Transcription
Peritoneal Dialysis (PD) Protocols ManualBy: Sonia Champoux B.Sc.(N), C.Neph(C)(PD nurse, Renal clinic)Designed by: Alexander Tom B.Sc.Giuseppe PascaleStaff consultants:Dr. Lorraine BellDr. Martin BitzanDr. Beth FosterDr. Indra. GuptaDr. Paul GoodyerDr. Michael ZappitelliAugust 2018
TABLE OF CONTENT11.11.21.3PRE-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS . 6Purpose: Patient preparation . 6Target audience . 6Elements of clinical activity . 61.3.1 Medication Protocol . 622.12.22.3POST-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS . 7Purpose: Catheter break-in . 7Target audience . 7Elements of clinical activity . 72.3.1 Theory . 72.3.2 Break-In Protocol. 82.3.3 Maintenance phase .102.43Summary Reference Table . 12NON-INFECTIOUS PERITONEAL DIALYSIS COMPLICATIONS . 133.1Purpose: PD complications . 133.2Target audience . 133.3Elements of clinical activity . 133.3.0 Summary of PD Complications and Corrective Measures .143.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK .153.3.2 Protocol for the Treatment of OUTFLOW FAILURE .173.3.3 Protocol for the Treatment of DEHYDRATION .173.3.4 Protocol for the Treatment of FLUID OVERLOAD .183.3.5 Protocol for the Treatment of MUSCLE CRAMPS .183.3.6 Protocol for the Treatment of AIR in the PERITONEAL CAVITY .183.3.7 Protocol for the BLOOD IN PD EFFLUENT .193.3.8 Protocol for the Protein Loss .193.3.9 Protocol for ACCIDENTAL DISCONNECTION (Refer to Section 10.4) .193.3.10 Protocol for PAIN DURING DIALYSATE INFLOW .193.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORINGSYSTEM .203.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING .243.3.13 Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections313.3.14 Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients .3244.14.24.3CHOICE OF PD SOLUTIONS & COMPOSITIONS . 33Purpose . 33Target audience . 33Elements of clinical activity – Summary . 334.3.1 PHYSIONEAL Physiological requirements .344.3.2 Other solutions available: NUTRINEAL .364.3.3 Other solutions available: EXTRANEAL .3755.15.25.3ROUTINE PD CARE, PRECAUTIONS & MISCELLANEOUS INFORMATION . 38Purpose . 38Target audience . 38Elements of clinical activity . 385.3.1 Shower & Bath .385.3.2 Activities & Sports .3966.1BASIC PREPARATION PROCEDURE . 40Purpose . 40Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale2
6.26.3Target audience . 40Elements of clinical activity . 406.3.1 Basic preparation procedure.406.3.2 EXIT SITE CARE – DRESSING CHANGE .4377.1HOMECHOICE CYCLER PREPARATION PROCEDURE . 48Elements of clinical activity . 487.1.1 BAG PREPARATION: Physioneal 5 liters.487.1.1 BAG PREPARATION: Physioneal 5 liters (continued) .517.1.2 BAG PREPARATION: Procedure for adding medication with Physioneal 5 liters .527.27.37.4Purpose . 53Target audience . 53Elements of clinical activity . 537.4.1 CYCLER PREPARATION .53617.4.3 CYCLER PREPARATION – Prime the lines .627.4.4 CYCLER PREPARATION – Nurses Menu .637.4.5 CYCLER PREPARATION – Connection with a PEDIATRIC Cycler Tubing withCassette .687.4.5 CYCLER PREPARATION –Connection with a PEDIATRIC Cycler Tubing .697.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing.707.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choicesystem or CAPD Twin Bag Manual System .727.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system orCAPD Twin Bag Manual System .7588.18.28.3PERITONEAL DIALYSIS BAG PREPARATION . 78Purpose . 78Target audience . 78Elements of clinical activity . 788.3.1 How to ADD a Bag During Dialysis .798.3.2 How to CHANGE a Bag During Dialysis .8299.19.29.3MANUAL CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) . 