PD nurse.
Treatment • You may need a new PD catheter. plan
The issue • There is fluid leaking under the skin. • There is bulging around the exit site, tunnel area, belly button or other parts of my child’s belly.
Possible • PD solution has leaked from the peritoneal cavity and cause collected under the skin.
What • Call the PD nurse. to do
Treatment • You may need to come in for a visit. plan
82 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue The PD fluid looks pink or bloody.
Possible Hemoperitoneum cause • New catheter • Trauma (pulling or tugging) • Menstruation or ovulation • Infection Only a small amount (1/2 teaspoon) of blood will turn the effluent cloudy or pink.
What • Call the PD nurse. to do
Treatment • You may be instructed by the PD nurse to add heparin to plan the dialysate. • Blood in the drain fluid can sometimes cause the catheter to clog.
Seattle Children’s Hospital 83 Lesson 5: PD Problem-Solving
The issue • There are white strands in the PD fluid. • The machine shows this message:
No Drain or Slow Drain
Possible Fibrin cause • New catheter • Irritation or trauma (a hit to the stomach or the catheter gets pulled on) • Menstruation
What • Add heparin (as instructed by PD nurse) to the dialysate to do fluid to prevent clotting.
Treatment • You may need to treat the dialysate bags with heparin plan as instructed by your nurse to prevent clotting.
84 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue There is a bulging area at the belly button, belly or groin/private area.
Possible Hernia cause • A weak spot in the abdominal muscle is allowing an intestine or dialysis fluid to poke through the peritoneum. • Can be common due to increased pressure in the abdomen from dialysate fluid
What • Call the PD nurse. to do
Treatment • You will need to see the kidney doctor. plan • Your child may need surgery to repair the hernia. • You may need to lower your child’s fill volume to prevent added strain or pressure on the weakened muscles.
Seattle Children’s Hospital 85 Lesson 5: PD Problem-Solving
The issue • Shoulder pain and/or upper abdominal pain • I see air in the dialysis tubing
Possible Air in the peritoneal cavity cause • Starting dialysis with unprimed tubing • Loose connections or accidental disconnection during treatment • Holes in the catheter or tubing
What • Secure any loose dialysis tubing and PD catheter connections. to do • Place your child with their hips above their head (Trendelenburg position) or knee-chest position to drain dialysate fluid from your child. • Call the PD nurse. • If a hole or crack is found, see the instructions above.
Treatment • You may need to come in for a visit. plan • Your child may need: • To be treated with antibiotics • The transfer set/tubing changed
86 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
The issue • The machine shows this message:
No Fill or Slow Fill
Possible Obstruction cause • Tubing can be kinked, twisted or clamped. • Fibrin may be present (see the Fibrin section above).
Catheter position • Child may be in a position that is kinking the catheter or blocking the flow. • The catheter may have migrated (moved) to a new position, causing obstruction.
What • Check the clamps and tubing for kinks or bends. to do • Check your child’s position: change or turn, stand or roll side-to-side. • Call the PD nurse if the fill takes longer than 15 minutes every cycle.
Treatment • Your child may need imaging to check the catheter plan placement in the abdomen if there is obstruction or migration. • You may need to add heparin to the dialysate for fibrin (see the Fibrin section above).
Seattle Children’s Hospital 87 Lesson 5: PD Problem-Solving
The issue • The machine shows this message:
No Drain or Slow Drain
Possible Obstruction cause • (See above.) Catheter position • (See above.) Constipation • Can cause fluid to be trapped, causing drainage problems • Can contribute to catheter migration
What • For obstruction or positioning, see above. to do • For constipation: Make sure your child has a bowel regimen, which possibly includes MiraLAX and/or stool softeners, exercise and a high-fiber diet. • If your child has not had a bowel movement In more than 2 days, call your PD nurse. See the Bristol Stool Chart on the next page.
Treatment You may need to: plan • Adjust your child’s bowel regimen medicines. • Add more fiber-rich foods in your child’s diet. • Encourage your child to exercise more.
88 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
Bristol Stool Chart
Seattle Children’s Hospital 89 Lesson 5: PD Problem-Solving
My child has these symptoms Pain during fill
Possible • Dialysate too cold cause • Fill too fast • Sensitive to solution • Poor catheter position • Fill volume may be too large
What • Make sure the dialysate bags cover the heater thermostat to do button. • Change your child’s body position. • Have your child use the restroom. • Call the PD nurse if your child has pain during every fill.
Treatment • Your child’s prescription fill volume may need to change plan temporarily.
90 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms Pain during drain
Possible • Drain too fast cause • Catheter irritation when the peritoneal cavity is empty • Constipation
What • Raise the cycler several inches. to do • Change your child’s body position. • Have your child use the restroom. • Call the PD nurse.
Treatment • Your child’s prescription may need to change. plan
Seattle Children’s Hospital 91 Lesson 5: PD Problem-Solving
My child has these symptoms Vomiting or gagging during or at the end of dialysis
Possible • PD patients can have nausea, vomiting or gagging at the cause end of dialysis as they approach their estimated dry weight. • Infants may have difficulty tolerating certain fill volumes with their feeds. • Vomiting can be a symptom of peritonitis. Please assess fluid, abdominal pain and fever.
What • Call the PD nurse or dietitian if your child is vomiting large to do amount of formula feeds every night/day. • Call the PD nurse about redosing important medicines if your child is vomiting.
Treatment • Your child’s PD prescription fill volume or feeding volume plan may need to be adjusted. • Your child may need medicine (i.e., Zofran) to help them tolerate feeds or medicines.
92 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms Spit-up, vomiting or upper abdominal pain
Possible GERD or reflux cause • PD patients can have gastro-esophageal reflux (GERD) due to large amounts of fluid and pressure in the abdomen.
What • Let your primary PD nurse and kidney doctor know about to do these symptoms at your next visit. • Call the PD nurse if you are concerned about dehydration or weight loss. • If your child has a fever and abdominal pain, call the kidney doctor immediately because these are signs of peritonitis.
Treatment • You might need to come in for a visit to make sure your plan child is not getting too dry or losing weight. • Your kidney doctor may prescribe a medicine to help with acid production in the stomach to stop some of the symptoms of reflux.
Seattle Children’s Hospital 93 Lesson 5: PD Problem-Solving
My child has these symptoms • Not ultrafiltrating as much • PD adequacy is decreasing
Possible Loss of peritoneal membrane function due to: cause • Multiple abdominal surgeries, causing scarring or adhesions (a band of scar tissue that binds 2 parts of your tissue that are not normally joined together) • Multiple peritonitis episodes (infections) • Severe peritonitis from fungus or gram-negative germs • Severe trauma to the abdomen • Using a high-dextrose concentration dialysate frequently
What • Call the PD nurse. to do
Treatment • Your child’s PD prescription may need to be adjusted plan to compensate for decreased membrane function and clearance of toxins. • You may need to use a higher dextrose-concentration dialysate to remove more fluid.
94 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms Difficulty breathing (especially when lying flat) • Drain problems on machine • Low UF (ultrafiltrate) or negative UF
Possible Dialysis fluid in the lungs cause • PD fluid has leaked from the peritoneal cavity into the lungs.
What • If your child is having difficulty breathing, call 911 and/or to do go to nearest emergency room. • Call the kidney doctor immediately. • Let the PD nurse know.
Treatment • Your child may need to be admitted to the hospital or plan intensive care unit for treatment.
Seattle Children’s Hospital 95 Lesson 5: PD Problem-Solving
My child has these symptoms Not peeing as much
Possible May be losing remaining kidney function cause • Some children still urinate although their kidneys do not work well enough on their own. This function and ability to urinate can decrease over time on dialysis.
What • Call the kidney doctor. to do
Treatment • Your child’s PD prescription and/or fluid restriction may plan need to be adjusted.
The issue The power has gone out.
