Peritoneal Dialysis - Acute Title of Guideline (must include the word “Guideline” (not protocol, policy, procedure etc)

Guideline for the nurses undertaking acute peritoneal dialysis in children and infants.

Contact Name and Job Title (author)

Roy Connell – Clinical Nurse Specialist Molly McLaughlin – Renal Critical Care Educator Directorate & Speciality

Family Health – Paediatric Nephrology Date of submission

January 2015 Date on which guideline must be reviewed (this should be one to three years)

January 2017

Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis)

Children and Young People treated with peritoneal dialysis under the care of the Children’s Renal Unit, Nottingham Children’s Hospital.

Abstract

This guideline describes the Assessment, set-up and management of acute peritoneal dialysis in paediatric patients.

Key Words

Dialysis, Peritoneal, Acute, Child, Young Person, Renal.

Statement of the evidence base of the guideline – has the guideline been peer reviewed by colleagues?

1b

Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well –designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer

Children’s Renal Unit guideline review. Paediatric Clinical Guidelines Group Clinicians and healthcare professionals caring for children and young people treated with peritoneal dialysis at Nottingham University Hospitals NHS Trust

Consultation Process Target audience

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

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Document Control

Document Amendment Record Version V1 V2 V3

Issue Date January 2011 January 2013 January 2015

Author Roy Connell Roy Connell Roy Connell

General Notes: Summary of changes for new version: Nursing procedures removed and replaced with links to appropriate documents.

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These guidelines are to be used by nurses undertaking acute peritoneal dialysis in children and infants in any clinical setting. Initial treatment will be commenced by the on-call paediatric Nephrologist. The on-call paediatric renal nurse will also be informed and can be available to commence treatment if required. The nurse will also be available for telephone advice thereafter. After the patient has been seen and assessed by the paediatric Nephrologist on-call and peritoneal dialysis has been prescribed, these guidelines should be adhered to unless instructed otherwise by the Nephrologist on-call. The weight and fill volume of the child will determine whether a manual PD set or Homechoice machine will be used to perform the dialysis. However, for insertion of the catheter and the first 12 – 24 hours of therapy, it is recommended that a manual set be used for all patients to make assessment and troubleshooting easier. 

Fill volumes below 100mls will require a manual PD set.



Fill volumes 100mls - 500mls will require Homechoice Pro (low fill mode).



Fill volumes above 500mls will require Homechoice Pro (standard mode). (all peritoneal dialysis equipment and consumables are available from Ward E17)

Contents Section 1: Catheter selection .................................................................................. 4 Section 2: Dressing, Exit site and Immobilisation. ................................................ 4 Section 3: Choice and composition of PD fluids. .................................................. 4 Section 4: Calculating therapy. ............................................................................... 6 Section 5: Adding heparin to PD fluid. ................................................................... 7 Section 6: Adding Potassium to PD fluid. .............................................................. 7 Section 7: Adding Sodium to PD fluid. ................................................................... 7 Section 8: Adding Antibiotics to fluid. ................................................................... 8 Section 9: Setting up PD .......................................................................................... 8 Section 10: Flushing a PD catheter ......................................................................... 9 Section 11: Trouble shooting .................................................................................... 9 Section 12: Infection ............................................................................................... 13 Section 13: References ........................................................................................... 14 Appendix 1................................................................................................................ 15

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Section 1:

Catheter selection

The majority of acute patients now have a ‘long term’ PD catheter inserted surgically under GA. The current catheter of choice is a double cuff, coiled swan-neck catheter. Three sizes   

Infant (Flexneck) Paediatric Adult

size 23cm size 42cm size 62.5cm

priming volume – 1.7mls priming volume – 2.4mls priming volume – 3.6mls

Nb: Priming volume is catheter only. Not inclusive of extension set. It certain situations, it may be necessary to insert an acute PD catheter. When this is required the consultant undertaking the procedure will select the appropriate type and size of catheter. Section 2:

Dressing, Exit site and Immobilisation.

