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- Using out of date stock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