Possible Power failure cause
What • Call the PD nurse. to do
Treatment • If the power is restored, the machine will continue as before. plan • If it is not, you will need to discontinue dialysis. • You may need to: • Restrict your child’s fluid more than normal. • Do manual exchanges if the child is fluid-overloaded. • Go to the nearest hotel or motel if the power doesn’t return so you can continue the dialysis using their power. • Bring your child to the hospital for continued dialysis.
96 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
My child has these symptoms The child is unresponsive.
Possible EMERGENCY cause • Cardiac/respiratory arrest • Shock
What Remain calm. to do • Call 911. • Check your child’s pulse and blood pressure. • If your child is unresponsive, is without a pulse or blood pressure or is not breathing, begin CPR (only if trained). • Put the machine on “Drain” and stop when the child’s peritoneal cavity is empty. • Call the PD nurse when able.
Seattle Children’s Hospital 97 Lesson 5: PD Problem-Solving
Key points
• If there was a touch contamination or a problem with connection or disconnection procedures during your child’s dialysis, you should call your PD nurse to let them know. • Noninfectious complications of peritoneal dialysis can include, but are not limited to, the loss of peritoneal membrane function, catheter problems, hernias and reflux. • If there is a problem with your PD machine, call Baxter for what to do next. • If there is a problem with the PD treatment, call the PD nurse. • If there are any medical concerns, call your kidney doctor. • If your child is unresponsive, call 911 immediately. • Always call the PD nurse if you are unsure or need help making decisions.
Touch contamination
• Touch contamination is any event where there may have been exposure of the PD catheter to germs from hands, nonsterile surfaces or even the air. • Touch contamination can occur with setup, supplies and/or the transfer set or catheter. • See Lesson 4 “Recognize” on page 58 for an example of various times that a touch contamination might occur. • Your PD nurse will ask you about any possible touch contamination events that may have occurred since your last visit. It is very important to let your PD nurse know if anything might have happened, so your child can get the treatment they might need to protect from infection.
98 Peritoneal Dialysis at Home Lesson 5: PD Problem-Solving
Key points
• Touch contamination or contamination events can happen to anyone who does peritoneal dialysis. • Contamination events can occur with setup, supplies and/or the transfer set or catheter. • Make sure you communicate with your PD nurse about any possible contamination events. • If a contamination occurs, your child may need antibiotics to protect them from a possible infection.
Seattle Children’s Hospital 99 Lesson 5: PD Problem-Solving
Notes
My questions:
My notes:
Important information from this lesson:
100 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 6
Balancing Your Fluids
In this lesson you will learn: • How fluid intake affects weight • How to keep at target weight • Signs of fluid overload and dehydration • The importance of high and low blood pressure readings • How to control fluid balance • Correct selection of dialysate solution
Seattle Children’s Hospital 101 Lesson 6: Balancing Your Fluids
Words to know
Fluid balance A balance of liquid between the tissue and blood in the body.
Target weight The weight of the body when it has the perfect amount of fluid.
Body weight The solid things in the body like bones, muscles and fat. This weight is unlikely to change a lot in a short period of time.
Fluid weight The weight of all of the liquid in the body. This weight can change a lot day to day.
Ideal weight The weight when there is the correct amount of fluid in the body; the “target weight.”
Physical assessment Looking at the general outside appearance of someone.
Dehydration Not enough liquid in the body.
Dextrose A simple sugar made from corn, and the main content of dialysate.
Fluid overload (hypervolemia) Too much liquid in the body.
Fluid limit/fluid restriction The maximum amount of fluid your child should eat or drink within a 24-hour time span.
102 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
How does fluid intake affect your weight?
Healthy kidneys balance the amount of fluid in the body by producing urine.
When large amounts of fluid are taken in, a large amount of urine will be produced. When the kidneys are not working properly, the body cannot get rid of the excess fluid through urine.
When small amounts of fluid are taken in, the kidneys will concentrate the urine and produce less. When the kidneys fail, the body loses its ability to make or concentrate the proper amount of urine for fluid balance.
Dialysis can get rid of some extra fluid, but not as well as healthy kidneys do.
Proper fluid control in kidney failure depends on the actions of your child and you. The following information will help determine how to check and control fluid balance.
What is target weight?
A target weight, also commonly called “dry weight,” is your child’s normal weight without any extra fluid or water in the body.
Seattle Children’s Hospital 103 Lesson 6: Balancing Your Fluids
What is fluid overload?
Having too much fluid or water in the body is called fluid overload or hypervolemia. One of the main functions of the kidneys is to balance fluid in the body. If too much fluid builds up in the body, it can have harmful effects on your child’s health, such as difficulty breathing and swelling.
If your child does not make any urine (pee) or doesn’t make enough urine, they will gain extra water weight from eating and drinking. The extra water weight stays in their body unless it is removed with dialysis. You may notice that the weight in the evening is higher than it was in the morning. Sometimes children will gain weight over a few days.
When first starting dialysis, finding your child’s dry weight may take a few treatments.
My child’s target weight is .
Dehydrated ← Target weight → Overload
104 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
How is fluid balance controlled?
Healthy kidneys balance the amount of fluid in the body by removing extra water from the blood in the form of urine. When the kidneys stop working, four things decide how much fluid stays in the body:
1. The fluid you take in by drinking and eating 2. The amount of urine your kidneys may still make 3. The amount of fluid that is removed by dialysis 4. The dialysate dextrose concentration
Reminder: Normally functioning kidneys remove toxins and extra fluid from the blood. PD will now do this function for your child because their kidneys no longer can. PD solutions work with the dialysis machine to remove toxins and extra fluid from your child’s body.
But, your child’s kidneys are not able to balance the amount of fluid in their body as well as healthy kidneys. So, it is important to measure and check the amount of fluid in their body each day to ensure that they are not dehydrated or overloaded with fluid.
Follow the instructions below to control the fluid balance for your child.
Seattle Children’s Hospital 105 Lesson 6: Balancing Your Fluids
How to keep at target weight
Weigh your child every day • Weigh before and after dialysis using the same scale on a hard, flat surface. (not on carpet) • Weigh without shoes. • Your child should wear similar clothing with each weight. • Babies should be weighed in a diaper only.
Your child’s weight will help decide how much fluid needs to be removed with the dialysis treatment.
An inaccurate weight of your child may result in choosing the wrong strength of dialysate for your child’s treatment. This can result in the wrong amount of fluid being removed from your child’s body, causing them to become fluid overloaded or dehydrated.
Record your child’s weight as directed by your PD nurse.
Your child’s daily weights, blood pressures, initial drain volume, ultrafiltration amount and any other significant information such as puffiness or illness will be used to decide nightly PD solutions.
Tools for monitoring fluid status
Look at your child. Take a general physical assessment: How does your child look? Do you see swelling anywhere? Are the eyes sunken? Is your child acting sluggish or tired?
Monitor weight: What is your child’s weight? How does this compare to the target weight?
Take blood pressure: What is their blood pressure today? Is it higher or lower than normal?
Other considerations: Has your child been sick with a cold, vomiting or diarrhea?
106 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
Checking your child’s weight One way to measure the amount of fluid in your child’s body is to monitor their weight. Total weight is made up of two things: body weight and fluid weight.
Body weight is all the solid things in the body like bones, muscles and fat. Body weight increases when too much is eaten. For most of us, body weight should stay almost the same every day unless you are eating more and gradually gaining weight. However, children’s weight will gradually increase as they grow.
Fluid weight is the part of the body that is liquid, not solid. The body tissues are actually full of liquid, and the blood is liquid. Fluid weight increases with liquid intake. For example, a 2-liter bottle of soda weighs 2 kilograms. If one person drinks all the soda, then their weight will increase by 2 kilograms.
Ideal weight Your child’s “target weight” is their ideal weight. This is the weight when they have the correct fluid balance in their body.
My child’s target weight is .
We use kilograms (kg) to measure your child’s weight. To convert pounds (lbs) to kilograms, take your child’s weight in pounds and divide by 2.2.
Example: 125 lbs ÷ 2.2 = 56.8 kg. You can also Google “online kg to lb weight converter tools.”