After the catheter has been inserted, it will need to be dressed and immobilised appropriately. Dry, non-occlusive dressings are recommended. If possible the initial dressing should remain undisturbed for 5 – 7 days. If oozing and/or bleeding occur, the exit site should be cleaned with Normasol and a new dry dressing applied. Silicone catheters are flexible and will exit the abdomen flush with the skin. They can therefore have a dry Mepore dressing applied and a Technol tube holder used to anchor it. Section 3:

Choice and composition of PD fluids.

A wide range of commercially made peritoneal dialysis fluids are available with varying compositions. To avoid confusion in this area only two are stocked but others are available at short notice if required. Dianeal PD4 is at present the routine solution of choice for both hospital and home peritoneal dialysis. The buffer solution in Dianeal is lactate, which in normal circumstances would be well tolerated but can become a problem with certain patients. Lactate is converted into bicarbonate mmol for mmol as long as the Liver is functioning normally. Neonates may be particularly intolerant of lactate because of the severity of illness and immature livers. For patients who have immature livers or are already suffering from a lactic acidosis, bicarbonate based fluids may be required. Pure bicarbonate based fluids can be hand made on the unit or in pharmacy if required and can be tailor made to suit the patients needs. It is recommended that the fluid should be made in a sterile production area. Unit prepared solutions are

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however, time consuming and require more frequent changes and blood tests. Commercially available reduced lactate fluid is now available in the form of Physioneal 40 and is suitable for most neonates. As well as the obvious advantages of the reduced lactate buffer, Physioneal 40 has also been shown to reduce pain on infusion during dialysis. The composition of P.D. solutions currently recommended for the use in acute patients are;  Dianeal PD4 Available in 1.36%, 2.27% & 3.86% glucose concentrations. Sodium 132 mmol/l Calcium 1.25 mmol/l Magnesium 0.25 mmol/l Chloride 95 mmol/l Lactate 40 mmol/l Osmolarity 344, 395 & 483 mOsmol/l. PH 5.3  Physioneal 40 Available in 1.36%, 2.27% & 3.86% glucose concentrations. Sodium 132 mmol/l Calcium 1.25 mmol/l Magnesium 0.25 mmol/l Chloride 95 mmol/l Bicarbonate 25 mmol/l Lactate 15 mmol/l Osmolarity 344, 395 & 483 mOsmol/l. PH 7.4 Other fluids available: Physioneal 35 -

Higher calcium (1.75mmol/l) and magnesium (0.75mmol/l) Lower lactate (10mmol/l) than Physioneal 40.

Specially prepared pure bicarbonate based solutions can be made. See appendix 1. Bags can be changed using a strict aseptic non-touch technique at any time without having to change the whole manual set.  Bags should be changed routinely every 24 hours  The whole PD set changed every 48 hours. (24 hours if infected)

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Section 4:

Calculating therapy.

Cycle = Fill / Dwell / Drain. Fill. This is when the prescribed amount of dialysate fluid is infused into the patients peritoneum. Dwell This is the length of time the dialysate fluid stays in the peritoneum. Drain This is when the dialysate and any extra fluid removed from the patient are taken out of the peritoneum. Fill volumes Fill volumes in acute patients are calculated as ml/kg. As an initial therapy, it is advisable to commence on 10 – 20 ml/kg. This can be increased slowly dependent on patient tolerance. A fill volume of around 30 – 50 ml/kg is usually well tolerated and should provide adequate dialysis. Dwell times Dwell times can vary throughout a patient’s treatment and it is advisable to check blood chemistry levels at least twice a day in order to adjust the dialysis to meet the patient’s requirements. As a starting point, hourly cycles are usually prescribed.  When using a manual PD set this will give a 5-minute fill, 45-minute dwell and a 10-minute drain. When making adjustments to dwell times it is not necessary to alter fill and drain times unless needed.  When using the Homechoice machine, the dwell time is automatically worked out using a calculation of the fill volume, total therapy volume and the therapy time. The formula below can be used to calculate the total therapy volume based on hourly dwells and continuous therapy.

