Continuous ambulatory peritoneal dialysis

Continuous Ambulatory Peritoneal Dialysis (CAPD) lets people with end-stage kidney disease take care of their dialysis needs in the community

  • Uses peritoneal membrane — body's own naturally occurring semi-permeable membrane that lines the abdominal cavity
  • Fluid is introduced into abdominal cavity through permanent PD catheter
  • Excess water and solutes (body wastes) removed when fluid drains out
  • Exchange of fluids occurs through one of a range of manual or automated methods and regimes
  • Each exchange has a drain, fill and dwell phase

Attention

  • Always shared care with peritoneal dialysis/renal unit
  • Management plan should include how and when to contact the unit
  • Biggest risk to patient is peritonitis. Usually caused by contamination of CAPD system. Can be life threatening, lead to dialysis failure
  • If 3 or more contaminations in 6 months — peritoneal dialysis/renal unit consult

Contamination of CAPD system

Contamination of patient line

Main causes of contamination

  • Most common — breakdown of sterile technique due to touching any of 
    • End of transfer set/extension line when disinfection cap off
    • Inside of disinfection cap
    • Patient connection part of peritoneal dialysis solution set
  • Using out of date stock
  • Using equipment that doesn't have protective cover/cap
  • Breakages in any part of delivery system
  • Failure to use aseptic technique when injecting additives into peritoneal dialysis bags

What you do

If you suspect contamination of CAPD system

  • Clamp PD catheter until transfer set/extension line changed or repaired
    • Use white PD catheter clamp
    • OR plastic scissor clamp with gauze between jaws and PD catheter
  • If person hasn’t taken antibiotics from kit and didn’t bring them to clinic — renal unit consult for antibiotics order. Give immediately
  • Work out how contamination happened, then decide what to do next
  • Contact renal dialysis unit or on-call renal registrar/nephrologist if
    • Contaminated fluid could have entered peritoneal cavity — must be drained out and fresh exchange performed
  • Transfer set/extension line must be changed due to any of
    • Set/line split
    • Disinfection cap off and end of set/line (dark blue piece) exposed
    • Exposed end of set/line (dark blue piece) touched
    • Set/line fallen off PD catheter at titanium connector

Hole or split in PD catheter
  • Will be wet clothing — fluid leaking from tubing
  • Caused by
    • Accidentally cutting catheter. Do not use scissors or sharp objects near catheter
    • Catheter caught in zipper
    • Catheter weakened by cleaning with alcohol wipes
    • Kink at titanium adaptor if taped incorrectly

What you do

  • Clamp catheter on patient side of hole/split —
    • Use white PD catheter clamp
    • OR plastic scissor clamp with gauze between jaws and catheter
  • Peritoneal dialysis/renal unit consult for further advice

Exit site infection
  • Will be discharge/pus draining from exit site
  • May be pain, redness, large amount of crusting
  • PD catheter tunnel tract may also be infected. Redness, pain, swelling over part of catheter under skin
  • May feel unwell, have poor appetite

What you do

  • Peritoneal dialysis/renal unit consult, especially if serious infection
  • Clean exit site with normal saline
  • Milk along tunnel tract, apply firm downward pressure over external cuff
  • Swab purulent discharge that runs out — send for MC&S
  • Continue daily exit site care

Disconnection of line at titanium adaptor
  • Person needs to check that line firmly screwed onto titanium adaptor every day. After daily shower is a good time
  • If line disconnects, peritoneal dialysis fluid will pour out

What you do

  • Clamp catheter close to abdomen 
    • Use white PD catheter clamp
    • OR plastic scissor clamp with gauze between jaws and catheter
  • Cover exposed end with 
    • Gauze — sterile or soaked in povidone-iodine
    • OR disinfection cap
  • Peritoneal dialysis/renal unit consult for antibiotics order and further advice

Peritonitis
  • If you suspect peritonitis treatment must be started urgently — can be life threatening and will not get better without treatment  — Urgent peritoneal dialysis/renal unit consult
  • Caused by
    • Contamination or damage anywhere along CAPD system
    • Accidental disconnection of line at titanium adaptor
    • Exit site infection
    • If female — infection of genital tract
    • Constipation or diarrhoea

Ask

  • If feeling very unwell
  • Fever, uncontrollable shivering
  • Poor drainage of PD fluid
  • Abdominal pain, nausea, vomiting
  • Diarrhoea, constipation
  • If female — vaginal discharge

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Head-to-toe exam with attention to
    • PD catheter and extension line for signs of damage, missing disinfection cap
    • Bag for colour of fluid

Do

  • Alert on-call nephrologist/renal registrar and medical consult about medicines
    • Add IP medicines together to new bag of fluid after drain and 'flush before fill'. Fluid must stay in body for 6 hours
    • Give pain relief
  • If PD catheter damaged, do repair or line change — peritoneal dialysis/renal unit consult
  • Carry out standard bag exchange 
    • If dehydrated — use low strength glucose 0.55% (white ring pull)
    • Reduced volume may help abdominal discomfort

