6EXPERT BASED GUIDELINES Guidelines by an ad hoc European committe on elective chronic peritoneal dialysis in pediatric patientsWatson, on behalve of the European pediatric dialysis working groupComprehensive pediatric nephrology Geary Schaefer
11Preparation of the patient and the family 1) It is essential that the child and family are prepared by a pediatric nurse experienced in chronic peritoneal dialysis with access to appropriate written information and other teaching aids such as dolls or videos.2) If the child has phobias then a child psychologist should be consulted3) Home visit / School visit4) Contact with other child /parents
12Preparation of the patient and the family A nutritional assessment will be required for all dialysis patients. If nutritional support is required then the appropriate route for supplementation (oral. Nasogastric or gastrostomy) should ho discussed with the pediatric renal dietitian and team members.If it is appropriate to consider a gastrostomy then this can be placed at the time of the PD catheter under the same anaesthesie with minimal additional morbidity.-
13Use of Catheter and Surgical Procedure The placement of a peritoneal dialysis catheter requires an experienced surgeon and should be given appropriate priority,A dialysis-catheter is a “LIFE”-line..with only few alternative options during the life-span of the patient.“early days” nephrologist was in the theatre..Now???
14Use of Catheter and Surgical Procedure Open techniqueLaparoscopic techniquePercutaneous technique
15Use of Catheter and Surgical Procedure 2) Double cuff curled catheters are preferred in most childrenpediatric size in patients 3-10 kgs body weightand adult catheter >10 kg.A single cuff catheter may be needed in infants <3kg.Data from the NAPRTCS registry suggestswan neck tunnels,two cuffand downward pointing exit sites.
16Use of Catheter and Surgical Procedure 2) Presumed advantages of curled cathetersbetter separation between abdominal wall and bowelMore catheter holesLess inflow painLess tendency for migrationLess prone for omental wrappingPotentially less trauma to the bowel
17Use of Catheter and Surgical Procedure Prior to theatre the exit site for the catheter should be agreed with the child and marked on the abdomen by either the dialysis nurse or surgeon.The exit site should avoid the belt line and be above the nappy or diaper line in infants.In all but the smallest infants the exit site should he downward facing.The exit site should be located as far as possible from other exits, ie gastrostomies, colostomies, urostomies to prevent infections.
19Use of Catheter and Surgical Procedure Laxatives should be given pre-operatively to children who suffer from constipationEmpty bladderPartial omentectomy may reduce postoperative obstruction but there are no prospective pediatric series addressing this issue.Consider elective herniotomv if any evidence of inguinal or other hernia prior to or during catheter placement.
20Use of Catheter and Surgical Procedure Entry into the peritoneum should be lateral or paramedianwith the deep cuff outside the peritoneum.The peritoneum is closed tightly around the catheterBelow the level of the deep cuff using a purse string suture.A tunneling device with a sharp point is recommended for creating the catheter tunneland strict haemostasis is required.No incision should be made at the exit site.The subcutaneous cuff should be at least 2cms from the exit site.A cephalosporin antibiotic should he given intravenously at the time of catheter implantation.
21Procedure in Theatre1) Catheter should be tested in theatre for patency and leaks with dialysis nurse or nephrologist present.2) No suture should be placed at the exit site which should be downward facing with the possible exveption of infants.
22The catheter will be irrigated in theatre until the dialysate is clear then capped off. The PD fluid should contain Heparin 5OOiu/L.Catheter must be immobilised at all times and no keyhole dressing applied.If the catheter has to be used for immediate dialysis then use only low volumes, 10ml/kg/cycle. In this situation keeping the patient supine for the first few days and adequate analgesia will also help to avoid high intraperitoneal pressure and possible leaks.If possible leave catheter for two weeks until the patient returns for training. This will allow initial healing to take place.
23IMMEDIATE POST OPERATIVE CARE Pain controle.Multiple low volume exchanges until clear effluent.Dry abdomen as long as possibleDressing is remained for 5 days.Bedrest for 7 days.
24FIRST WEEK POST OPERATIVE CARE Remove primary dressing at day 5Exit site care done by an experienced nurse.Secure normal position of the catheter.Avoid lifting.Allow catheter to heal as long as possible.
25Forbidden: - to take a bath - to swim - contact sports (football…) GENERAL INSTRUCTIONSForbidden: to take a bath to swim contact sports (football…)Advice against: sand (beach) intensive sports (basket ball…)Tollerance of: shower
26CONCLUSIONS Catheter complications are to be expected when dressing is not remained intact for 5 to 7 day (difficult healing - tunnelinfection)immediate use of the catheter (leakkage)poor fixation (difficult healing and outgrow cuff)Catheter characteristics are to be respected:to prevent malpositonto prevent outgrow cuffExit site care is extremely important:to prevent infectionto assure a long life of the access
27THE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCE
28EVIDENCE / CONTROVERSY SOME THINGS ARE WRONGSOME THINGS ARE GOODMOST THINGS HAVE GOOD AND BAD POINTS..where the final decision balances, depending on “choices” made
29Fistula superior to catheter ? YesBut if you choose for nighttime dialysis… not possible (A. Raes oral presentation ESPN)
30Fistula superior to catheter ? YesIf you are goingfor pre-emptive transplantation,and waiting list is rather short..And time to start dialysis is not predictable
31Integrated care model (Van Biesen) Every patient with CKD.. may need every method for renal replacement therapy such asPeritoneal dialysisTransplantHemodialysisRetransplant…
32Integrated care model (Van Biesen) Peritoneal dialysisIs probably not the best choice in adultsIf there is no residual renal functionIf BSA / BMI is very highIDDM??So PD… and PD catheter is treatment of choice in children becauseyou preserve vascular access for later
33Acute dialysis Hemodialysis Catheter Single / double Lumen Genius… then double lumenFemoral catheterOften the choiceTo not interfere with other central catheters
34Acute dialysis Peritoneal catheter Surgical Percutaneous Tenckhoff Often time… to surgery is longPercutaneous TenckhoffAdults good experienceIn children few reportsSeldinger place acute catheter (pigtail) (Buchmann, Vande Walle adv Perit Dialysis)Especially in small childrenCardiac surgeryTo gain time when there is hyperkaliemia (Start dialysis in 10min)Two catheter techniqueContinuous flow dialysis (Vande Walle Adv Perit Dial)