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. Gupta Dr. Paul Goodyer Dr. Michael Zappitelli August 2018
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3.1 Purpose: PD complications ......................................................................................................... 13 3.2 Target audience .......................................................................................................................... 13 3.3 Elements of clinical activity ......................................................................................................... 13
3.3.0 Summary of PD Complications and Corrective Measures .......................................14 3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK ...........................15 3.3.2 Protocol for the Treatment of OUTFLOW FAILURE ................................................17 3.3.3 Protocol for the Treatment of DEHYDRATION ........................................................17 3.3.4 Protocol for the Treatment of FLUID OVERLOAD ...................................................18 3.3.5 Protocol for the Treatment of MUSCLE CRAMPS ...................................................18 3.3.6 Protocol for the Treatment of AIR in the PERITONEAL CAVITY .............................18 3.3.7 Protocol for the BLOOD IN PD EFFLUENT .............................................................19 3.3.8 Protocol for the Protein Loss ...................................................................................19 3.3.9 Protocol for ACCIDENTAL DISCONNECTION (Refer to Section 10.4) ...................19 3.3.10 Protocol for PAIN DURING DIALYSATE INFLOW ...................................................19 3.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORING SYSTEM ............................................................................................................................20 3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING ................................................24 3.3.13 Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections 31 3.3.14 Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients ..........32
4 CHOICE OF PD SOLUTIONS & COMPOSITIONS ....................................................................... 33 4.1 Purpose ....................................................................................................................................... 33 4.2 Target audience .......................................................................................................................... 33 4.3 Elements of clinical activity – Summary ...................................................................................... 33
4.3.1 PHYSIONEAL Physiological requirements .............................................................34 4.3.2 Other solutions available: NUTRINEAL ..............................................................36 4.3.3 Other solutions available: EXTRANEAL ..............................................................37
5 ROUTINE PD CARE, PRECAUTIONS & MISCELLANEOUS INFORMATION ............................ 38 5.1 Purpose ....................................................................................................................................... 38 5.2 Target audience .......................................................................................................................... 38 5.3 Elements of clinical activity ......................................................................................................... 38
6.2 Target audience .......................................................................................................................... 40 6.3 Elements of clinical activity ......................................................................................................... 40
6.3.1 Basic preparation procedure ....................................................................................40 6.3.2 EXIT SITE CARE – DRESSING CHANGE ..............................................................43
7 HOMECHOICE CYCLER PREPARATION PROCEDURE ............................................................ 48 7.1 Elements of clinical activity ......................................................................................................... 48
7.1.1 BAG PREPARATION: Physioneal 5 liters ................................................................48 7.1.1 BAG PREPARATION: Physioneal 5 liters (continued) .............................................51 7.1.2 BAG PREPARATION: Procedure for adding medication with Physioneal 5 liters ....52
7.2 Purpose ....................................................................................................................................... 53 7.3 Target audience .......................................................................................................................... 53 7.4 Elements of clinical activity ......................................................................................................... 53
7.4.1 CYCLER PREPARATION .......................................................................................53 61 7.4.3 CYCLER PREPARATION – Prime the lines ............................................................62 7.4.4 CYCLER PREPARATION – Nurses Menu ..............................................................63 7.4.5 CYCLER PREPARATION – Connection with a PEDIATRIC Cycler Tubing with Cassette .............................................................................................................................68 7.4.5 CYCLER PREPARATION –Connection with a PEDIATRIC Cycler Tubing ..............69 7.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing.........70 7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System ........................................................................72 7.4.8 CYCLER PREPARATION – Disconnection with an ADULT home choice system or CAPD Twin Bag Manual System ........................................................................................75
8 PERITONEAL DIALYSIS BAG PREPARATION ........................................................................... 78 8.1 Purpose ....................................................................................................................................... 78 8.2 Target audience .......................................................................................................................... 78 8.3 Elements of clinical activity ......................................................................................................... 78
8.3.1 How to ADD a Bag During Dialysis ..........................................................................79 8.3.2 How to CHANGE a Bag During Dialysis ..................................................................82
9.3.1 CAPD manual set-up with TWIN BAGS ...................................................................86 10 PROCEDURE FOR ATTACHMENT OF EXTENSION TUBING .................................................... 96
10.1 Purpose ....................................................................................................................................... 96 10.2 Target audience .......................................................................................................................... 96 10.3 Elements of clinical activity ......................................................................................................... 97
10.3.1 How to attach TITANIUM adaptor to Pd catheter ....................................................97 10.4 Accidental Disconnection ............................................................................................................ 98 10.5 ACCIDENTAL CONTAMINATION ............................................................................................. 99
10.5.1 Basic Rules .............................................................................................................99 10.5.2 Accidental Contamination prior to PD Treatment ................................................... 100 10.5.3 Accidental Contamination at the start of PD Treatment ......................................... 101 10.5.4 Accidental Disconnection Between the Extension and Tubing ............................... 102
10.6 Elements of clinical activity ACCIDENTAL DISCONNECTION ............................................. 104 10.6.1 How to change a contaminated BAXTER EXTENSION TRANSFER SET ............. 104 10.6.2 How to change the Transfer Set and a titanium connector of the PD catheter when it is damaged ....................................................................................................................... 107