Fill volume x 24 = Total therapy volume. Nb: see ‘Setting up the Homechoice’ for how to program and examples of therapies. See section 12 ‘Troubleshooting’ for information on adjusting dwell times.

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ADDITIVES Heparin, antibiotics and electrolytes can be added to new bags at any time. All additives are prescribed in a concentration per litre to avoid errors when different sized bags are used. Adding drugs to PD bags requires 2 staff members (one of whom is IV drug competent) and should be done as a non-touch procedure. A wide range of additives can be added to PD fluid including various electrolytes and drugs. Discussion with your pharmacist is advisable to avoid precipitation. Before adding to dialysis fluid bags, the expiry date, type of fluid and fluid strength should be double checked.

Section 5:

Adding heparin to PD fluid.

The dose of Heparin for PD fluid is 500units/litre – unless prescribed otherwise. Heparin should be added to the PD bags for the first 24 hours of therapy to avoid any problems with blood clots from surgery. It can also be added to the bags if experiencing any problems on drainage or fibrin is visible in the drainage bag. (See also – PD Nursing Procedure.) Section 6:

Adding Potassium to PD fluid.

Potassium can be added to fresh bags at any time and the bag changed without having to change the whole set. It is common to add potassium after dialysis has been running for a while as PD is a very effective way of removing potassium even in an anuric patient. The dose of Potassium is patient and condition dependant. The usual accepted dose for maintenance is 4 mmol/litre. This can vary between 3 – 5 mmols/litre. (See also – PD Nursing Procedure.) Section 7:

Adding Sodium to PD fluid.

In cases of hypernatraemia in patients requiring PD it may be necessary to add sodium to PD fluids to ensure sodium correction does not occur too rapidly. The sodium content of both Physioneal & Dianeal is 132mmol/L, so without the addition there is a significant risk the patient’s serum sodium could drop too quickly. If the patient’s plasma sodium is greater than 150mmol/L it will be necessary to add sodium chloride (5mmol/ml) to bags of Physioneal or Dianeal to prevent a rapid fall in plasma sodium. It should never fall >10mmol/L in 24 hours. (See also – PD Nursing Procedure.)

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Injectable Sodium chloride contains 5mmol/ml of sodium. Target Na+

Addition to 5 litre bag

Addition to 2.5 litre bag

150

18mls of sodium chloride

9mls of sodium chloride

160

28mls of sodium chloride

14mls of sodium chloride

170

38mls of sodium chloride

19mls of sodium chloride

180

48mls of sodium chloride

24mls of sodium chloride

190

58mls of sodium chloride

29mls of sodium chloride

(mmol/L)

Remove same volume from PD fluid bag before addition (i.e. for target 150mmol/L remove 18mls from Physioneal/Dianeal, then add 18mls sodium chloride (5mmol/ml)

Section 8:

Adding Antibiotics to fluid.

Most antibiotics are compatible in PD fluid but if using one that has not been tried before – advice should be sought from pharmacy in case of precipitation. The main reason for antibiotics to be added to PD fluid is to treat peritonitis (see Peritonitis section 12 and Peritonitis in Paediatric Peritoneal Dialysis Patients. Other uses include; Prophylaxis for condition or leakage, Precautionary use due to suspected contamination. (See also – PD Nursing Procedure.) For loading and maintenance doses of antibiotics please refer to Peritonitis in Paediatric Peritoneal Dialysis Patients

Section 9:

Setting up PD

For setting up PD for either manual or Homechoice please refer to PD Nursing Procedure.

