Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement ASDIN Advanced Techniques Pre-course Peritoneal Dialysis Catheter Placement
Feb. 24, 2012
New Orleans, La
Randall L. Rasmussen, MD Special thank you to Drs. Rajeev Narayan, San Antonio, Tx and Hemant Dhingra, Fresno Ca for lending me slides from their teaching files to use for this talk.
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Permanent CAPD catheters Four placement techniques: • straight or arcuate inter-cuff segment • Peritoneoscopic • two cuffs – deep cuff that is implanted in the rectus muscle • Fluoroscopic – superficial cuff that is positioned two cm from the exit site • Surgical • variable length from the deep cuff to the coil • Laparoscopic • a coiled distal end
• Blind technique - abandoned
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
There are advantages to both the peritoneoscopic and Peritoneoscopic and fluoroscopic techniques the fluoroscopic technique are favored by interventional doctors - peritoneoscopic procedure offers visualization of - but placing these catheters requires a different skill the peritoneal cavity which is important in patients with a history of extensive surgery or set than those interventional doctors are use to adhesions
- fluoroscopic placement is the least invasive 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Pre-procedure assessment Immediately pre-procedure
History document emptied bladder – meds, allergies, previous surgery – regular bowel pattern and not constipated mark the belt line with the patient sitting Physical exam – obesity, hernias start prophylactic antibiotics Laboratory – Cefazolin 1 gram IVPB – coagulation profile – Vancomycin 1 gram IVPB Evaluation by CAPD nurse – assess the patient’s ability to learn administer IV sedation
Both peritoneoscopic and fluoroscopic Peritoneal Dialysis Catheter Placement techniques start with an abdominal US - demonstrated in workshops
Peritoneoscopic and fluoroscopic techniques both Sub Q fat require: Measure distance skin to rectus Ant rectus sheath • abdominal ultrasound • incision to expose the anterior sheath on the Measure thickness of rectus lateral border of the rectus muscle Rectus muscle • gain entry into the peritoneal cavity • confirm entry into the peritoneal cavity Post rectus sheath • insert the catheter • check catheter function and close the incision Peritoneal cavity Document free movement
Peritoneal Dialysis Catheter Placement
US is used to identify any major vascular structure Peritoneoscopic and fluoroscopic techniques
The second step is an incision, ½ distance between the ASIS and “normal location” of the umbilicus, to expose the anterior sheath on the lateral border of the rectus muscle.
The incision should be: Inferior epigastric artery arises from the external iliac artery and courses cephalad along with the inferior epigastric vein between the posterior wall of - off the belt line the rectus muscle and the posterior rectus sheath - as long as it is deep Expose an area the size of a half dollar (3 cm in diameter) –> to get good visualization of the rectus sheath 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Peritoneoscopic and fluoroscopic techniques
The third step is to gain entry into the peritoneal space
• access to the peritoneal cavity can be visualized with real time ultrasound
• need to avoid the pre-peritoneal space
• an incision is made to expose the anterior sheath on the lateral border of the rectus muscle
• ligate or bovie any bleeders
Need to avoid the pre-peritoneal space Need to avoid the pre-peritoneal space
Pre-peritoneal space Posterior rectus sheath Parietal peritoneum Rectus muscle
Pre-peritoneal space
Parietal peritoneum
The pre-peritoneal space is less likely to be entered if an The pre-peritoneal space is the space between the insertion site is selected above the level of the anterior posterior rectus sheath and parietal peritoneum superior iliac spine.
