1. 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

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

3. 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

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

5. 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

6. 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

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

8. 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

9. 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

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

11. Modality - Manual Dialysis < 5kg

12. 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 units/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

13. Malawi

14. 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

16. Appropriate Research for Africa
Tim Bunchman pic
IMG_5847.JPG

17. 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