Case – Peritoneal Dialysis - PD 20 kg child with sepsis and oliguria on norepinephrine with a BP of 95/45 post-operative cardiac Vent at 70% FIO2 and a PEEP of 8 FO at 15% K of 6 meq/dl and a BUN of 100 mg/dl

Peritoneal Dialysis in PICU London Peritoneal Dialysis in PICU Dr Mignon McCulloch Evelina London Children’s Hospital, Guy’s & St Thomas’ Trust, London UK

PD access PD catheter inserted by cardiac surgeons at time of surgery in theatre/OR Elective PD started on return to PICU Many cardiothoracic units work on this principle PD catheters do not often work – in view of positioning

ACUTE PERITONEAL DIALYSIS Mignon McCulloch Departments of Paediatric Nephrology & PICU Red Cross Children’s Hospital & University of Cape Town

PD catheter inserted in theatre/OR Experienced Paediatric surgeon under laparoscopic technique Formal Tenckhoff catheter – straight/pig tail/swan neck Omentectomy and identify any adhesions Pexy catheter to pelvis by suture loop Tunnel catheter Achieve haemostasis

Practicalities of PD – access and location Bed-side insertion by Paeds Nephrologist/Intensivist/Surgeons (Surgeons as backup) Cook/Peel Away Tenckhoff/Formal Tenckhoff Position Abdominal wall midline or lateral iliac fossa Avoiding inferior epigastric vessels Empty Bladder first Sedation + Local Anaesthetic Independent person managing the airway

Types of PD catheters - size Formal PD Catheters Cook Multipurpose Catheters Peel-away’ Tenckhoff

Continuous flow PD Performed with two bedside placed catheters: the first conventionally placed in the midline below the umbilicus the second one placed midway between the superior iliac crest and the umbilicus

Practicalities of PD Prescription Dialysis fluid Start off with 10-20ml/kg fluid per exchange – 200 – 400ml per exchange Increase as tolerated to 50ml/kg - Adapted to ventilatory requirements Dialysis fluid Lactate buffered – Dianeal or Bicarbonate based - Bicavera Weak 1.5%/Medium 2.5%/Strong 4.25% ‘Home-made solutions’ – Ringers and 50% Dextrose Cycles: Fill/Dwell/Drain 10/30-90/20mins

Modalities – Automated - > 5kg Home choice - Baxter Sleep safe - Fresenius

Modality - Manual Dialysis < 5kg

What is your prescription Over what period of time do you remove fluid Usually continuous PD over 24hrs Variable depending on peritoneum – rate of equilibration Review on a regular basis 4-6hrly - can be surprised by volumes that can be UF’d How do you dose Medications & Heparin into bags Heparin in all 500-1000units/litre Cefotaxime/Vancomycin stat dose Antibiotics into bags – pending sensitivities Alterations according to drugs being dialysed off***** Nutrition Makes space for fluid Neonates in particular – can use strength of bags for maintaining glucose when total fluid requirement is severely restricted E.g. would not normally manage 40ml/kg without hypoglycaemia

Malawi

Improvised equipment and solution used in the procedure Art of Medicine? Innovative and Creative Cannulaes Naso-gastric tubes/Chest Drains Venous Central lines Rigid ‘Stick’ catheters ‘Peel away’ Tenckhoff Flexible Multi-purpose drainage catheters Auron A et al Am J Kidney Dis 2007

Appropriate Research for Africa Tim Bunchman pic IMG_5847.JPG

What is your dialysate/convection flow rate? Modality PD CFPD BFR 10-20 mls/kg/pass 20-40 mls/kg/pass Dialysis Flow Rate 0.5-2 liters/hr Convective Flow Rate Systemic Anticoagulation none Thermic control partial Ultrafiltration control Solutions Industry made Drug clearance Continuous Nutritional clearance Hemodynamic stability (1 best; 4 least) 3 2 Solute clearance 5 4