Seattle Children’s Hospital 107 Lesson 6: Balancing Your Fluids
Why kilograms? Using kilograms instead of pounds makes the math much simpler because in the metric system, liquid weights (liters) and people weights (kilograms) match up more easily. Using kilograms also allows for a more precise measurement.
When measuring fluid weight:
1 kilogram (weight) = 1 liter (liquid) (1 liter = 1000 mL or about 33 ounces)
If we measured 1 liter of water, it would weigh 1 kg. If we measured 1.5 liters of water, it would weigh 1.5 kg. And so on.
1 kg 1 L
Example 1
This morning, Joe’s weight was 21 kg. Tonight, when his mom is setting up for dialysis, his weight is 22.4 kg. How much weight did he gain?
22.4 − 21.0 = 1.4 kg
Remember, 1 kg = 1 liter (1000 mL), so Joe gained 1.4 liters (1400 mL).
Rapid weight gain (like the example above) can show us that there is extra fluid in your child’s body.
Example 2
After dialysis this morning, Julie’s weight was 45.2 kg. Tonight, when her dad is setting up for dialysis, he notices that her weight is 44.7 kg. Does Julie have any extra fluid in her body?
45.2 − 44.7 = 0.5 kg
Tonight’s weight was 0.5 kg lower than this morning’s weight. So, Julie probably does not have any extra fluid in her body.
Weight gain and loss can help determine fluid status in your child’s body.
108 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
What blood pressures mean
The blood pressure reading can help you tell which type of weight (fluid weight or body weight) your child may have gained.
In most cases, fluid weight will show up in your child as: • Sudden weight gain • Higher blood pressure • Swelling (edema)
In most cases, body weight gain will show as: • Your child’s weight will gradually increase with growth. • Your child’s blood pressure will be normal.
If your child’s weight goes down, it can mean: • Your child may have lost body weight. • Your child has less fluid in their body.
Weight loss can be caused by eating less. Most dialysis patients do not need to lose body weight.
If you notice your child’s body weight dropping, call the PD nurse.
Other reasons you child’s blood pressure could be high or low Causes of high blood pressure:
• Too much fluid in the body (fluid overload) • Not enough blood pressure medicine • Too much salt/sodium intake
Causes of low blood pressure:
• Not enough fluid in the body (dehydration) • Diarrhea or vomiting (loss of fluids from the body) • Too much blood pressure medicine • Dialysis took off too much fluid
Seattle Children’s Hospital 109 Lesson 6: Balancing Your Fluids
Fluid limits
If dialysis is unable to remove enough extra fluid from your child’s body each night, your medical team may limit the amount of fluid your child should eat or drink each day. This is often referred to as a “fluid restriction” or “fluid allowance.”
Remember: There is liquid in some things you eat too!
Talk with the PD nurse or dietitian if your child is having difficulty staying within the fluid allowance.
Regular drinks (juice, water, soda, etc.) +
Certain fruits + Jell-O or gelatin desserts +
Ice cream +
Soup +
Popsicles
Your child’s fluid restriction is L Each day
mL Each day
oz Each day
110 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
Why worry about fluids?
Your child’s body is made up of fluid weight and body weight. In fact, the body is about 70% fluid. When the kidneys are no longer making as much urine as they used to (or none at all), fluids become very important. Too much fluid entering and staying in the body fluid is known can causefluid overload. Dehydration can be a result of too much fluid leaving the body during PD.
Signs of fluid overload • Feeling tired • Feeling short of breath • Swelling • Weight increase • Blood pressure increase • Headache • Itching • Irritated skin
Signs of dehydration • Dizziness • Feeling weak or sick • Dry lips • Feeling thirsty • Dark circles around the eyes • Muscle cramps • Weight decrease • Blood pressure decrease
Balancing how much liquid your child is taking into their body and how much is coming out in urine and/or dialysis is important. Sometimes, to help balance their fluids, the PD Clinic may place you on fluid restriction and give you a fluid allowance. This is the amount of fluid your child can safely drink each day. Fluid comes from both liquids and food intake.
It can sometimes be hard for children to stay on this strict fluid allowance. However, if they don’t, fluid intake above the allowance can lead to fluid overload and the problems listed above (high blood pressure, swelling, trouble breathing, etc.). If your child has fluid overload, you may need to use a higher dialysate dextrose to remove the extra fluid.
Seattle Children’s Hospital 111 Lesson 6: Balancing Your Fluids
Checking your fluid balance
Weigh your child before and after dialysis. • Weigh in the morning right after the last exchange and in the evening right before the start of dialysis. It is important to record these numbers in some type of log. • Have your child wear similar clothing with each weight (heavy clothes add weight). • Weigh without shoes. • Make sure the scale is on a hard, flat surface not( on carpet). • Record the weight and compare to the prescribed target weight. • Call the PD Clinic if your child’s weight is outside of the prescribed range.
My child’s target weight is .
My child’s prescribed range is .
Measure your child’s blood pressure (BP) twice daily. • Check your child’s BP in the morning right after the last exchange and again in the evening right before the start of dialysis. Record your number on your log. • Place the BP cuff properly over bare skin. • Hold the arm or leg with the BP cuff on still. Moving while the machine is measuring the BP can cause a false measurement. • If you get an unusual BP, readjust the BP cuff and try measuring again. • Record the BP and compare to previous readings. • Call the PD Clinic with an abnormal BP.
Call the PD Clinic if your child’s blood pressure is above .
Call the PD Clinic if your child’s blood pressure is below .
112 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
Keep track of your child’s urine output. • Sometimes the amount a child urinates decreases the longer they are on dialysis. • You do not have to measure their urine daily. However, make note of the number of times each your child urinates each day and the approximate amount each time in a diary. • If the amount or number of times per day changes, be sure to notify the PD Clinic.
Check your child’s body for swelling several times a day. • Check eyes and face for puffiness, especially in the morning. • Check hands, legs, ankles and feet for swelling, especially in the evening after moving around all day. • For babies, gently check the soft spots on top of their head (fontanels) for bulging.
Record your child’s numbers. Record weight, blood pressure and dialysis information (initial drain and ultrafiltration along with dialysate strength) every day on the sheets that the PD Clinic gives you or on your dialysis machine.
Friendly reminder: All PD logs and diaries should be reviewed with clinic visits so that your child’s team can help you manage their care.
Teach-back moment
Mild fluid overload can be corrected by:
• Lowering the amount of salt/sodium your child eats. • Drinking (and eating) less fluid. • Using a stronger (higher %) dialysate solution during your child’s exchange. • Talk to your PD team.
Mild dehydration can be corrected by:
• Drinking (and eating) more fluid like water and clear broths. • Use a weaker (lower %) dialysate solution during your child’s exchange. • Talk to your PD team.
Seattle Children’s Hospital 113 Lesson 6: Balancing Your Fluids
Correct selection of the best dialysate solution
Fluid overload (too much fluid in the body) is a sign of kidney failure, but it can also be related to the peritoneal dialysis treatment. Fluid overload can be caused by selecting the incorrect strength of dialysate solution for your child’s dialysis, which results in too little fluid being removed. The nurse will give instructions on how to select the appropriate dextrose strength.
Water moves from the blood to the PD solution through the peritoneal membrane based on a type of sugar in the dialysate solution, called dextrose. Dextrose is a type of sugar made from corn.
Ultrafiltration can be increased by increasing the amount of dextrose in the PD solution. PD solutions are available with 3 different amounts of dextrose: 1.5%, 2.5% and 4.25%. Dialysate dextrose concentration is selected by comparing your child’s predialysis weight to their target or ideal weight.
Dialysate comes in 3 dextrose (sugar) strengths marked by a colored cap (see above). Yellow is the least concentrated and red is the most concentrated.
Teach-back moment
Fill in the blanks above with the concentration based on the cap color.