85Purpose . 85Target audience . 85Elements of clinical activity . 859.3.1 CAPD manual set-up with TWIN BAGS .8610PROCEDURE FOR ATTACHMENT OF EXTENSION TUBING . 9610.1 Purpose . 9610.2 Target audience . 9610.3 Elements of clinical activity . 9710.3.1 How to attach TITANIUM adaptor to Pd catheter .9710.410.5Accidental Disconnection . 98ACCIDENTAL CONTAMINATION . 9910.5.110.5.210.5.310.5.410.6Basic Rules .99Accidental Contamination prior to PD Treatment .100Accidental Contamination at the start of PD Treatment .101Accidental Disconnection Between the Extension and Tubing .102Elements of clinical activityACCIDENTAL DISCONNECTION . 10410.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET .10410.6.2 How to change the Transfer Set and a titanium connector of the PD catheter when itis damaged .107Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale3
11PROCEDURE TO COLLECT A DIALYSATE EFFLUENT SAMPLE . 11111.1 Purpose To maintain an aseptic environment while collecting a dialysate effluent sample . 11111.2 Target audience . 11111.3 Elements of clinical activity . 11111.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag with cycler11211.3.2 How to collect a sterile effluent sample via a seringe attached to the extension .11711.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININECLEARANCE .11811.3.4 How to collect an effluent sample via the PEDIATRIC SETUP .12112SET-UP PROCEDURE FOR A PEDIATRIC MANUAL CAPD SYSTEM . 12212.1 Purpose . 12212.2 Target audience . 12212.3 Elements of clinical activity . 12212.3.1 FRESENIUS STAYSAFE SETUP.12212212.3.2 How to set-up the pediatric manual CAPD system .12312.4How to set-up the pediatric manual CAPD system: Quick reference . 12312.4.1 How to set-up the pediatric manual CAPD system .12512.5 Procedure for Connection/Disconnection with Pediatric Setup - STAYSAFE ConnectionProcedure . 13012.5.112.5.212.5.312.5.412.5.5Purpose .130Target audience .130Elements of clinical activity .130FRESENIUS STAYSAFE CONNECTION procedure .131FRESENIUS STAYSAFE DISCONNECTION procedure .13313PROCEDURE FOR STAYSAFE CATHETER ADAPTER INSTALLATION. 13413.1 Elements of clinical activity . 13413.1.1 FRESENIUS STAYSAFE CATHETER ADAPTER INSTALLATION procedure .13414PROCEDURE FOR HEPARINIZATION WITH PEDIATRIC SETUP . 13614.1 Elements of clinical activity . 13614.1.1 FRESENIUS STAYSAFE SAMPLE PORT CONNECTION PROCEDURE .13615PROCEDURE TO SAFELY DISPOSE OF BIOLOGICAL DIALYSATE EFFLUENT . 13815.1 Purpose . 13815.2 Target audience . 13815.3 Elements of clinical activity . 13816PROCEDURE TO CHART DIALYSIS EXCHANGES . 13916.1 Purpose . 13916.2 Target audience . 13916.3 Elements of clinical activity . 13916.4 PROCEDURE TO CHART DIALYSIS EXCHANGES . 140PERITONEAL DIALYSIS RECORD . 14017PROCEDURE TO MANAGE A BLOCKED PD CATHETER WITH TPA (rt-PA) PROTOCOL(ALTEPLASE) . 14117.1 Purpose . 14117.2 Target audience . 14117.3 Elements of clinical activity . 14118PROCEDURE TO PERFORM A PERITONEAL EQUILIBRATION TEST (PET PROTOCOL) . 14218.1 Purpose . 14218.2 Target audience . 14218.3 Elements of clinical activity . 14218.3.1 How to perform a PET test .143Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale4
19PROCEDURE TO PERFORM AN INTRAABDOMINAL PRESSURE MESUREMENTS (IPP) . 14719.1 Purpose . 14719.2 Target audience . 14719.3 Elements of clinical activity . 147Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale5
