Page 2316 - Cote clinical veterinary advisor dogs and cats 4th

1151.e2 Peritoneal Dialysis

Peritoneal Dialysis
VetBooks.ir

• Peritoneal dialysis catheters
Difficulty level: ♦♦♦
○ Dogs: tunnel all catheter types subcutane- • Electrolyte imbalances (hypochloremia, hypo-
kalemia, hyponatremia, hypomagnesemia,
Overview and Goal ously to decrease the risk of dialysate leak hypocalcemia, hyperkalemia, hyperglycemia)
Exchange of dialyzable solutes and fluid between and the incidence of peritonitis. Cats: Uncommon:
the peritoneal vessels and the dialysate solution. secure with purse-string suture to linea • Overhydration and pleural effusion
Exchange occurs across the semipermeable alba • Hemorrhage
peritoneal membrane due to diffusion, ultra- ○ Percutaneous placement with trocar or • Dialysis dysequilibrium
filtration, and convection. guide wire–inserted silicon tube (e.g., • Hypoalbuminemia
Mila chest tube) restricted to emergency • Septic peritonitis
Indications situations or for short-term use because
• Acute kidney injury unresponsive to con- omental obstruction is a common Procedure
ventional medical management occurrence. • General anesthesia for mini-laparotomy
• Hyperkalemia (p. 495) or hypercalcemia ○ Mini-surgical approach options include approach in stable patients or sedation and
(severe) (p. 491) fenestrated, modified silicone catheters regional anesthesia in critical patients or
• Intoxication from ethylene glycol (<24 hours with or without Dacron cuffs such as percutaneous technique
after ingestion) (p. 314), barbiturates, and Tenckhoff catheters; fluted T-catheters; • Place in dorsal recumbency.
ethanol Blake surgical drains; and Jackson-Pratt • Clip, aseptically prep, and drape the area
• Hypothermia or hyperthermia surgical suction drains. Dacron cuffs from the xiphoid to the pubis.
• Resistant metabolic acidosis (severe) facilitate fibrous attachments, decreasing • Administer cefazolin 25-30 mg/kg IV 30
the risk of dialysate leakage and incidence minutes before PD catheter insertion.
Contraindications of peritonitis. • Mini-surgical approach for catheter place-
• Peritoneal fibrosis (impaired semipermeable • Dialysate solution ment (author’s preference)
membrane) ○ Commercially prepared dialysate solutions ○ At the level of the umbilicus, make a
• Pleuroperitoneal leak (predisposition to are available but often cost-prohibitive. small (2-3 cm) paramedian skin and
iatrogenic pleural effusion) ○ Homemade solutions using lactated subcutaneous incision.
• Recent thoracic or abdominal surgery Ringer’s solution, 0.9% NaCl, or 0.45% ○ Place a small stay suture in the rectus
(including percutaneous endoscopic gas- NaCl with dextrose added are more cost- sheath to facilitate manipulation of the
trostomy [PEG] tubes) effective. Strict aseptic technique (mask body wall.
• Inguinal or abdominal hernia and sterile gloves) must be followed during ○ Tent the abdominal wall, and make a small
• Severe hypercatabolic states (e.g., burn preparation to reduce contamination. stab incision into the peritoneum.
patients) Use single-use or new vials when adding ○ Grasp the PD catheter using a curved
medication. Wipe all injection ports with hemostat, and advance the catheter into
Equipment, Anesthesia alcohol before use. the abdomen toward the pelvic inlet.
• General anesthesia (stable patient) or sedation ○ Add the following to the solution: Release the catheter, and remove the
and regional anesthesia (critical patient) ■ Dextrose to act as an osmotic agent; con- hemostat.
• Clippers centration depends on patient’s hydra- ○ Secure the Dacron cuffs (if present) within
• Surgical scrub tion status. A 4.5% solution (85 mL the rectus muscle (inner cuff) and within
• #15 scalpel blade of 50% dextrose/L) in fluid-overloaded the subcutaneous tissues (outer cuff) using
• Local anesthetic (e.g., 2% lidocaine at patients, whereas a minimum 1.25% a purse-string suture.
1-2 mg/kg) solution (30 mL of 50% dextrose/L) ○ Tunnel the distal end of the catheter
• Surgical pack must be used in normovolemic patients. through the subcutaneous tissues, and
• Suture material ■ Unfractionated heparin (250 to exit the skin 2-5 cm away from the
• Surgical drapes 1000 U/L) for the first few days to abdominal insertion site. If no Dacron
• Adhesive dressing (e.g., OpSite) reduce the risk of catheter obstruction cuffs are present, begin tunneling under
• Closed Y connection system or a 3-way by fibrin clots the external sheath of the rectus abdominis
stopcock with one attachment to dialysate ■ Electrolytes should be added based on muscle before tunneling subcutaneously.
line and the other to sterile collection regular serum electrolyte monitoring. ○ Before closure, connect the PD catheter to
system ○ Prophylactic antibiotics are not routinely the dialysate solution in a sterile manner,
• Dialysate solution (see below) added. A one-time loading dose of and infuse a small volume of dialysate
• Peritoneal dialysis (PD) catheter (see cefazolin 1000 mg/L of dialysate, followed (2-5 mL/kg) into the abdomen. The
below) by a maintenance dose of 250 mg/L of dialysate should flow by gravity into
dialysate can be added to the dialysate the collection system if no occlusion is
Anticipated Time solution in cases of suspected peritonitis present. Redirect if needed until gravity
Setup: 15 minutes; placement: 30-45 minutes while awaiting confirmation from cytology flow occurs.
and culture. ○ Close the entry site through the external
Preparation: Important sheath of the rectus abdominis muscle over
Checkpoints Possible Complications and the PD catheter with a simple interrupted
• Drain the urinary bladder before PD catheter Common Errors to Avoid pattern using an absorbable monofilament.
placement to reduce the risk of iatrogenic Common: ○ Close the skin incision with a simple
puncture. • Dialysate retention (obstruction by omentum interrupted pattern using non-absorbable
• Rehydrate before anesthesia, and avoid or fibrin, improper placement, kinking of monofilament.
hypotension to minimize further renal catheter) ○ Secure the catheter to the exit site using
compromise. • Subcutaneous leakage/limb edema a purse-string and fingertrap suture.

www.ExpertConsult.com