114 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
Peritoneal dialysis solution guide
1.5% (removes the least fluid) 2.5% (removes more fluid) 4.25% (removes the most fluid)
When to use a lower dextrose
• Low blood pressure • Signs of too little fluid (muscle cramps, dizziness, sunken eyes) • Weight loss • Vomiting/diarrhea
When to use a higher dextrose
• High blood pressure • Swelling (edema) • Increasing weight
My child normally uses:
bags of 1.5% solution
bags of 2.5% solution
bags of 4.25% solution
Seattle Children’s Hospital 115 Lesson 6: Balancing Your Fluids
Fluid overload versus dehydration
Fluid overload happens when your child has in too much fluid and/or sodium in their body. Signs of fluid overload include an increase in weight, BP and/or swelling.
Correct fluid overload by:
• Drinking (or eating) less fluids • Eating less salt • Using a higher-strength dialysate
Dehydration can happen when your child takes in too little fluid. Vomiting and diarrhea can also lead to dehydration. Signs of dehydration are a decrease in weight, a low BP, feeling tired, dizzy or thirsty.
Correct dehydration by:
• Drinking (or eating) more fluids like water and clear broth • Using a lower-strength dialysate
The goal of peritoneal dialysis is to keep your child well hydrated and promote fluid balance. This will help them to feel well and have healthy energy levels.
When to call the PD nurse
• Your child has low blood pressure. • Your child has high blood pressure that doesn’t improve after dialysis. • Your child is not acting normally.
Always call the PD nurse if you are unsure or need help making decisions.
When to call 911 or go to the Emergency Department
• Difficulty breathing • Lethargic • Unresponsive
116 Peritoneal Dialysis at Home Lesson 6: Balancing Your Fluids
Key points
• Blood pressure is just one sign of fluid balance. But for kids, blood pressure is the main indicator for fluid overload. • Use all the information you have (blood pressure, weight, heart rate and how your child looks) to decide about fluid balance. • High blood pressure is more often due to excessive fluid in the body rather than not enough blood pressure medicine. Your PD team can help you figure this out. Do not give extra blood pressure medicine without approval from the PD team. • Your child can still have extra fluid in the body even if blood pressure is normal. It is better to remove the extra fluid rather than give more blood pressure medicine in this situation. • Call your child’s nurse if you notice low blood pressure, especially if your child takes blood pressure medicine. The medicine may need to be adjusted. • Call your child’s nurse if you notice high blood pressure that does not improve with dialysis.
Seattle Children’s Hospital 117 Lesson 6: Balancing Your Fluids
Notes
My questions:
My notes:
Important information from this lesson:
118 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 7
Dialysis Medicines
In this lesson you will learn: • About medicines for: • Anemia • High blood pressure • One-disease prevention • Diabetes • Peritonitis • Which over-the-counter medicines are OK to take while on dialysis • Help for constipation
Seattle Children’s Hospital 119 Lesson 7: Dialysis Medicines
Words to know
Anemia The body does not have enough red blood cells in the bloodstream to work properly. Antibiotics A prescribed medicine to treat infections caused by bacteria. Erythropoietin (EPO) A hormone made by healthy kidneys that tells the bone marrow to make red blood cells. Epogen is the human-made form of this hormone. Growth hormone A medicine used to help children grow if they are growing more slowly than expected. Hemoglobin A protein in the blood that contains iron and transports oxygen through the body. Heparin A medicine used in dialysate fluid to stop fibrin formation. Insulin A hormone made by a healthy body that “unlocks” the cells and allows sugar to enter the cells in the body. Iron A nutrient that acts as a building block to keep red blood cells healthy. Multivitamins Supplements that are used to replace the vitamins that are removed by dialysis. Over-the-counter (OTC) medication A medicine that can be bought at the store or pharmacy without a prescription from a medical provider. Phosphorus binders A medicine that binds phosphorous in the food you eat and keeps it from being absorbed through the gut. Most phosphorous cannot be removed by dialysis, so this helps to balance phosphorous and calcium levels in the body. Vitamin D A nutrient made by the body that is important for strong bones and teeth. Healthy kidneys can convert to the active form; unhealthy kidneys require either other-the-counter or prescription supplementation.
120 Peritoneal Dialysis at Home Lesson 7: Dialysis Medicines
Why all the medicine?
Medicines are sometimes needed to help keep your child healthy when their kidneys are not working properly. It is important to take the prescribed medicines as instructed by your dialysis team. Carry a list of the names, purpose and doses of each medicine with you at all times.
Important medicine-taking tips:
• Never stop any medicine unless the kidney doctor or dialysis nurse tells you to stop. • Bring a list of your child’s medicines to the clinic visit each month as medicines may need to be adjusted. • Always check with your kidney doctor if another doctor prescribes a medicine for your child. • Refill all your medicines before the bottle is empty.
Anemia
Children with kidney disease often suffer from anemia. Anemia is when the body does not have enough red blood cells to work properly. The kidneys play an important role in making red blood cells.
Children with anemia are often tired because red blood cells carry oxygen in the body. In addition to being tired, some children may feel short of breath when walking or playing, look pale or feel as if their heart is racing.
Treatment for anemia Healthy kidneys make a hormone called erythropoietin (err-ith-roh-POY-uh- tin), which tells the bone marrow in the body to make red blood cells. Many children on dialysis will need extra erythropoietin because their bodies don’t make enough of it naturally.
Hemoglobin is a protein in the blood that contains iron and transports oxygen through the body. If your child’s hemoglobin level is less than 11, it’s a sign they are not making enough red blood cells and they need erythropoietin.
You will be trained on how and when to give this medicine by injection. Labs will be monitored at least once a month. This helps the dialysis team determine the appropriate dose.
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Some different medicine names for erythropoietin are:
• Epogen (epoetin alfa) • Procrit (epoetin alfa) • Aranesp (darbepoetin alfa) • Mircera (epoetin beta)
Rubber stopper Needle Vial
Important tip: All erythropoietin products must be stored in the refrigerator.
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Iron
Iron is a mineral that works in your body to help make red blood cells. There are two ways to receive your iron supplement: by mouth (oral) as a pill or liquid or through a vein (IV). Your body must have iron for the Epogen (and other erythropoietin products) to work.
IV forms of iron • Venofer • Ferrlecit
The intravenous (IV) form might be given if your child cannot tolerate the oral tablets. The IV iron may be given monthly at your PD Clinic visit.
Oral forms of iron • Ferrous sulfate • Iferex • Fer-in-Sol (liquid)
More information about iron • After taking iron with food, it takes 30 minutes to 1 hour for the body to replace the iron stores it used up in making red blood cells. • Do not take iron pills with phosphorus binders, antacids or milk. • Your body needs iron in order for the Epogen, Mircera and Aranesp to work!
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Blood pressure medicine
Blood pressure medicines work in several different ways. They are used to help lower blood pressure, reduce how hard the heart works and to help decrease the frequency of headaches. Some blood pressure medicines might decrease your child’s heart rate. Your dialysis team will tell you whether to take these medicines before or after dialysis. Lisinopril (generic) • Type: ACE inhibitor • Works by: Relaxes the blood vessels. Blocks (inhibits) a substance in the body that causes the blood vessels to tighten. • This medicine might be used to try to preserve existing kidney function.
Amlodipine • Type: Calcium channel blocker • Works by: Blocks the use of calcium by the heart, relaxing blood vessels so blood can flow more easily and your heart does not have to pump as hard.
Isradipine • Type: Calcium channel blocker • Works by: Relaxing the muscles of the heart and blood vessels.
Minoxidil • Type: Vasodilator • Works by: Opening up the blood vessels.
Labetalol • Type: Beta blocker • Works by: Relaxes blood vessels and slows the heart rate to improve blood flow and decrease blood pressure. • This medicine may hide the signs of low blood sugar. If you have diabetes, you may need to watch your blood sugar closely.
Other information about blood pressure medicines • You may be asked to take your child’s blood pressure at home before giving the medicine. • Your kidney doctor will give you the proper range for your child’s blood pressure. • You will be asked to report blood pressures higher or lower than this range. • Your doctor may recommend other medicines.