1PRE-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS1.1Purpose: Patient preparationThis protocol has been developed to prepare the patient for the OR and minimize the chances of infectionpost-op.1.2Target audienceNursing and medical staff responsible for the care of the peritoneal dialysis patient.1.3Elements of clinical activity1.3.1Medication ProtocolThe following medications should be administered as per instructions listed in Table 1-1.Table 1-1: Medications pre-ORStepMedicationDose1Saline enema untilclear10–20 cc / kg2DDAVP (IV)0.3 mcg / kg in 50 cc NS3CEFAZOLIN (Ancef) 20 mg / kg(IV)4BACTROBAN(Mupirocin)1If needed5 days in the nose Bid2Q month5BACTROBAN(Mupirocin)or Gentamicin3cream If neededSmall quantity at the exit siteMaximum doseInstructionsThe day of surgery or the eveningbefore.Maximum finalconcentration:0.5 mcg / mlMaximum dose :20 mcgTo be given 30-60 min before OR(peak activity at 1 hour).1 gram1 hour pre-op or with induction ofanesthesiaApply for a positive nose culture forstaphylococcus aureus.Only when theexit site is healedRequested by the nephrologistApply for positive culture forstaphylococcus aureus¹ Nasal swab for culture: swab the two nostrils with the same swab. If patient is positive in the nose forS. Aureus, then treat with bactroban² If the patient is using BACTROBAN in the nose,the patient should then be treated the first 5 days of each month bid.Note: Nose cultures are to do be done monthly in the renal follow-up clinic. No more cultures are requiredif staphylococcus aureus carrier status is positive. We should test the care giver as well.3. If positive for S. Aureus, nephrologist should order antibiotic cream as described in the Table 1-1. For all medications listed above, please refer to their policy for indications, contraindications, dosagesand precautions.Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale6
2POST-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS2.1Purpose: Catheter break-inThis protocol has been developed to care for the patient and peritoneal catheter immediately post-OR.2.2Target audienceNursing and medical staff responsible for the care of the peritoneal dialysis patient.2.3Elements of clinical activity2.3.1TheoryThe break-in period refers to the time immediately following catheter insertion.The purpose of the break-in procedure is to:a.clear the intra-peritoneal blood and fibrin from the catheter, andb.minimize the possibility of omental adhesion, andc.reduce the incidence of leakage by maintaining low intra-abdominal pressure.i. Leakage delays the ingrowth of fibrous tissue into the catheter cuff which provides a mediumfor bacterial growth. This may lead to peritonitis or an exit-site infection.ii. Intra-abdominal pressure is minimized by the restriction of: dialysate volume, and patient activity.It is preferable to delay continuous ambulatory peritoneal dialysis (CAPD) (i.e., chronic dialysis), ifpossible for 2 to 4 weeks after catheter implantation.Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale7
2.3.2Break-In ProtocolTable 2-1: Break-In Protocol: Immediate post-insertion period, usually 12-16 hoursStepProcedureInstructions1X-Ray (plain film) To be done in recovery room and should be reviewed. Break-in protocol (i.e.,peritoneal dialysis) can be initiated as soon as patient is back on the medicalnephrology floor.2aRapid in-out exchanges untilclear (about 3 exchanges) byinfusing into peritoneal cavity.These exchanges may bedonea) manually (i.e., nurse infusesdialysis fluid using a “twin bag”system), orb) using the cycler, on “Hidose” mode (or OCPD mode).Done by ward nurse or PDnursePD solution: Suggest using 1.36% physioneal solution unless MD suggestsotherwise.Volume 10ml/kgADD to PD solution:HEPARIN 1000 units/L in dialysate bag250 units/L for NICU & PICU babystContinue adding heparin to the PD solution for the 1 week, then reassessCEFAZOLIN 250 mg/ L for the first 12–16 hrs. Stop the morning post-catheterinsertion. Individualize according to patient’s status.2bWhen dialysate (effluent) isclear, begin hourly exchangesi. 