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Section 10: Flushing a PD catheter The flushing of an acute PD catheter is done to combat poor filling and drainage caused by a potential blockage and should be done using a strict aseptic non-touch technique. The flushing of a PD catheter should be undertaken after discussion with the paediatric Nephrologist or renal nurse on-call. It should only be performed by central line competent nurses.

Do not aspirate as this can cause damage to the peritoneum.

Section 11: Trouble shooting

Troubleshooting and alarms for the Homechoice are covered in the Homechoice manual. The problems listed below relate mainly to manual set use.

Flow problems: No/reduced flow on fill. Cause Clamped or kinked lines or catheter. Fibrin blockage. - Fibrin is a form of protein that looks like strands of cotton wool.

Position of catheter obstructing drain. Fluid may have fully drained out straight into drain bag because drain clamp not clamped.

Solution Unclamp or un-kink lines. Flush catheter with heparin & NaCl And add heparin to bags. Reposition patient. Clamp drain clamp. Fill and drain patient (no dwell) observing closely for signs of over filling.

No/reduced flow on drain. Cause Clamped or kinked lines or catheter. Fibrin blockage Position of patient obstructing fill.

Roy Connell

Solution Unclamp or un-kink lines. Flush catheter with heparin & NaCl And add heparin to bags. Reposition patient.

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Therapy problems: More fluid removal required. Suggestion Increase strength of dialysis fluid.

Action Add more glucose to bag if using unit prepared solution. Use higher strength bag if using pre-made. Nb: try using a mix of two strengths as opposed to going straight to next one up. Shorten the length of time the dialysate stays in the patient. This can increase the fluid removal but can also have an effect on solute removal. Increasing the amount of fluid going into the patient can sometimes increase fluid removal but should be done cautiously. This will also increase the solute removal.

Decrease dwell times.

Increase fill volumes.

Too much fluid being removed Suggestion. Decrease the glucose concentration.

Lengthen the dwell time.

Roy Connell

Action Add less glucose to the bag if using unit prepared solution. Use a weaker strength bag if using pre-made. Nb: try using a mix of two strengths. Leaving the dialysate in the patient for longer will remove less fluid.

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More clearance of waste and electrolytes required. Urea

One hour dwell times are usually sufficient to remove urea at an acceptable rate. Dwell times can however be lowered to remove more urea

Potassium

Shorter dwell times are required to remove more potassium. Half hourly rapid cycling can be used if required. Continuous dialysis can reduce potassium levels too far and may require adding it to bags.

Sodium

High plasma sodium should be lowered slowly to avoid any adverse effects. 1mmol per hour is a safe reference to use. Very hypernatraemic patients (eg: >150mmols) should have sodium chloride added to the dialysate to avoid lowering levels too quickly.

Calcium

Calcium contents of the unit prepared solutions can be adjusted according to patient’s status. Pre-made solutions are available with different calcium concentrations ranging from 0 – 1.75mmols/litre.

Creatinine

Creatinine is not removed very well during peritoneal dialysis and requires longer dwell times to increase removal. It is however, a useful indicator of kidney function and should be observed in the acute setting for any improvement.

Nb: Unit prepared solutions can be made patient specific if required or additives can be put into pre-made dialysis fluid.

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General problems Pain on infusion: Cause Internal position of catheter.

Solution Tidal dialysis can be tried in order to keep a pool of fluid in the peritoneum and hopefully float the catheter. Change patient’s position.

Intra-abdominal pressure

Air under diaphragm

Repositioning of catheter can be tried if an acute line is being used. Reduce fill volume Cross flow dialysis Usually self-correcting within 30 minutes. Analgesia

Dialysate too acidic.

Cross flow dialysis Switch to a more bicarbonate based fluid. Eg: Physioneal 40.

Pain on outflow: Cause Internal position of catheter.

Solution Tidal dialysis can be tried in order to keep a pool of fluid in the peritoneum and hopefully float the catheter. Change patient’s position. Repositioning of catheter can be tried if an acute line is being used.