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Preventing bone disease
One of our goals is to keep your child’s bones healthy. To do this, the body needs to keep two very important minerals in your child’s body in balance; the minerals are calcium and phosphorus. Both of these minerals come from the foods we eat. Calcium and phosphorus are in a constant tug-of-war with each other. When phosphorus is high, calcium is low.
A healthy calcium level in the bones of kidney disease patients is balanced by a diet of low-phosphorus foods, the use of phosphorus binders and vitamin D supplements.
Phosphorus binders Phosphorus is a mineral found in bones, teeth and blood and is normally removed by the kidneys. When the kidneys are not working properly, the phosphorus is not removed and the level increases in the blood. As phosphorus increases in the blood, it triggers a gland in the neck (the parathyroid) to release a hormone that causes calcium to be removed from the bones and teeth, making them weak.
To protect your bones and teeth from losing calcium, phosphorus binders are prescribed.
Phosphorus binders include:
• Tums (calcium carbonate) • Renvela (sevelamer powder) • Renagel (sevelamer tablet) • Other:
Other information about phosphorus binders
• Take your phosphorus binders as directed by your dialysis doctor. • Binders work best when taken with meals. • Your binder medicine is: . • If your child attends school, they will need to take phosphorus binders at lunchtime during their school day. Your dialysis nurse will help set this up with the school nurse.
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Vitamin D For the body to absorb calcium from the food we eat, a special type of vitamin D produced by the kidney is needed. In kidney failure, this vitamin is not produced, so the body cannot absorb the calcium from food and instead pulls it from the bones and teeth. When calcium is removed from the bones, bone pain and fractures can occur.
An active form of Vitamin D is given to most dialysis patients to protect the teeth and bones. Commonly prescribed vitamin D supplements include:
Active vitamin D
• Calcitriol (Rocaltrol and Calcijex) • Paricalcitol (Zemplar)
Vitamin D2
• Ergocalciferol • Doxercalciferol (Hectorol)
Other vitamins
Multivitamins Vitamin supplements are given to replace the vitamins that are removed by dialysis. These vitamins are necessary for general health. Always take vitamins after dialysis. Please check with your kidney doctor before taking any over-the-counter vitamins to ensure they are kidney-friendly.
These are names of common prescription multivitamins your child’s kidney doctor may order:
• Dialyvite (pill) • Nephronex (liquid) • Nephrocaps (soft gel)
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Key points
• Erythropoietin works with iron to make healthy red blood cells. • Blood pressure medicine helps to keep the heart from being overworked. • Phosphorus binders help balance the phosphorus and calcium levels in your child’s body. • Calcium and phosphorus work together with vitamin D to keep your bones and teeth strong. • Multivitamins help keep your child healthy.
Teach-back moment
My child takes…
Type Name When? of medicine of medicine How much?
Erythropoietin replacement
Iron
Blood pressure medicine
Phosphorus binder
Vitamin D
Multivitamin
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Insulin for diabetes
If your child has diabetes, they may need insulin added to their PD solution bag.
Glucose (sugar) is fuel for your cells. You need insulin to let the sugar into the cells. Usually your body makes enough insulin and will automatically release enough to use the sugar available.
There are two types of diabetes:
• Type 1: Picture your cells as locked doors. Insulin is the key that unlocks the door and lets sugar in. If your body stops making insulin, you cannot open the door to let sugar in. Your body starves because all the sugar is in your blood. Your blood sugar will be very high. • Type 2: If you have the wrong insulin “key” or insulin resistance, you have a lot of keys floating around, but none of them unlock the door. Type 2 diabetes often makes lots of insulin, but just not the right kind your body needs.
In either type of diabetes, we might need to give you extra insulin in the PD solution bags to help your body have enough insulin to deal with the sugar that is in the dialysis fluid.
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Taking over-the-counter (OTC) medicines
Not all over-the-counter (OTC) medicines are safe for people with kidney disease. Below is a list of medicines that are generally best to use. Use these medicines only if recommended by your dialysis nurse or doctor. Check with your healthcare provider first before giving any type of medicine to your child.
Problem Pain or fever
Medicine you can give • Tylenol (acetaminophen)
Tips to remember • Tylenol is the preferred medicine for relief of pain and fever. • Call your doctor before you use ibuprofen (Motrin) or naproxen (Aleve).
Problem Congestion or cough
Medicine you can give • Guaifenesin (Mucinex and plain Robitussin) • Dextromethorphan (Robitussin DM and Mucinex DM)
Tips to remember • Do not use cold and cough medicines in children under age 4. • Give only the plain and DM forms of Robitussin. • Never give your child the decongestant form (Mucinex D). • Never give your child Vicks NyQuil or similar product.
Problem Allergies
Medicine you can give • Diphenhydramine (Benadryl) • Fexofenadine (Allegra) • Loratadine (Claritin) • Chlorpheniramine • Cetirizine (Zyrtec) (Chlor-Trimeton)
Tips to remember • Benadryl may cause drowsiness. • Never give your child the decongestant form (Claritin-D or Zyrtec-D). • Never give your child Vicks NyQuil or similar product.
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Medicines commonly used to treat peritonitis
Peritonitis is an infection anywhere in the peritoneum (abdomen or its lining). It is caused by bacteria that can make you sick. Antibiotics are a type of medicine that fight bacterial infections by either killing the germs or keeping the germs from growing. The number of days your child will need to take the antibiotic will depend on what type of infection they have. Antibiotics are prescribed for up to 21 days and it’s always important to take all the medicine until it’s gone, even if your child starts feeling better.
There are two types of antibiotics: 1. Broad spectrum: Targets both gram-positive and gram-negative bacteria. • Cefepime 2. Narrow spectrum: Targets either gram-positive or gram-negative bacteria. • Cephalosporins • Vancomycin • Gentamicin
Your child may be given “antifungal” medicine when they are placed on an antibiotic. This medicine helps prevent overgrowth of fungi in your intestine. Fungus can grow in the body when the antibiotics disrupt the normal “good” bacteria that keep the fungi in control.
Common antifungal medicines are nystatin and fluconazole. • It comes in liquid or tablet form. • If your child is able, teach them to swish the liquid medicine around the mouth and hold it there for as long as possible before swallowing it. • If your child is a small baby, you may use a special dropper that the pharmacist gave you. You will give half the dose on each side of the tongue. • Your child should not eat for at least 10 minutes after a liquid dose is given. • Your kidney doctor will prescribe the best type for you.
For directions on how to add antibiotics to your child’s PD solution bags, see page 18.
Remember: Signs and symptoms of peritonitis may be one or more of the following: • fever • abdominal pain • cloudy fluid
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Heparin
• Heparin is a medicine used to prevent blood clots. It is also added to PD solution bags if fibrin is present to keep more from forming. • Fibrin is a tough strand of protein that helps blood clot. Fibrin can clog your PD catheter or slow down the flow in and out of the catheter.
Fibrin will look like small white or beige pieces or strands and float in your drain fluid (effluent). See the photo below. Be sure to tell your PD nurse if you notice fibrin. Your dialysis nurse will give you instructions on using heparin.
For directions on how to add heparin to your child’s PD solution bags, see page 139.
Growth hormone
Children with kidney disease are sometimes prescribed growth hormone (GH) therapy, which can help when a child is growing poorly. However, there are a number of issues like bone disease and nutrition that need to be addressed before GH is prescribed. Your dialysis nurse and doctor can determine if and when GH therapy is right for your child.
Resources
Visit the National Institute of Diabetes and Digestive and Kidney Diseases website for information on growth failure in children with chronic kidney disease: www.niddk.nih.gov
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Help for constipation
This is a subject that most people are embarrassed to talk about, but it is common in people with kidney disease.
Your child may be constipated if: • They have two or fewer bowel movements in a week. • They frequently strain during a bowel movement. • Their stools are hard. If your child becomes constipated, it may cause the PD catheter to work poorly.
Talk to the dialysis nurse or doctor if you are concerned that your child is not having a stool every day.
Remember: Constipation is very common in kids on dialysis. Don’t be embarrassed to talk about it with your child or PD staff.