If fluid cloudy — take sample from bag

  • Hang drain bag for at least 15 minutes
  • Wipe bung of each culture bottle with alcohol wipe. Use new wipe for each bottle
  • Wipe sampling port with new alcohol wipe
  • Take 
    • 1 x aerobic blood culture bottle (room temperature)
    • 1 x anaerobic blood culture bottle (room temperature)
    • 1 x EDTA tube (fridge not freezer)
    • 50mL in 'red top' (gamma sterilised) specimen container (fridge not freezer)
  • Mark pathology form ‘URGENT Notify nephrologist/renal registrar’ send copy to peritoneal dialysis/renal unit. Request 
    • White blood cell and differential count
    • Gram stain
    • MC&S

Other problems

Fibrin in effluent

Fibrin may be seen when peritoneal membrane irritated

  • Usually seen with peritonitis
  • May look like stringy threads in drain fluid, or egg white, or jellyfish as drain fluid cools
  • Can block PD catheter if left untreated

What you do

  • If effluent otherwise clear and good drainage — review in 24 hours
  • If effluent clear and poor drainage — use heparin 1000 unit/L (2L bag needs 2000 unit) in all bags until no fibrin for 24 hours, drainage improved
  • If not sure — peritoneal dialysis/renal unit consult

Difficulty draining in or out
  • Caused by
    • Closed twist clamp on transfer set
    • Closed clamp on drain line
    • Frangible (inline seal) not broken completely
    • Kinks in drain/fill lines
    • Fibrin
    • Not enough gravity for flow
  • May also be
    • Catheter tip floating up out of pelvis
    • Catheter trapped in loop of bowel or fold of peritoneum
    • Constipation

What you do

  • Check tubing. Start from exit site and work outward looking for kinks, closed clamps, unbroken frangible, fibrin in drain fluid
  • Check that infusion bag high enough and drainage bag low enough for gravity to help with filling and drainage. Ask person to stand, move around, bend forward and backward
  • Ask person about recent bowel habits. If constipation — give laxatives
  • If problem persists — peritoneal dialysis/renal unit consult

Fluid leak at exit site

Do not ignore — suspect if dressing and clothes become wet

What you do

  • Clean exit site with normal saline
  • Press firmly along line of catheter toward exit site
  • Put glucose part of a U/A dipstick onto expressed fluid
    • If dipstick positive for glucose — drain fluid from peritoneal cavity
  • Peritoneal dialysis/renal unit consult

Extruded dacron cuff

  • First of 2 cuffs on PD catheter has come out. Part or all can be seen
  • Caused by 
    • Pulling or tugging on PD catheter
    • Exit site infection
    • Poor insertion technique
    • Large weight loss

What you do

  • Secure PD catheter in natural fall line — never let it hang loose
  • Clean twice daily. Never trim cuff back
  • Treat exit site infection if needed
  • Peritoneal dialysis/renal unit consult

Blood in effluent
  • 1 teaspoon of blood in 2L of effluent can look like pure blood, don’t panic
  • Usually caused by
    • Trauma (straining, heavy lifting)
    • If female — period. Peritoneal membrane is open at fallopian tubes
  • Can be sign of peritonitis

What you do

  • Add heparin 1000 unit/L (2L bag needs 2000 unit) to all bags until fluid is clear
    • Can take up to 48 hours
    • Regular dialysis helps remove blood

Nausea and vomiting
  • Can be early indication of peritonitis and can lead to dehydration
  • Can be food poisoning or gastroenteritis. Check other family members

What you do

  • Do bag exchange. If person dehydrated — use 0.55% glucose-strength bag
  • Treat nausea and vomiting. Encourage person to rest, have small frequent sips of water and ice
  • Review in 24 hours. If still unwell — peritoneal dialysis/renal unit consult
  • May need to sample drain fluid

Dehydration
  • May have
    • Low BP, headache, cramps, sunken eyes, dry cracked coated tongue, dizziness on standing
    • Weight below ideal body weight
  • Caused by —
    • Not drinking enough
    • Using wrong glucose-strength bags — too strong
    • Vomiting or diarrhoea
    • Peritonitis, other infection, illness with fever

What you do

  • Check level of dehydration. Increase oral fluids, may need IV rehydration
  • Treat cause of dehydration
  • Use lower than usual glucose-strength bag — 0.55%
    • If not available — use only 1.5%
  • Only do 3 exchanges over next 24 hours
  • Peritoneal dialysis/renal unit consult

Fluid overload
  • May have 
    • Weight above ideal body weight
    • High BP
    • Oedema (fluid build-up) in legs, face especially around eyes
    • Headache
    • Difficulty breathing, especially when lying flat
  • Caused by 
    • Drinking too much, using too much salt
    • Not draining fully
    • Using wrong glucose-strength bags — too weak

What you do

  • Peritoneal dialysis/renal unit or on-call renal registrar/nephrologist consult for advice
    • If severe — can do rapid 4.25% glucose exchanges
  • Make sure full drain occurring. Check person's draining method (technique)
  • Do 5 exchanges in next 24 hours
  • Treat constipation — slows drainage
  • Check urine output — aim for 0.5mL/kg/hr
  • Talk about diet and fluid intake. Advise person to drink less than 500mL/day, stop adding salt to food

Stress and depression

  • Chronic illness, anaemia, doing dialysis 365 days a year, waiting on transplant list, all likely to reduce quality of life, cause stress and depression
  • May have mood swings, lack of interest in anything, feel unable to cope, sleep longer than usual but do not feel rested

What you do

  • Have person talk to someone — friend, partner, nurse, doctor, ATSIHP
  • Contact renal unit. Some have psychosocial support workers, patient groups
  • Review regularly