50 min. dwell (including filling time),10 min. drain. Note: when using cycler, the cycler will determine the drain time.2cRepeat cycles hourly for 12-16 Individualize according to patient’s status.hours or less2dRepeat all of Step 2for 8 more hours ONLY IFcriteria to the right is fulfilledi.2eProceed to the MaintenancePhase (i.e., wait for chronicdialysis or if necessary, start) After 12-16 hours of clear & colourless dialysate with appropriate draining.3Prescribe antiemetic PRN fornausea/ vomiting and for painSee nausea and pain post-PD catheter insertion protocol next page.Suggest First line: :Ondansetron 0.1 mg/kg iv every 6 hours PRN orSecond line: Dimenhydrinate 0.5 -1mg/Kg/dose iv every 6 hours PRN4Pain ManagementSee nausea and pain post-PD catheter insertion protocol.Suggest Dilaudid or morphine, depending on age and PO status.5Use stool softenersColace or Docusate: 5 mg / kg / day bidOr Lax- a- DayOnly if after 16 hours there is unclear and/or coloured dialysate and/or withinappropriate draining.Reassess. For all medications listed, refer to their policy for indications, contraindications, dosages andprecautions.Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale8
2.3.2Break-In Protocol (continued)Table 2-1a: Nausea and pain protocol post Peritoneal Dialysis Catheter insertion1Antiemetics First line: Ondansetron 0.1 mg/kg IV every 6 hours PRN (max 4 mg/dose) Second line: Dimenhydrinate 0.5mg/kg/dose PO/IV every 6 hours PRN (max25 mg/dose if less 6 years old; max dose 35mg if 6-12 years old; max dose50 mg if over 12 years old)2aPain managementNon-opioid analgesic 2bPain managementOpioids IVAcetaminophen (refer to MUHC Pediatric drug formulary for updated dosagerecommendations):i.Term infants more than 10 days old and children/adolescents: 1015 mg/kg/dose (max. 75 mg/kg/day) every 6 hours regular for 48hours then PRNGFR 10mL/min./1.73m2, intermittent peritoneal dialysis: adjustadministration frequency to every 8 hours. First line: HYDROmorphonei.0.01 mg/kg IV every 4 hours PRN (For small patient, dilution may berequired for a final concentration of 0.1 mg/mL 2 mg ofhydromorphone in 19 mL of NS) Second line: Morphineii.Avoid Morphine (active metabolites may increase duration of action andincreases risk of accumulation with renal dysfunction). If used, adjustinterval: e.g. 0.03-0.05 mg/kg every 6-8 hours PRN. Evaluate the effectand readjust the dose/interval. Avoid in children less than 3 months old.Max dose 3 mg iv. Antidote for Morphine: Nalaxone 20 kg: 0.01– 0.1 mg/ kg / dose q 3-5 min 20 kg: 2 mg / dose q 3-5 min IV, SC, IM.2cPain managementOpioids ORAL 35 kg: HYDROmorphone 0.03 mg/kg PO every 4 hours PRN (tablet) max dose15 mg 35 kg: Morphine 0.15 mg/kg PO every 4 hours PRN (pill or suspension)Recommendations from APS 2017 05 19Dr Chantal FrigonAnnik Otis CSNPeritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale9
