Peritoneal Dialysis n'at.

[RustedFox]

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Theres a dearth of threads about actual medicine and current practices on here these days.

Someone please teach me something about peritoneal dialysis. No special reason why other than I resusc'ed a gal from the brink early this morning and got her to the unit (on eleventeen drips; this gal was arguably the sickest patient that I've taken care of as an attending), and she is a peritoneal dialysis with her catheter in her abdomen, etc.

Everyone chime in; students/residents/all welcome. No special direction with this'n. Just "the more you know".

 

[EvoDevo]

Was she septic? Common thing with this kind of dialysis..

 

[RustedFox]

She was multifactorial with regard to acidosis. Hemoglobin was FIVE, sugar was 508. Anuric. Sick as hell for a long time. First lactate was 15 with a pressure in the tank and bradying down. After fluids, pressors, and 2 U pRBCS, I got that lactate down to 11 and the vitals to normalize. She regained responsiveness. My only thought by the time I got her up to the unit (and went home 2 hours after my shift... stayed resusc'ing her) was "yeah... but she's gotta CLEAR that lactate somehow."

 

[Rendar5]

I do know that nephrology and your local dialysis center are your friends =p for accessing the dialysate and for infusing your antibx right into the diasylate. That lactate is still huge, was she on metformin or something?

 

[Hair Police]

Dx is made on >100 WBCs per mm^3 of fluid, clinical features are similar to SBP, usually skin flora. also - the PD catheter caps are generally single-use and hard to find, which makes getting a fluid sample a pain.

 

[Bostonredsox]

when she gets to me I pull the catheter. those PD septic shock bellys are nasty. Put in a temp IJ for HD and let the belly cool down. Vanc/Ceftaz/Metronidazole. usual EDGT protocol.

an interesting pearl I guess as you were asking for general PD info.....it turns out the peritoneal membrane is a far better diasylate filter than fistulas/grafts/HD caths. I have learned that almost all PD patients are on REPLACEMENT K+ as the Peritoneal membrane filters out K+ so much more efficiently than in HD they are invariably all Hypokalemic. There. I learned something on my nephron month don't anyone say I didn't.

 

[RustedFox]

Dx is made on >100 WBCs per mm^3 of fluid, clinical features are similar to SBP, usually skin flora. also - the PD catheter caps are generally single-use and hard to find, which makes getting a fluid sample a pain.

Diagnosis of what, exactly ? (not meant to sound snarky at all, sorry - there's just no easy way to phrase that). Peritonitis in the presence of PD?

 

[dotcb]

Diagnosis of what, exactly ? (not meant to sound snarky at all, sorry - there's just no easy way to phrase that). Peritonitis in the presence of PD?

bacterial peritonitis - like SBP but not exactly spontaneous.

 

[Hair Police]

Diagnosis of what, exactly ? (not meant to sound snarky at all, sorry - there's just no easy way to phrase that). Peritonitis in the presence of PD?

In SBP, the diagnosis is made with >250 WBCs per mm^3 of ascitic fluid. Peritonitis in the presence of a PD cath is diagnosed with >100 WBCs per mm^3. There's a lower limit/tolerance for leuks in PD because of the catheter. Just talking about one condition prompts the connection to another related disease.

 

[Hamhock]

bacterial peritonitis - like SBP but not exactly spontaneous.

Is it not >250 like in SBP?

I actually discharged a 178 tonight! 😱

HH

 

[Hair Police]

when she gets to me I pull the catheter. those PD septic shock bellys are nasty. Put in a temp IJ for HD and let the belly cool down. Vanc/Ceftaz/Metronidazole. usual EDGT protocol.

I would be hesitant to pull the cath right away, given it allows for easy administration of the antibiotics right to the source.

Random guideline that supports my stance: http://www.pdiconnect.com/content/30/4/393.full.pdf

 

[VentdependenT]

She was multifactorial with regard to acidosis. Hemoglobin was FIVE, sugar was 508. Anuric. Sick as hell for a long time. First lactate was 15 with a pressure in the tank and bradying down. After fluids, pressors, and 2 U pRBCS, I got that lactate down to 11 and the vitals to normalize. She regained responsiveness. My only thought by the time I got her up to the unit (and went home 2 hours after my shift... stayed resusc'ing her) was "yeah... but she's gotta CLEAR that lactate somehow."

Shes clearing it thanks to your resuscitation efforts. Brownie points that what youre doing is working. The beans dont help much in the way of lactate clearance. 15 is ridiculously high. Those folks have the Bill and Teds Excellent Adventure grim reaper standing next to them.

Strong work anyhoots. She was really trying to die on you.

I dont see much PD and will have to read more about peritonitis in relation to them.