Peritoneoscopic technique entrance to the peritoneal Fluoroscopic technique(s) entrance to the peritoneal cavity is done using a quill guide assembly set cavity is done using a Veress needle
Quill guide assembly set Veress needle Rectus Quill guide, cannula & trocar are inserted through the rectus at a 30-450 angle directed towards the coccyx
“Pops” can be felt when the Veress needle pierces the anterior and posterior rectus sheath. Rectus muscle Note that saline will run freely once the peritoneal cavity is entered. 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Peritoneoscopic and fluoroscopic techniques Peritoneogram The fourth step is to confirm peritoneal location
• usually requires 10cc of ½ strength contrast • using the peritoneosope the white-pink appearance of the peritoneum can be directly visualized and moves with respiration • contrast can be injected through the cannula during the peritoneoscopic approach • a white appearance means pre-peritoneal location • both techniques can confirm the location by performing a peritoneogram • contrast can be injected through a sheath or dilator inserted over a guidewire during the fluoroscopic • a .035 guidewire that easily curls across the midline technique is good evidence of intraperitoneal location • saline runs wide open
Peritoneogram demonstrates .035 Guidewire in the Peritoneogram with free .035 Guidewire easily contrast trapped in the pre-peritoneal space flow of contrast in the curls across the midline pre-peritoneal space meets resistance and peritoneum with minimal resistance does not cross the midline
Complications of peritoneoscopic and fluoroscopic CAPD catheter insertion occur with entry into the Peritoneal Dialysis Catheter Placement peritoneal cavity
* perforation of bowel, bladder or a vessel
* can usually be taken care of with minimal adverse outcomes as long as the complication is recognized.
* aspirate after gaining entry to the peritoneal cavity for blood, urine or bowel contents
Interpret this peritoneogram done at the time of CAPD catheter insertion. 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
The fifth step is to insert the catheter
• in both techniques, a small volume of NS is first instilled into the peritoneal cavity
Interpret this peritoneogram done at the time of CAPD catheter insertion. Abdel-Aal A K et al. AJR 2009;192:1085-1089
Peritoneoscopic technique Peritoneal Dialysis Catheter Placement Insufflation of the peritoneal cavity with room air
Peritoneoscopic technique
• the CAPD catheter is mounted on a lubricated stylet for insertion
• the catheter is inserted over the quill guide into the clear space
• note that during catheter insertion, the stylet should be inserted the minimal distance into the Peritoneoscopy allows the quill guide assembly peritoneal cavity to be advanced into a clear space under direct visualization using the peritoneoscope.
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Peritoneoscopic technique Fluoroscopic techniques
• a peel-away sheath is advanced over a .035 guidewire then the guidewire is removed
• the CAPD catheter is mounted on a lubricated stylet for insertion
• the CAPD catheter is inserted into the peritoneal cavity through the peel-away catheter
Quill guide Dilate Cath insertion Tunnel 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Fluoroscopic techniques After insertion of the catheter into the peritoneal cavity:
the deep cuff is anchored in the rectus muscle using an implanter device
a tunnel is created for the exit so that the cathetecatheterr is off the belt line and oriented lateral or inferior-lateral
the superficial cuff is positioned 2 cm from the exiexitt CAPD catheter uncoiling site through 16 Fr peel-away CAPD catheter in position, sheath with contrast freely flowing Note the stylet location
Peritoneal Dialysis Catheter Placement Peritoneal Dialysis Catheter Placement
Lastly, check the catheter function and close the incision Head
Feet • confirm catheter position by contrast injection
• check catheter function with 250 cc of dialysate or NS flush
The deep cuff is implanted into the rectus muscle prior to tunneling the catheter to the exit site
Peritoneal Dialysis Catheter Placement Head
Feet The catheter is oriented inferior-lateral Post-procedure checklist
Sutures is the coil center no more than 5 cm cranial to the top of the symphysis pubis ? is the angle of the intraperitoneal straight portion more than absorbable subcutaneous sutures are used to close 15 degrees from the horizontal? dead space only if it is “excessive” is the coil of the catheter in its natural shape (me(meaninganing that no part appears to cross any other part)? non-absorbable sutures are used to close the skin are there any kinks in the catheter? was the deep cuff visible in the rectus?
sutures are not usually placed at the exit site is the angle of the catheter at the exit site horizohorizontalntal or downward (not upward)? 8th ASDIN Annual Scientific Meeting
Peritoneal Dialysis Catheter Placement
Post-procedure
the patient must have a follow-up appointment for dressing change and flush
consider Rx stool softeners postoperatively and analgesic medications that do not cause constipation
patients should expect minimal post-operative discomfort and must be given instructions to call for any sign of symptom that requires medical attention