2.3.3Maintenance phaseTable 2-2: Maintenance Phase for patients not in need of immediate dialysisStepProcedureInstructions1Perform an In/Out exchange(zero dwell-time)This will be done by PD nurse,either by manual exchange orusing cycler.i. Once per week (or as assessed by Nephrologist), perform an In/Out exchange(zero dwell-time),Heparinize PD catheter withtransfer set extension orcatheter adapterPatients 15 kg:2ii. Using 15 ml / kg or volume of last fill (e.g., if previous fill volume was 10 ml/kg)of 1.36% Dextrose dialysate (Physioneal).Ideally, if patient’s condition is allowing it, we should not use the catheter for 2weeks to a month for dialysis. The PD nurse should perform an in/out exchangeonce per week. ADD heparinized 1000 units per liter or 250 units per liter forbaby in NICU & PICU to dialysis fluid. We could increase frequency ofexchanges if presence of fibrin.i.Infuse 5 – 10 ml/kg as last fill volume (same solution as box1 of this table)ii. Inject 4.0 cc heparinized saline into the catheter using the syringe that isattached at the end of the Baxter transfer set (MMS 068746)iii. HepNS:Heparin 300 Units/ml concentration for a total of 4.0 cc[ mix: 1.2 ml Heparin (1000 U/ml) 2.8 ml NS ]After HepNS injection, close the system with aproviodine Mini Cap (MMS 023005)Patients 15 kg:i.Infuse 5 – 10 ml/kg as last fill volume (same solution as box1 of this table)ii. Inject 3.0 cc HEPALEAN (100 Units/ml) into the catheter using a syringeattached at the end of the Baxter transfer set (MMS 068746)After HepNS injection, close the system with aproviodine Mini Cap (MMS 023005)NICU & PICU babies: ask nephrologist for heparin concentrationi.Infuse 5 – 10 ml/kg as last cycle volume, (same solution as box1 of thistable)Inject 2.5 cc [25, 50, or 100 Units/mL HEPALEAN]Using the Fresenius Stay-Safe sample port (MMS 91532 )Close the system with a Fresenius Stay Safe Cap (MMS 072101).Should be done by the PD nurse3Notify the nephrologist for any fibrin strands For all medications listed above, please refer to their policy for indications, contraindications, dosagesand precautions.Peritoneal Dialysis (PD) Protocols Manual – revised August 2018 2018 Sonia Champoux B.Sc. (N), C.Neph(C) - Alexander Tom B.Sc. - Giuseppe Pascale10
2.3.3Maintenance phase (continued)Table 2-3: Maintenance Phase for patients in immediate need dialysisStep1ProcedureInfuse dextrose dialysatecontaining 1000 Units/Liter ofHeparin:(concentration ordered bynephrologist).Use dialysate with 250units/Liter of Heparin for theNICU & PICU.InstructionsTime Periodst1 24 hoursnd2 24 hoursrd3 24 hoursthenthenVolume (ml / kg)10 ml / kg,15 ml / kg,20 ml / kg for 4 weeks,25 ml / kg for 1 week,30 ml / kg for 4 -8 weeks.To be reassessed after 8 weeks.If needed, 10 or 15 ml/kg volumes may be continued for a longer period (e.g.,respiratory compromise; leak risk)Notes:i. Ambulation is not permitted when the abdomen is filled with the regular volume for the first 6weeks. Mobilization is permitted if the patient is filled with the last fill.ii. The sitting position is not permitted when filled with the regular volume for the first 2 weeks(except the last low-volume fill).iii. Heparin in the dialysate should be started at 1000 Units / liter for the first week, thennddecreased to 500 Units / litre for the 2 week – if no fibrin. Use 250 units per liter in the NICU& PICU.iv. If there is no presence of fibrin strands or blood clots,Heparin can be discontinued from the dialysis solution two weeks post-catheter insertion.v. CAPD or manual dialysis may be started 2-4 weeks post PD catheter insertion with volumestarting at 20 ml/kgvi. The healing period of the PD catheter exit site may take 6 – 12 weeks. For all medications listed above, please refer to their policy
Peritoneal Dialysis (PD) Protocols Manual By: Sonia Champoux B.Sc.(N), C.Neph(C) (PD nurse, Renal clinic) Designed by: Alexander Tom B.Sc. Giuseppe Pascale Staff consultants: Dr. Lorraine Bell Dr. Martin Bitzan Dr. Beth Foster Dr. Indra.
