Austere peritoneal dialysis

Overview

  • Improvised PD has been done in resource-limited settings such as the earthquakes in Turkey in 1999 and Haiti in 2010
  • Indications in the austere setting are the same in non-austere settings
  • Consider contacting a nephrologist via telemedicine if available

Indications

  • See indications in AKI
  • However, there are certain situations that are more likely in disaster or combat situations:
    • Rhabdomyolysis from crush injuries
    • Severe pediatric dehydration and AKI
    • Toxin clearance

Contraindications

  • No absolute contraindications
  • Relative contraindications include:
    • Recent abdominal surgery
    • Diaphragmatic injury with communication into thoracic space
    • Overlying diffuse abdominal wall infection
    • Known severe peritoneal adhesions
    • Patients with severe respiratory failure that may not do well with intraperitoneal fluid

Equipment Needed

  • Types of possible peritoneal catheters:
    • Flexible Tenckhoff catheter is gold standard, but not available in austere setting
    • Rigid trocar, non-tunneled catheter
    • Improvised: NGTs, suprapubic catheters, pediatric chest tubes, large bore central venous catheters ("Cordis"), pigtail catheters, 8-10 Fr Foley catheters
  • Scalpel
  • Lidocaine
  • Sterile preparation, sterile equipment
  • Ultrasound

Procedure

  • Consider giving preprocedural antibiotics such as ertapenam before start
    • Fungal coverage where suspected to be an issue
    • Ensure sterile technique in creating dialysate
    • Additionally, antibiotics such as cephalosporins can be added to each PD bag
  • Improvised flexible
    • Local anesthesia, then midline incise 2 cm below umbilicus
    • Blunt dissect to linea alba, then puncture through linea alba with rigid catheter, and insert a small volume of dialysate under US guidance
    • Insert a guidewire through the initial catheter, then dilate using Seldinger technique to final catheter
  • Rigid catheter
    • Local anesthesia to area just lateral to umbilicus
    • Advance pointed trocar, directed caudal toward iliac fossa
  • See reference for dedicated tunneled PD catheter insertion

Dialysate

  • Lactated Ringer's is the most readily available IVF and most similar to commercial dialysate fluid, but dextrose must be added to produce an osmotic dialysate
  • Increasing dextrose concentration increases volume removal for hypervolemic patients
    • Commercial dialysates usually have 1.5-4.25% dextrose
    • Generally, dextrose concentrations increase 1% for every 20 mL of D50 per liter
  • 500 units of heparin per liter can prevent PD catheter obstruction
     Peritoneal dialysate.jpg

Dialysis Process

  • Attach threeway stop-cock to improvised catheter
  • Infuse 1-2 L of dialysate in an adult, with dwell time of 2-4 hours, four times per day
    • Smaller volume dwells of 500-1000 mL with 2-4 hours of dwell time may be more appropriate in the austere combat setting
    • In pediatrics, give 10-20 mL/kg of dialysate, with total exchange time of 60-90 minutes, with 30-40 minutes of dwell time\
    • Volume usage per day may range from 4 all the way to 70 L per day depending on targets of therapy
  • Drainage is done by gravity or aspiration
  • Frequently measure electrolytes and BUN/Cr, alongside collecting daily EKGs

Complications

  • Hemorrhage, bowel or solid organ injury
  • Peritonitis, including fungal peritonitis not otherwise covered by prophylactic antibiotics
  • Dialysate leakage, especially in abdominal surgical patients with newly healing abdominal wounds
  • Hydrothorax
  • Catheter obstruction

References

  • Gorbatkin C, Bass J, Finkelstein F, Gorbatkin S. Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management. West J Emerg Med. 2018 May;19(3):548-556.

Authors:

Kevin Lu