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Child Health Guideline Identifier

Renal - chronic peritoneal dialysis catheter insertion

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Peritoneal dialysis catheter insertion in the chronic peritoneal dialysis patient

Pre-operative patient preparation

  1.  Admit to ward 26B day prior to surgery
  2.  Record weight and height
  3.  Maintain strict fluid balance
  4.  Chlorhexidine shower night before and morning of operation
  5.  If already established on supplemental feeding can have usual feed until NBM time. Inform dietician patient has been admitted
  6.  Review regular medications and chart as appropriate. Start Nilstat QID if gastrostomy insertion planned at the same time as peritoneal dialysis (PD) catheter insert
  7.  NBM 0200 if on AM list, 0700 if on PM list
  8.  26B staff should ensure Operating Room (OR) peritoneal dialysis kit ready to go to OR to prevent delays when child is called to theatre
  9.  Chart Cefazolin 20mg/kg IV (max 500mg) to be given at induction then 24hrly for a total of 3 doses
  10.  Manual script should be completed before child goes to theatre so catheter flushes can start immediately on return from PACU post op: 1.5% dialysate 15ml/kg x 2 quick in/out flushes. Final flush 1.5% 15ml/kg with heparin 1000iu/litre dialysate. In/out and cap.
  11.  Complete standard pre-op checklist
  12.  IV access and tests required
    1.  Obtain IV access & discuss fluid management for NBM with nephrologist on call
    2.  FBC, Retics,Ret-He
    3.  Clotting: APPT and PR
    4.  Group and hold
    5.  Chemistry: sodium, potassium, chloride, calcium, phosphate, urea , creatinine, bicarbonate, albumin, ALP, iron studies, PTH. (Bloods need to be done on admission and should not be deferred till the day of procedure)
    6.  RBC folate, Vitamin B12, zinc ( if not done in last 6 months)
    7.  25(OH)Vitamin D, TSH, liver enzymes (if not done in last year)
    8.  Abdominal x-ray to check for constipation
    9.  Nasal swab for Staphylococcus aureus surveillance (NOT MRSA)
    10.  Urine specimen if producing urine for microscopy, culture and proteinuria
    11.  Left hand x-ray for bone age & renal osteodystrophy surveillance (if not done in last 6 months)

Supplies for surgery

  1. Operating Room (OR) peritoneal insertion dialysis kit from 26B -
    1. Materials are held in ward 26B room 6.44 in shelves marked "OR Bag and Guidelines", and "Quick Guides" ( guide to flushes in OR)
    2. Bag should contain all materials as per Orange peritoneal dialysis (PD) catheter insertion pack and laminated OR guide for flushes
      1. Ensure that heater pad is returned to 26B
      2. Two kits should be ready at any time. If a bag is used another kit should be assembled before the end of shift
  2. Peritoneal dialysis catheters are kept in OR
    1. Use double cuff catheter for chronic patient (unless <5kg). Downward facing exit site. Avoid exit site in region of potential future gastrostomy, nappy or belt line
    2. If the appropriate length double 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.
  3. See PD Insertion Pack Guide below

Post operative management

  1. Peritoneal dialysis (PD) catheter flushes to be done as prescribed pre op on manual PD form. All PD to be done by PD competent nurses as per paediatric peritoneal dialysis protocols to minimize infection risk. Continue with additional flushes if any concern for persistent debris or heavy blood staining of effluent. Discuss early with renal team if:
    1. Inflow time >10minutes/ outflow time >20minutes
    2. PD fluid heavily blood stained after 3 flushes
    3. Clear fluid is leaking out the exit site or operative sites that tests positive for glucose on urine dipstick
    4. Any other concerns re catheter function
  2. Once catheter is capped off, if renal function is stable, aim is to not use the catheter for 2 weeks to allow full healing
  3. Analgesia - Chart regular paracetamol for 48hours and up to 3 doses of IV Fentanyl: 0.25mcg/kg Max dose 30mcg) Q 15 min PRN. If further analgesia required, the patient should be reviewed by RMO first. 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.
  4. Continue IV antibiotics for 2 further doses (24 hourly). If longer add Nystatin prophylaxis
  5. Exit site dressing :
    1. Check exit site and ensure dressing fully occlusive - change or reinforce immediately on return from OR if required.
    2. Post op visible to be kept dry and remain in situ for 7 days unless excessive ooze or dialysate leak is compromising seal. Change dressing as per weekly exit site dressing protocol only on instruction from renal nurse specialist or nephrologist.
    3. Ensure Flexitrak in situ. Immobilisation of catheter is crucial to minimizing catheter related complications.
    4. NO showering or baths for 2-3 weeks while catheter heals but daily sponge baths avoiding the exit site must be done.
  6. Laparoscopic / incision site dressings:
    1. To remain intact for 7 days unless saturated with fluid / blood in which case notify the surgical registrar on call.
  7. Feeds - to be restarted or initiated as per renal consultant and dietician.
  8. Staphylococcus aureus nasal carriers: If nasal swab comes back positive start 5 days BD mupirocin to both nares to eradicate.

Peritoneal dialysis insertion pack guide

Contents:
- 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:\\ahsl6.adhb.govt.nz\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 andL:\everyone\paediatric nephrology\medical protocols
  • Bleeding associated with uraemia may respond to DDAVP - IV 0.3 microgram/kg (max 20 microgram) repeated if necessary.

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Document Control

  • Date first published: 17 February 2017
  • Date last published: 17 February 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Nephrology, Paediatric Surgery
  • Author(s): Neil Price, Tonya Kara, Jane Ronaldson, Georgina Yonge
  • Owner: Paediatric Nephrology
  • Editor: Greg Williams
  • Review frequency: 2 years

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