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Child Health Guideline Identifier

Renal - acute peritoneal dialysis catheter insertion

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Pre operative patient preparation

  1.  Nil by mouth - establish if not done prior to transfer.
  2.  Record weight and height if available
  3.  Estimate insensible losses at 400ml/m2. If the height is not available use 30ml/kg/day to estimate this. Use this to calculate fluid requirements. Do not use normal maintainance fluid calculations. Fluid type will depend on degree of hyponatremia, hyperkalaemia and acidosis.
  4.  See Starship Clinical Guidelines for acute management of Hyperkalaemia
  5.  Seek senior advice in case of severe Hyponatraemia. In case of symptomatic Hyponatraemia give 1-2ml/kg of 3% saline (in PICU only) and review sodium post dose.
  6.  Maintain strict fluid balance
  7.  Discuss with on call surgical team and anaesthetics. Include most recent results for Hb, Plt and potassium in booking and details of any hyperkalaemia management.
  8.  Consider whether child should be managed in PICU or 26B
  9.  26B staff should prepare Operating Room (OR) peritoneal dialysis kit when decision is made for the child to go to OR to prevent delay when child is called to theatre.
  10.  IV access and blood tests required
    1.  FBC
    2.  Clotting: APTT and PR
    3.  Group and hold
    4.  Gas for rapid result on potassium, HCO3, ionized Calcium if available
    5.  Chemistry: sodium, potassium, chloride, calcium, phosphate, urea , creatinine, albumin
    6.  Stool specimen for E coli if Haemolytic Uraemic Syndrome (HUS) suspected
    7.  Urine specimen if producing urine for microscopy and proteinuria
    8.  Other bloods may be required depending on the underlying cause of the AKI (Acute Kidney Injury/Insult) and should be discussed with on call Renal Consultant. These may include:
      1.  HUS - blood film, LDH, Haptoglobins, glucose, liver function tests
      2.  Suspected vasculitis -Complements, ANA, ASOT, ANCA, ESR, anti GBM

Supplies for surgery

  1.  Operating Room peritoneal insertion dialysis kit from 26B:
    1.  Contact Ward coordinator in 26b if child is in PICU
    2.  Materials are held in ward 26b room 6.44 in shelves OR Bag and Guidelines, and Quick Guides ( guide to flushes in OR)
    3.  Bag should contain all materials as per Orange PD Catheter insertion pack and laminated OR guide for flushes
    4.  Ensure that heater pad is returned to 26B
    5.  Two kits should be ready at any time. If a bag is used another kit should be assembled before the end of shift
  2.  Send NG tube (Corpark 8Fr) to theatre with child if not placed already, or if temporary NG in situ.
  3. Chart Cefazolin 20mg/kg IV 24 hourly for 3 days unless child is already on antibiotics for systemic infection in which case review with on call nephrologist.
  4. Automated Peritoneal Dialysis (APD) - Manual prescription should be completed whilst child is in theatre so dialysis can be setup prior to return from PACU.
  5. Packed red cells and/ or platelets should be sent to theatre if these are low eg in HUS or sepsis. These may need to be given pre operatively but this carries significant risk of precipitating/worsening hyperkaleamia and/or symptomatic fluid overload. Suggested volumes are 10ml/kg for platelets and 10-15ml/kg for packed red cells
  6. Peritoneal dialysis catheters are kept in OR.
    1. Use single cuff catheter for acute patient unless this is thought to be a late presenting end stage patient in which case a double cuff catheter may be requested.
    2. If the appropriate length single cuff catheter is not available then consider an insertion site higher or lower than usual to allow the tip to sit in the pelvis. Avoid cutting additional holes in catheter.
  7. See PD Insertion Pack Guide below