 

[RustedFox]

Shes clearing it thanks to your resuscitation efforts. Brownie points that what youre doing is working. The beans dont help much in the way of lactate clearance. 15 is ridiculously high. Those folks have the Bill and Teds Excellent Adventure grim reaper standing next to them.

Strong work anyhoots. She was really trying to die on you.

I dont see much PD and will have to read more about peritonitis in relation to them.

Thanks for the warm fuzzy. For realsies.

Someone please post a picture of the Bill n' Ted reaper.

 

[Apollyon]

Those folks have the Bill and Teds Excellent Adventure grim reaper standing next to them.

Dude, Bogus Journey Dude!

 

[RustedFox]

Love the scene where he looks "up" at god, shrugs his shoulders, and says meekly - "They melvin'ed me."

 

[diphenyl]

Love PD myself. There is a general trend toward people doing treatments at home.
Besides their trend towards hypokalemia since it is so efficient, they also have fewer cardiac complications when compared with people with similar disease process that undergo AVF implantation. It's obvious why these people have cardiac complications, we are cutting their life short by creating an arterial-venous fistula.
I do however treat these people when they develop fevers, like ones with a central line. It's a line infection until proven otherwise.

 

[VentdependenT]

love the scene where he looks "up" at god, shrugs his shoulders, and says meekly - "they melvin'ed me."

roflmao

 

[VentdependenT]

From what I was reading you only pull the line if:
-the fluid frm belly still has + cx after several days of peritoneal cavity abx
-recurrent peritonitis
-fungal peritonitis
-line site infection which isnt improving

Yes abx are to be given intraperitonallyv(in this case IV as well)

 

[EM2BE]

From what I learned as well, the goal of PD is 2L off per day.

SBP / BP happens in on average 1x/yr/pt on PD.

Running abx through catheter is efficient (for BP), and if stable, can do this at home as well.

 

[Bostonredsox]

Every case of PD peritonitis I have seen was the second or third for that pt in a given calendar year, because they were all low IQ pts who couldn't dialyse themselves sterily. In the case of multiple catheter infections in one year, the guidelines recommend pulling the catheter and converting to HD. But I should have been clearer, I don't pull the catheter in a pt who is having their first case of PD peritonitis and who I have ruled out an abdominal abscess on ct. If its a repeat offender or theirs an abscess.....catheter comes out.

 

[Rendar5]

Every case of PD peritonitis I have seen was the second or third for that pt in a given calendar year, because they were all low IQ pts who couldn't dialyse themselves sterily. In the case of multiple catheter infections in one year, the guidelines recommend pulling the catheter and converting to HD. But I should have been clearer, I don't pull the catheter in a pt who is having their first case of PD peritonitis and who I have ruled out an abdominal abscess on ct. If its a repeat offender or theirs an abscess.....catheter comes out.

Everywhere I worked, PD patients were always high IQ patients for just that reason. That said, those high IQ patients generally come in before they're ICU sick.

 

[nlax30]

Was she having abdominal pain? Was her belly scanned? Wonder if she was having some intestinal ischemia with a lactic that high.

But peritoneal dialysis is pretty straightforward. A dialysate solution is instilled into the peritoneum and allowed to dwell for certain length of time and then drained. This process is either repeated automatically by a machine overnight or several times throughout the day. Generally the solutions having varying degrees of glucose for hypertonicity that allows for differing amounts of fluid removal and the patient should know which "concentration" of solution they use.

Obviously peritonitis is a concern here. Have also read about a sclerosis phenomenon leading to obstruction.

What were her renal labs like? Usually these folks are fairly well educated on their PD and a close eye is kept on their clearances for signs of ineffective dialysis for any number of reasons (peritoneal membrane not filtering, "pocketing" solution in peritoneum, etc...)

Nephro doc I was on with not long ago liked for his PD patients to have an AV fistula just in case they had to go on HD.....hated catheters.

 

[dryhops]

Had a pt like this on inpatient med. Few things that I learned/did:
- Vanc/gent given IV for first dose (as per renal/green book). Random levels were measured and the following doses were given IP during PD.
- As above, you can still do PD w/ an infected peritoneum.
- The longer the infection brews, the higher risk for fibrotic changes of the peritoneum. This becomes a problem because a patient might want to get back onto PD in the future and there is poor exchange through a fibrotic peritoneum.
- Constipation worsens mesenteric blood flow required for effective dialysis and should be treated aggressively.
- Our patient had to have the PD catheter surgically removed because of the way it was inserted. If in doubt, don't just pull it because you might get more than just PD catheter back. Like abdominal wall.
- Consider giving a dose of Fluconazole 200 in the ED (if pt will be admitted) to start fungal ppx since they will be on some heavy duty abx.