Other than diet and exercise, medicines are sometimes given to help with your child’s bowels.
Common stool softeners and laxatives Colace
Type: Stool softener
Stool softeners help prevent constipation. A stool softener is a gentle type of laxative that works by causing the body to draw water into the intestines. The water is absorbed by the stool matter, making the stool soft and easier to pass.
Senna or Dulcolax
Type: Stimulant laxatives
This type of laxative makes stool move faster through the intestines. Since stimulant laxatives can irritate the intestine lining, it is recommended for short-term use.
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MiraLAX
Type: Osmotic laxative
MiraLAX holds fluid in the intestine. MiraLAX will also draw fluids into the intestine from other tissue and blood vessels. This extra fluid in the intestines makes the stool soft and easier to pass. MiraLAX is best taken in the morning when you are able to drink with it.
Your team may ask you to tell them what your child’s stool looks like. The following chart may be helpful to you when characterizing their poo.
Bristol Stool Chart
• Types 1 and 2 indicate constipation. • Types 3 and 4 are the ideal stools since they are easier to pass. • Types 5, 6 and 7 may indicate diarrhea and urgency.
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Green Zone To stay in the Green Zone
Where you want to be! Stool softener • Poop every 1 to 3 days Type • No straining Number • Poop is soft Amount (Bristol Stool Chart Types 4 and 5) Times a day
Laxative
Behaviors Sit on the toilet Times a day
Feet flat on the floor (or a stool) with knees above hips
Yellow Zone To move out of the Yellow
• No poop for 3 to 5 days Zone • Straining and pain Stool softener • Poop is hard Type (Bristol Stool Chart Types 1 and 2) Number Amount Times a day
Laxative Type Number Amount Times a day for days
Call your doctor to let them know you are in the Yellow Zone.
Red Zone To move out of the Red Zone
• No poops for more than 5 days Enema (once) • Extreme pain or blood with bowel Suppository movements After your child has had a poop with the • Bloated abdomen, decreased enemas, return to the Yellow Zone. appetite, leakage of stool Call your doctor to let them know you are in the Red Zone and have to give an enema.
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Notes
My questions:
My notes:
Important information from this lesson:
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How to add antibiotics to the PD solution bags
If there are concerns for peritonitis, you should always bring your child to Seattle Children’s or your local emergency department.
What do I do before I start? Gather these supplies and place them on a clean surface:
Antibiotic Sterile Water vials if needed Syringes and needles Alcohol swabs Mask and gloves Dialysate bags: 2 L (liter) cycler, 3 L cycler, 5 L cycler, 1.5 L Ultrabag, 2.5 L Ultrabag
Check the bag(s) of dialysate for: Solution (dextrose concentration) Expiration date Amount and appearance (is there anything floating in the solution?) Leaks
Check medicine and sterile water vials for: Expiration date Flip top securely in place and vial intact (means it has not been tampered with)
How do I mix the antibiotics? There may be times you will need to mix a powder antibiotic with sterile water to turn the medication into a liquid form. This liquid form will allow you to add the antibiotic to the dialysate bags.
How to mix the powdered antibiotics (typically vancomycin)
1. Put on a mask. 2. Wash your hands and wear gloves. 3. Scrub the top of the sterile water vial with an alcohol swab for 15 seconds. Let dry for 15 seconds. 4. While the sterile-water vial is drying, scrub the top of the vancomycin vial with an alcohol swab for 15 seconds. Let dry for 15 seconds. 5. Add about 5 mL of air to the sterile water vial.
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6. Draw 10 mL of sterile water into the syringe and add it to the powdered antibiotic vial. 7. Gently mix by rolling the vial between your hands or using a “swirling” motion. It must become clear. 8. Draw the antibiotic into the syringe to be added to the dialysate bag(s). See the pharmacy medication label for the right dose (amount) of antibiotic to add to each bag.
How to prepare the premixed antibiotics (typically gentamicin)
Some antibiotics are in premixed vials (already in liquid form).
1. Put on a mask. 2. Wash your hands and wear gloves. 3. Scrub the top of the liquid antibiotic vial with an alcohol swab for 15 seconds. Let dry for 15 seconds. 4. Add about 1 mL of air to the premixed vial. 5. Draw the antibiotic into the syringe to be added to the dialysate bag(s). See the pharmacy medication label for the right dose (amount) of antibiotic to add to each bag.
How do I add the medicines to the dialysate? 1. Put on a mask. 2. Wash your hands and wear gloves. 3. Line up all the bags on the clean surface. 4. Scrub each medicine port on the bags with an alcohol swab for 15 seconds. Let dry for 15 seconds. 5. Insert the needle of the syringe into the medicine port at the inner circle mark (looks like a bull’s-eye). If it feels hard to push the needle in, then pull back and gently try again. Be sure not to push the needle through the side of the medicine port. 6. Once the needle is in place, push on the syringe plunger to add the antibiotic to the bag. 7. Remove the needle from the bag and throw the whole syringe into the appropriate sharps container. Use one syringe for each antibiotic/medicine for each bag of dialysate. (For example, if you are using 5 bags, you will need 5 syringes for each antibiotic.) Do not use the same needle and syringe for each bag.
Follow the pharmacy medication label for how many vials you will need.
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How do I give my child the medicines? 1. Put on a mask. 2. Wash your hands and wear gloves. 3. Set up as you normally do. Remember to gently shake the bags to mix the antibiotics. 4. Start your dialysis routine no sooner than 3 to 6 hours after giving the loading dose of antibiotics. 5. Take the antibiotics with each dialysis as instructed – do not miss a dose. 6. Finish all the days of antibiotic therapy even if your child is feeling better. 7. Your child may also be instructed to take an antifungal medicine orally (by mouth) while on the antibiotics.
If there are concerns for peritonitis, you should always bring your child to Seattle Children’s or your local emergency department.
Ideally a loading dose of antibiotics is given at Seattle Children’s by the dialysis nursing staff or your local emergency department.
If you are instructed to give a loading dose at home, follow these instructions: 1. Put on a mask. 2. Wash your hands and wear gloves. 3. Prepare the antibiotics by following “How to add antibiotics to the PD solution bags.” You will be using an Ultrabag for a loading dose. Do not use a cycler bag. 4. Flush your child’s peritoneal cavity. 5. If connected to the cycler, disconnect from the cycler. Then connect to the Ultrabag with no antibiotics added and do some in-and-out flushes. 6. If not connected to the cycler, then connect to the Ultrabag with no antibiotics added and do some in-and-out flushes. 7. Disconnect from the Ultrabag used to flush. 8. Connect to the Ultrabag containing the antibiotics. 9. Drain any leftover flush solution. 10. Then, using normal fill volume, instill the dialysate solution with antibiotics.
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11. Clamp. 12. Disconnect and cap the PD (peritoneal dialysis) catheter with the MiniCap. 13. The antibiotic needs to dwell for 3 to 6 hours or per instructions from the nephrologist.
How to add heparin to the PD solution bags
What do I do before I start? Gather these supplies and place them on a clean surface:
Heparin vials Syringes and needles Alcohol swabs Mask and gloves Dialysate bags – 2 L (liter) cycler, 3 L cycler, 5 L cycler, 1.5 L Ultrabag, 2.5 L Ultrabag
Check the bag(s) of dialysate for:
Solution (dextrose concentration) Expiration date Amount and appearance (is there anything floating in the solution?) Leaks
Check the medicine and sterile water vials for:
Expiration date Flip top securely in place and vial intact (means it has not been tampered with)
How to prepare the heparin The heparin vial is premixed.
1. Scrub the top of the heparin vial with an alcohol swab for 15 seconds. Let it dry for 15 seconds. 2. Add about 1 mL of air to the heparin vial and then draw the heparin into the syringe to be added to the dialysate solution bag. See the pharmacy medication label for the right dose (amount) of heparin to add to each bag.