Post operative management

  • Start Periotneal Dialysis (PD) as prescribed, usually 10- 15ml/kg hourly cycles 1.5% glucose. Use chronic PD handwashing protocol to minimize infection risk ( Chlorhexidine 4% handwash and Chlorhexidine handrub)
    • If starting PD in 26B:
      • On APD -bypass first dwell to do quick in and out flush for catheter.
      • If resting or manual 3x in out flushes 10mls/kg then proceed
      • Copy of post op order sheet should be in patient notes
      • Discuss early if inflow time >10 minutes, outflow time >20 minutes or other concerns re catheter function.
      • Discuss adding heparin with renal team if PD fluid blood stained at any point
    • If starting PD in PICU
      • PICU flow sheets (CR5734) used for prescribing and reviewing. This should be completed on the flow sheet daily and include volumes, concentration, dwell times and any drugs to be added to the dialysate:
        - inflow should be recorded on the input row
        - outflow on the output row and will be recorded as total outflow
      • Manual 3 x in-out flushes 10ml/kg then proceed
      • Discuss with medical staff early if inflow time >10 minutes/ outflow time >20 minutes, PD fluid blood stained or other concerns re catheter function.
      • In non - ventilated patient prescribe 10-15ml/kg
      • In ventilated patient - prescribe 10ml/kg as larger volumes may impact on ventilation, causing splinting of the chest wall and decreased compliance of the diaphragm.
  • Feeds - the usual starting renal feed is Kindergen. Volumes of feed will depend on fluid allowance.
  • Analgesia - See Starship Clinical Guideline for  Acute Pain Relief in Children with Renal impairment for additional recommendations and advice. Morphine and NSAIDS should generally be avoided in this group.  Alternatives are Fentanyl and Oxycodone.
  • Continue IV antibiotics for 2 further doses (24 hourly). If longer add Nystatin prophylaxis
  • Dressing:
    • Check exit site and ensure dressing fully occlusive - change or reinforce immediately on return from OR if required.
    • Post op visible to be kept dry and remain in situ for 7 days unless excessive ooze or dialysate leak. Do not change dressing without instruction from renal nurse specialist or nephrologist.
    • Ensure Flexitrak in situ. Immobilisation of catheter is crucial to minimizing catheter related complications.

Peritoneal dialysis insertion pack guide

- 2 x catheter adaptor luer locks
- 2 x 40cm catheter extension lines
- 1 x 1.5% Staysafe balance 2 litre manual bag
- 2 x disinfection caps
- 2 x post op visible dressings
- laminated OR guideline card
Add prior to going to OR:
- Thermosafe manual bag heater
- Staysafe white organiser and grey holder
- 1 x hanging scale

Information for families

Information for families on kidney disorders in children

Other resources and information

  • Starship Clinical Guideline for Acute Pain Relief in Children with Renal impairment
  • Starship Clinical Guideline for Hypertension
  •  Starship Clinical Guideline for Hyperkalaemia
  • Peritoneal Dialysis "how to" guides for flushes and how to flush at luer lock available on ADHB network here: \\\main\Groups\Everyone\POLICY\LocalProtocols\StarshipChildrens\PaedMedicalSpecialties\Peritoneal Dialysis - 26B.pdf
  • Antibiotic dosing in renal failure available on ADHB network here: N:\Groups\INTRANET\Pharmacy\Other documents\GOSH Dose adjustment in renal failure.pdf and L:\everyone\paediatric nephrology\medical protocols
  • For symptomatic hyponatremia - give 1-2ml/kg of 3% saline (in PICU only) and review sodium post dose.
  • For bleeding associated with uraemia consider DDAVP - IV 0.3 microgram/kg (max 20 microgram) repeated if necessary.
  • For further transfusions once dialysis established can use calculator at to estimate volume of blood required.

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Document Control

  • Date first published: 21 February 2017
  • Date last published: 21 February 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Nephrology
  • Author(s): Georgina Yonge, Jane Ronaldson, Neil Price, Tonya Kara
  • Owner: Paediatric Nephrology
  • Editor: Greg Williams
  • Review frequency: 2 years

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