1. Complications of Dialysis
Presented by :
Saud Mahmoud RN BScN

2. Complications of Dialysis
Infectious
Non Infectious

3. Patient Assessment Daily weight Blood pressure lying and standing
Physical assessment observing for signs fluid overload /dehydration
Temperature
Blood chemistry
Observe for complications

4. Patient Assessment cont

5. Patient Assessment Ask patient about bowel habits
Check if patient has urine output
Check exit site on admission
Culture if infection suspected
Check clarity of PD fluid

6. Infectious Complications
Peritonitis
Exit site infection
Tunnel infection

7. Definition:
Peritonitis is a generalized or localized inflammation of the peritoneum.
This condition most often results from contamination and may be a complication of one of the following:
Diverticulitis
Colitis
Peritoneal Dialysis
Appendicitis

8. Causes of Peritonitis
Organisms enter the peritoneum in various ways namely:
Intraluminal - infections travel to the peritoneum via the catheter. Touch contamination or damaged PD systems are examples of this method of entry.
Per luminal - – bacteria entering the peritoneum via the peritoneal tract or tunnel, e.g. exit site infection.

9. Causes of Peritonitis
Tran mural - bacteria enter the peritoneum through the bowel wall, e.g. constipation.
Hematogenous - infections come from the blood stream.
Transvaginal - organisms can travel through the reproductive tract.

10. Common Organisms Gram Positive: Organism Port of Entry Information
Diptheroids
Intraluminal
Periluminal
Normal Skin flora – poor hygiene / break in technique and poor handwashing
Enterococcus
Transmural
Fecal organisms, sometimes hospital acquired – cross contamination
Staphylococcus Aureus
Nasal Carrier
Staphylococcus Epi
(Coagulase negative staph)
Due to break in technique (touch contamination)
Streptococcus
Hematogenous
Found in soil, water, vegetation and dairy products. Normal GI flora and respiratory tracts

11. Common Organisms Gram negative: Organism Port of Entry Information
Acinetobacter
Intraluminal
Periluminal
Found in soil, water and sewage
Enterobacteria
Transmural
Indication of fecal contamination
Escherichia (E.Coli)
Found in nature, animal and human intestinal tract
Hemophilus
Organisms from this species are normal of the upper respiratory tract

12. Common Organisms Gram negative: Organism Port of Entry Information
Klebsiella
Intraluminal
Periluminal
Normal flora of the GI tract, colonization of the upper respiratory tract
Proteus Species
Transmural
Found in soil, water and sewage. Normal fecal flora
Pseudomonas
Found in soil and water
Serratia
Hospital acquired

13. Common Organisms Yeast: Mycobacterium: Organism Port of Entry
Information
Candida Albicans
Intraluminal
Periluminal
Transvaginal
Diabetes, those on antibiotics at high risk. Moist exit sites
Organism
Port of Entry
Information
Mycobacterium TB
Hematogenous
Diagnosis: lymphocytes in PD fluid cell count often elevated.

14. Peritonitis

15. Signs and Symptoms Cloudy fluid +/- Fever Abdominal pain
Nausea/ vomiting

16. Classification of Peritonitis
Recurrent Peritonitis - an episode that occurs within four weeks of completion of therapy of a prior episode but with a different organism.
Relapsing Peritonitis - an episode that occurs within four weeks of completion of therapy of a prior episode with the same organism or one sterile episode.

17. Classification of Peritonitis
Refractory peritonitis - failure to respond to appropriate antibiotics within 5 days. Recommendation – catheter removal to protect the peritoneal membrane for future use.
Re-infection - new episode 4 weeks after completion of treatment.

18. Nursing Intervention Obtain dialysate effluent from the first bag
BFH (body fluid hematology) Lavendar tube
Gram stain & culture ( send whole bag)
Strict aseptic technique with collection
Specimens sent to lab STAT

19. Immediate care Specimens sent to lab STAT Perform 3 quick flushes
4th bag add the loading dose of antibiotics and heparin as prescribed
The loading dose must dwell for 6 hrs

20. Diagnosis BFH - White cell count >100mm3 Polymorph more than 50%
Gram stain – positive
Culture
Cloudy effluent and abdominal pain

21. Effective Culture Technique
Solution must dwell in peritoneum for at least 4 hrs prior to sampling
Mix effluent well before sampling
Obtain sample aseptically Send a large volume to lab > 50ml (for centrifuging and performing a gram stain on sediment) preferable to send whole bag
Inform lab if patient has received any antibiotics within the last week

22. Management Do not leave patient on extended drain.
Empirical antibiotic therapy to start
as soon as possible as per standing order for suspected peritonitis
ISPD recommendations 2005

23. Management
Antibiotic therapy will be adjusted according to the organism
Patient to be taught to add own meds as soon as able to do so
Re-evaluation of technique

24. Exit Site Infection Exit site infection Signs and symptoms
Inflammation at the catheter exit site
Redness and pain
+/- purulent discharge

25. EXIT SITE INFECTION

26. Risk Factors Trauma e.g. excessive manipulation of catheter
Cuff extrusion
Staph Aurous nasal carrier
Leak at exit site
Skin breakdown

27. Management Minimum of twice daily dressing
Use Normal saline ( no spirit based lotions)
Topical antibiotic – Gentamicin cream
IP / Oral antibiotics
Assess response to antibiotic therapy
Keep exit site clean and dry ( no showering)
Shave the cuff if exposed

28. Tunnel Infection
Infection in subcutaneous tunnel between exit site and peritoneum.
Signs and Symptoms:
Redness along tunnel
Purulent discharge
Pain tenderness along tunnel
Abscess over tunnel
Exit site infection and or peritonitis
present

29. References