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How do I add the medicines to the dialysate? 1. Put on a mask. 2. Wash your hands and wear gloves. 3. Line up all of the bags on the clean surface. 4. Scrub each medicine port on the bags with an alcohol swab for 15 seconds. Let dry for 15 seconds. 5. Insert the needle of the syringe into the medicine port at the inner circle mark (looks like a bull’s-eye). If it feels hard to push the needle in, then pull back and gently try again. Be sure not to push the needle through the side of the medicine port. 6. Once the needle is in place, push on the syringe plunger to add the heparin to the bag. 7. Remove the needle from the bag and throw the whole syringe into the appropriate sharps container.
Maintenance dosing with the cycler 1. Set up as you normally do. Remember to gently shake the bags to mix the heparin. 2. Start your dialysis routine as you normally do. 3. When the therapy is complete, discontinue as you normally do.
Loading dose with Ultrabag (manual) 4. Put on a mask. 5. Wash your hands and wear gloves. 6. Flush your child’s peritoneal cavity. This can be done one of two ways: • If connected to the cycler, leave connected and bypass the dwells. • If not connected to cycler, then connect to the Ultrabag and do some in and out flushes. 7. Disconnect from the cycler or Ultrabag used to flush. 8. Connect to the Ultrabag containing the antibiotics. 9. Drain. 10. Use normal fill volume. Clamp. 11. Disconnect and cap PD (peritoneal dialysis) catheter. Needs to dwell for 3 to 6 hours.
140 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 8
Caregivers
In this lesson you will learn: • What you can expect if you are setting up to do dialysis at your home • Tasks to learn • Home and family interruptions • Sharing your concerns with your dialysis team • Ways to support your child
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What you can expect with dialysis at home
The medical perspective Peritoneal dialysis (PD) is a “home therapy.” A parent or caregiver completes a training program to manage dialysis for their child at home versus going to a healthcare facility or kidney center.
Remember: The goal of training is for you to learn the skills and information that will help you feel comfortable in performing PD.
Once you complete the training program, you should feel confident that you can manage PD independently.
Remember that this is a team effort and you can always reach your back-up team by calling the on-call numbers. In addition, the dialysis doctors and on-call PD nurse can be reached 24/7 for urgent issues.
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Responsibilities at home
It may look overwhelming at first, but as you go through training, you will see how it all comes together and how PD fits into your child’s daily life. After a few weeks, dialysis will become part of your daily routine. When the choice is made for home PD, there are some very important things to consider.
Here are the tasks you will need to master for successful home dialysis:
• Complete a 2-week daily PD home training program.
Once home:
• Perform nightly PD. • Assess for infection and other complications of treatment. • Troubleshoot machine (equipment) issues. • Take and record weight and blood pressures morning and night. • Complete daily record sheets. • Perform skin care around the site where the catheter comes out. • Give daily medicines and order refills as needed. • Order monthly PD supplies and keep them well-stocked. Your PD supply company is: Koffel Medical Supply
• Attend monthly PD appointments. • Contact the PD Clinic with questions, concerns and issues. • Plan and monitor your child’s diet.
Here are the home and family interruptions you can expect: Managing PD at home can be a very overwhelming process. Here are examples of expected changes to be aware of when you start PD at home:
• Space in your home You will need to locate storage space for PD supplies in your home and a place for the dialysis machine in your child’s bedroom. These are constant reminders of your child’s medical condition. This can be an adjustment for you and your child. You will need, at minimum, around 80 square feet of storage space.
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• Changes to your daily routine Your day will now revolve around PD and the effects it may have on your child and your family.
• Parent or medical provider? You will be managing your child’s medical care at home and be familiar with any and all of the symptoms your child may be having. Being responsible for the medical care of your child and being a parent can be stressful. You may notice that you change the way you parent your child as a result of these new responsibilities.
• Vacations Your home will be the place where your child receives nightly medical treatment and management. One advantage of PD is you are able to travel rather than being “tied” to a clinic for hemodialysis. Traveling will become more complex than it was before because your child will need all of their PD supplies to get nightly PD when traveling.
• Family dynamics The entire family unit is affected by PD at home, even children who are not on PD. Often, the family focuses mostly on their child with PD, which can leave other children feeling neglected.
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Having a voice: Sharing your issues, concerns and suggestions with the dialysis team
The dialysis team welcomes your suggestions about the clinic or your child’s care. Open communication between the team and the family is critical to successful PD at home. We are here to support you and want to hear any and all of your issues, concerns or suggestions.
The dialysis team is made up of many members. Here are the team members, the roles they play and the reasons why you might need to contact them to share your thoughts.
• Your child and you the caregiver(s). Your medical team knows PD but you know your child. We rely on you to let us know of any concerning changes related to your child. We will then work together to come up with a plan to resolve any concerns about the care of your child.
• Your child’s PD nurse is here to help with general dialysis questions, concerns about supplies, PD prescriptions, touch contaminations, medicine refills and any abnormal medical symptoms your child is having.
• The primary nephrologist (kidney doctor) is your child’s dialysis doctor. Your child will visit the nephrologist once a month or more frequently if needed. The nephrologist prescribes medicines and the PD prescription for the cycler, monitors all lab results and, if needed, refers your child to other specialists.
• A social worker can help with questions and concerns about insurance, housing, community resources for transportation or supportive counseling.
• A dietitian can help with weight management and appetite, and will review lab results that may result in a change in diet. The dietitian can connect you to resources for formula and food assistance and can help you with meal planning and food management.
• The Child Life specialist can help if you are concerned about how your child is coping, offer sibling support or provide education to your child about their kidney disease. The Child Life specialist can use “medical play” to prepare your child for procedures. This special play can help lessen anxiety during labs, clinic visits or hospital stays.
• The behavioral psychologist can help with bigger behavioral concerns, such as difficulty coping with chronic illness, refusal to take medicine or resistance to medical treatment.
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Being your child’s advocate
• Share the most effective ways to communicate with your child with your care team. You know your child best. What works well with your child at home? What does not work well? It will be helpful for your child’s dialysis team if you can identify how we can best communicate with you and your child.
• Ask questions. Write down any questions you or your child have and bring the list of questions to your clinic appointments. Is something not working at home? Do you need extra help or advice? Asking questions will help you feel more in control. Never be afraid to ask questions!
• You are part of the team! If you see something happening that is not in the best interest of your child or if you have any questions, say something. Your team wants to know when they can be doing something better or differently!
• Empower your child. Encourage your child to ask questions, make suggestions and interact with the dialysis team. This will help your child feel more comfortable with the care team and give your child a sense of control, which can be empowering. As a parent, you may be tempted to jump in to answer questions and provide information but try to let your child take the lead and fill in only when needed.
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• Offer comfort. If your child gets nervous during tests or procedures, make sure that you’re close by to comfort them. Ask to hold your child’s hand during a procedure or test. The Child Life specialist can make suggestions for other simple ways to comfort your child when they are nervous or afraid. • Be informed. Ask questions if you feel confused. Understanding your child’s medical care plan helps you feel confident in your ability to manage your child’s care.
• Stay organized. There is so much information to remember! It’s easy to become overwhelmed. Staying organized and having all your resources in one place can greatly reduce your stress. Keep this handbook close to you in the beginning and get a 3-ring binder or notebook for storing papers and writing down questions.
Most importantly, you and your child are the most important part of our team. Always let us know how we can help!
Supporting your child at home
A change like PD at home can result in stress and anxiety, especially for your child. There are several ways that you can help reduce stress and anxiety around medical procedures. Here are some suggestions for helping your child feel confident and in control about their PD.
• Help your child to understand why they need dialysis. When a child understands why they need to have a treatment, procedure or medicine, they are more likely to cooperate. Your Child Life specialist can provide you with support on how to best educate your child based on their age and development.
• Maintain normal predialysis activities. It is important to maintain a routine for your child. As much as you can, allow them to participate in normal activities they did prior to starting dialysis. This helps to normalize their lives and your own! It can help to promote positive coping skills.