Breathlessness: Cause Intra-abdominal pressure P.D fluid passing into chest

Roy Connell

Solution Reduce fill volume Cross flow dialysis Change to extracorporeal therapy.

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Leakage: Leakage is a common problem with acute peritoneal dialysis. The main cause for this is the early use of PD catheters without the recommended resting period enable adequate healing or the use of acute PD catheters, which are inserted directly into the peritoneum without tunnelling. If the entry site of the catheter becomes enlarged due to movement, fluid can easily escape along the tract. The patient then becomes an even higher risk for infection. To avoid leakage the catheter should be well anchored to restrict any movement in the entry site. If leakage occurs a slight pressure dressing should be applied around the site in order to stem the flow of fluid. Nb: the dressing should be weighed prior to application in neonates so it can be reweighed if fluid continues to leak and fluid loss is inaccurate. Suturing around the entry site may be attempted by the medical staff. If leakage continues and becomes a problem then a new catheter should be considered.

Section 12: Infection Patients are at a high risk of infection when receiving acute peritoneal dialysis. This is due to the position and placement of the PD catheter and the flow of a glucose based solution in and out of the peritoneum. Potential sites of infection are the peritoneum (Peritonitis) and the catheter exit site. Observations of these two areas are simple to carry out and can aid quick recovery. Exit site.  The catheter exit site should be carefully examined when changing the dressing. Signs of infection such as redness, oozing, pain and swelling should be looked for and the site should be swabbed if infection is suspected.  Oral or intravenous antibiotics should be prescribed if infection is proved or strongly suspected.  Topical agents such as Mupirocin ointment (Bactroban) can also be used, but long term usage has been shown to cause some resistance. Peritonitis Peritonitis is an inflammation of the peritoneum caused by infection. This infection is can be introduced to the peritoneum in various ways such as:  Contamination  Poor set-up technique  Exit/tunnel infection  Through gut wall.

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See peritonitis guideline for more information. The signs of peritonitis are: o Cloudy fluid o Temperature o Abdominal pain. Advice should be sought if any of these are seen in an acute patient.

Section 13: References Baxter Renal Replacement Product information guide. Baxter Healthcare Ltd 2003. Consensus guidelines for the treatment of peritonitis in paediatric patients receiving peritoneal dialysis. International Society of Peritoneal Dialysis (ISPD). 2012. Advisory committee on Peritonitis Management in Paediatric Patients. Guidelines by an Ad Hoc European committee on adequacy and the paediatric peritoneal dialysis prescription. Fischbach, Stefanidis & Watson. 2002. European Paediatric Peritoneal Dialysis Working Group. Guidelines for children starting or receiving peritoneal dialysis for chronic renal failure. Roy Connell. 2015. (Revised edition) . Schaefer et al. (2007). Worldwide variation of dialysis associated peritonitis in children. Kidney International. 72, pp. 1374-1379.

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Appendix 1

Unit prepared solutions. Take a 1000ml bag of sterile water for irrigation, remove 90mls and discard, then add: Additive

Strength

Sodium Bicarbonate Sodium Chloride

8.4% (1mmol/ml) 30% 18mls (5mmols/ml) 20mmol/10mls 2mls 50% (2mmol/ml) 0.4mls

Potassium Chloride Magnesium Sulphate Dextrose

Volume to add 40mls

50% (0.5g/ml)

30mls

Final concentration 40mmols/litre 90mmols/litre 4mmols/litre 0.8mmols/litre 15g/l (1.5%)

This solution contains: Na 130mmols/litre Cl 92mmols/litre HC03 40mmols/litre Mg 0.8mmols/litre K 4mmols/litre Gluc 1.5% It does not contain phosphate. This can be added in the form of Potassium acid phosphate. It does not contain calcium. This should be administered separately as an infusion of 0.5 – 1.0 mmols/kg/day. The solution may be adapted as required but should be done by somebody familiar with manipulating dialysate fluid contents.

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