• Create and keep a nighttime schedule. At home, PD will be a big life change for you and your child. Work with your child to create a schedule so they know when it is time for their dialysis treatment. Include all the steps in the schedule for each evening: bath, brushing teeth, pajamas, getting connected to start dialysis and reading a book; “lights out” will help the PD treatment seem like a normal routine.
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• Encourage participation to give back control. This is very important for your child. Having daily treatments can be overwhelming, and sometimes your child may not feel like cooperating even when they know it’s important. Giving your child control over other daily activities (such as selecting dinner time, helping with assembling supplies for dialysis, and picking what time the dialysis starts) can help your child feel in control. At the doctor’s visit, ask your child which arm they prefer for a shot or blood draw. Having your child participate in their own medical care, in little and in big ways, can make a world of difference!
• Encourage medical play. Your child is never too young to start playing with medical play toys (as long as there are no choking hazard pieces for the little ones). Playing with medical toys can help your child feel more comfortable and familiar with the devices and tools of their treatment. Play is how children learn best! It can also help identify worries, questions and misunderstandings or misconceptions that children have about their medical care, which allows you to address those issues. Ask your care team about medical play toys.
148 Peritoneal Dialysis at Home Lesson 8: Caregivers
• Be aware of changes in behavior. Your child may begin to display subtle signs of stress and anxiety. Here are some things to look for: • Not wanting to go to school • Having constant ailments (headache, stomachache) • A lack of energy or loss of interest in things • Decline in performance at school • Expressing fear, crying or having nightmares • Withdrawn behavior • Regression (reverting back to younger behaviors)
• Validate feelings. Children need to be heard. Let them know all their feelings are normal and OK. When your child is upset, name their emotions: “I see you are feeling angry.” This can help them understand what they are feeling. This is especially true for younger children. Validating or naming emotions does not take the place of setting boundaries. You can discuss emotions while also setting limits. For example: “I know you are mad right now, but it is not okay to hit people. You may not do that again. Rather than hitting, what else could you do when you are mad?” This approach can help your child brainstorm ideas and solutions. Or, you can suggest an idea if and when the behavior continues. For example: “Next time you start to get mad, I want you to tell me, ‘Mom I am starting to get mad,’ and we will take a break.”
Seattle Children’s Hospital 149 Lesson 8: Caregivers
Caregiver burnout and self-care
It is common for many caregivers to experience what is called “caregiver burnout” when providing daily care to a child with chronic illness. Caregiver burnout can be different for different people. What’s most important is to recognize how you are being affected by the stress of being a caregiver. Your medical team will help.
Common signs of caregiver burnout Emotional and mental • Not feeling like yourself. • Feeling frustrated, sad, angry, helpless or overwhelmed more often than not. • Feeling like you are alone and isolated, like no one can understand what you are going through. • Loss of interest in doing things that you normally love to do.
Physical • Drastic loss or gain in weight. • Sleeping too much or not enough. • Regular head and body aches.
Caregiver burnout has the power to negatively impact all aspects of your life. This includes the relationship with your medical team and your personal and professional life. There are many things that can be done to prevent and manage the stressors of being a caregiver.
150 Peritoneal Dialysis at Home Lesson 8: Caregivers
Ways to care for yourself
Identify a support system
This can include reliable friends and family who can come spend time with you or to speak with over the phone. This can also be community members, religious groups or support groups.
Educate and communicate
The better understanding you have of your child’s illness, the better you are able to make sense of their symptoms and understand their need for medicines and regular involvement with the medical team. It is important to talk with the medical team when you have questions or concerns about your child’s diagnosis and medical management. This can minimize your stress.
Take time for yourself
This can seem impossible to do, but it is important. Rely on your support system to help you take at least an hour a week to do something you enjoy, something fun or relaxing. Some examples are to take a long walk, go to the salon, have dinner with a friend, exercise, take a nap, read a book and work on your scrapbook or journal.
Seattle Children’s Hospital 151 Lesson 8: Caregivers
Notes
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My notes:
Important information from this lesson:
152 Peritoneal Dialysis at Home Peritoneal Dialysis at Home – Lesson 9
Automatic Dialysis with a Cycler Machine Versus Manual Dialysis
In this lesson you will learn: • Review the steps of a peritoneal dialysis cycler or exchange • Review what Automated Peritoneal Dialysis (APD) is • Learn how to set up, use and troubleshoot your cycler • Learn how to set up, use and troubleshoot Manual PD
Seattle Children’s Hospital 153 Lesson 9: Automatic Dialysis Versus Manual Dialysis
Words to know
APD Automated Peritoneal Dialysis, sometimes called CCPD.
CAPD Continuous Ambulatory Peritoneal Dialysis (also known as manual PD). This type of dialysis is done manually. Gravity is used to drain and fill your peritoneal cavity with dialysis solution.
Catheter A tube that carries the dialysate into and out of your body.
CCPD (APD) Continuous Cyclic Peritoneal Dialysis. This type of dialysis is done with a machine called a cycler. The cycler will automatically drain, fill and dwell the dialysis solution from your peritoneal cavity..
Cycler Machine used to do peritoneal dialysis.
Dialysate A liquid that has a sugar called dextrose in it to help pull waste and extra fluid into the peritoneal cavity.
Dialysis The process of removing waste products and excess fluid from the body.
Dwell time The time the dialysis solution sits in your peritoneal cavity.
Exchange or cycle The process of draining, filling and dwelling the dialysis solution from your peritoneal cavity.
What is a PD cycle or exchange?
PD exchange is a cyclical process that removes waste products and fluid from your child’s body and replaces it with new dialysate solution.
154 Peritoneal Dialysis at Home Lesson 9: Automatic Dialysis Versus Manual Dialysis
There are three steps to each PD exchange:
1. Drain Removes old dialysate solution, along with urine waste products and extra body fluid.
2. Fill Replaces old dialysate solution in the peritoneal cavity with new dialysate solution.
3. Dwell The time when dialysate solution is in the peritoneal cavity. This is when dialysis takes place.
Seattle Children’s Hospital 155 Lesson 9: Automatic Dialysis Versus Manual Dialysis
Automated peritoneal dialysis
Automated Peritoneal Dialysis (APD) is a kind of peritoneal dialysis (PD) that uses an electric machine called a cycler. You will be trained to use a cycler for automatic PD.
• APD works during the night while your child sleeps. • The cycler is set up to automatically do PD exchanges. • Your nurse will tell you if your child needs a PD exchange during the day (in addition to or in place of a nighttime exchange).
Below are some pictures of common cycler machines:
HomeChoice Pro Cycler AMIA Cycler (typically for babies (typically for older kids and toddlers) and teenagers)
Teach-back moment
The name of the cycler I will be using at home is:
.
• If using the HomeChoice Pro Cycler: Refer to your handouts and material provided by Baxter. • If using the AMIA Cycler: Follow the cycler on-screen instructions and material provided by Baxter.
156 Peritoneal Dialysis at Home Lesson 9: Automatic Dialysis Versus Manual Dialysis
Manual peritoneal dialysis
Manual peritoneal dialysis is done manually. Gravity is used to drain and fill the peritoneal cavity with dialysis solution. You will be trained to use manual peritoneal dialysis in the event of a power outage.
• For Manual/CAPD/Gravity exchanges: Refer to the Baxter Ultrabag handout.
Seattle Children’s Hospital 157 Lesson 9: Automatic Dialysis Versus Manual Dialysis
Notes
My questions:
My notes:
Important information from this lesson:
158 Peritoneal Dialysis at Home Notes
Seattle Children’s Hospital 159 Seattle Children’s offers interpreter services for Deaf, hard of hearing or non-English speaking patients, family members and legal representatives free of charge. Seattle Children’s will make this information available in alternate formats upon request. Call the Family Resource Center at 206-987-2201. 8/20 This handout has been reviewed by clinical staff at Seattle Children’s. However, your child’s needs are unique. Before PE3156 you act or rely upon this information, please talk with your child’s healthcare provider. © 2020 Seattle Children’s, Seattle, Washington. All rights reserved. Dialysis