11 PROCEDURE TO COLLECT A DIALYSATE EFFLUENT SAMPLE .......................................... 111 11.1 Purpose To maintain an aseptic environment while collecting a dialysate effluent sample ..... 111 11.2 Target audience ........................................................................................................................ 111 11.3 Elements of clinical activity ....................................................................................................... 111
11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag with cycler 112 11.3.2 How to collect a sterile effluent sample via a seringe attached to the extension .... 117 11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE ................................................................................................................... 118 11.3.4 How to collect an effluent sample via the PEDIATRIC SETUP .............................. 121
12 SET-UP PROCEDURE FOR A PEDIATRIC MANUAL CAPD SYSTEM .................................... 122 12.1 Purpose ..................................................................................................................................... 122 12.2 Target audience ........................................................................................................................ 122 12.3 Elements of clinical activity ....................................................................................................... 122
12.3.1 FRESENIUS STAYSAFE SETUP.......................................................................... 122 122 12.3.2 How to set-up the pediatric manual CAPD system ................................................ 123
12.4 How to set-up the pediatric manual CAPD system: Quick reference ....................................... 123 12.4.1 How to set-up the pediatric manual CAPD system ................................................ 125
12.5 Procedure for Connection/Disconnection with Pediatric Setup - STAYSAFE Connection Procedure .............................................................................................................................................. 130
13 PROCEDURE FOR STAYSAFE CATHETER ADAPTER INSTALLATION................................ 134 13.1 Elements of clinical activity ....................................................................................................... 134
13.1.1 FRESENIUS STAYSAFE CATHETER ADAPTER INSTALLATION procedure ...... 134 14 PROCEDURE FOR HEPARINIZATION WITH PEDIATRIC SETUP ........................................... 136
14.1 Elements of clinical activity ....................................................................................................... 136 14.1.1 FRESENIUS STAYSAFE SAMPLE PORT CONNECTION PROCEDURE ............ 136
15 PROCEDURE TO SAFELY DISPOSE OF BIOLOGICAL DIALYSATE EFFLUENT .................. 138 15.1 Purpose ..................................................................................................................................... 138 15.2 Target audience ........................................................................................................................ 138 15.3 Elements of clinical activity ....................................................................................................... 138
16 PROCEDURE TO CHART DIALYSIS EXCHANGES .................................................................. 139 16.1 Purpose ..................................................................................................................................... 139 16.2 Target audience ........................................................................................................................ 139 16.3 Elements of clinical activity ....................................................................................................... 139 16.4 PROCEDURE TO CHART DIALYSIS EXCHANGES ............................................................... 140 PERITONEAL DIALYSIS RECORD ...................................................................................................... 140
17 PROCEDURE TO MANAGE A BLOCKED PD CATHETER WITH TPA (rt-PA) PROTOCOL (ALTEPLASE) .......................................................................................................................................... 141
17.1 Purpose ..................................................................................................................................... 141 17.2 Target audience ........................................................................................................................ 141 17.3 Elements of clinical activity ....................................................................................................... 141
18 PROCEDURE TO PERFORM A PERITONEAL EQUILIBRATION TEST (PET PROTOCOL) .. 142 18.1 Purpose ..................................................................................................................................... 142 18.2 Target audience ........................................................................................................................ 142 18.3 Elements of clinical activity ....................................................................................................... 142
18.3.1 How to perform a PET test .................................................................................... 143
1 PRE-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS
1.1 Purpose: Patient preparation
This protocol has been developed to prepare the patient for the OR and minimize the chances of infection post-op.
1.2 Target audience
Nursing and medical staff responsible for the care of the peritoneal dialysis patient.
1.3 Elements of clinical activity
1.3.1 Medication Protocol
The following medications should be administered as per instructions listed in Table 1-1.
Table 1-1: Medications pre-OR
Step Medication Dose Maximum dose Instructions
1 Saline enema until clear
10–20 cc / kg The day of surgery or the evening before.
2 DDAVP (IV) 0.3 mcg / kg in 50 cc NS
Maximum final concentration: 0.5 mcg / ml
Maximum dose : 20 mcg
To be given 30-60 min before OR (peak activity at 1 hour).
3 CEFAZOLIN (Ancef) (IV)
20 mg / kg 1 gram 1 hour pre-op or with induction of anesthesia
4 BACTROBAN (Mupirocin)
If needed1
5 days in the nose Bid
Q month2
Apply for a positive nose culture for staphylococcus aureus.
5 BACTROBAN (Mupirocin)
or Gentamicin cream If needed
3
Small quantity at the exit site Only when the exit site is healed
Requested by the nephrologist
Apply for positive culture for staphylococcus aureus
¹ Nasal swab for culture: swab the two nostrils with the same swab. If patient is positive in the nose for S. Aureus, then treat with bactroban
² 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 required if 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, dosages
2 POST-CATHETER INSERTION - INITIATION OF CHRONIC PERITONEAL DIALYSIS
2.1 Purpose: Catheter break-in
This protocol has been developed to care for the patient and peritoneal catheter immediately post-OR.
2.2 Target audience
Nursing and medical staff responsible for the care of the peritoneal dialysis patient.
2.3 Elements of clinical activity
2.3.1 Theory
The 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, and
b. minimize the possibility of omental adhesion, and
c. 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 medium for 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), if possible for 2 to 4 weeks after catheter implantation.
Table 2-1: Break-In Protocol: Immediate post-insertion period, usually 12-16 hours
Step Procedure Instructions
1 X-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 medical-nephrology floor.
2a Rapid in-out exchanges until clear (about 3 exchanges) by infusing into peritoneal cavity.
These exchanges may be done
a) manually (i.e., nurse infuses dialysis fluid using a “twin bag” system), or
b) using the cycler, on “Hi-dose” mode (or OCPD mode).
Table 2-1a: Nausea and pain protocol post Peritoneal Dialysis Catheter insertion
1 Antiemetics 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 (max 25 mg/dose if less 6 years old; max dose 35mg if 6-12 years old; max dose 50 mg if over 12 years old)
2a Pain management
Non-opioid analgesic
Acetaminophen (refer to MUHC Pediatric drug formulary for updated dosage
recommendations):
i. Term infants more than 10 days old and children/adolescents: 10-
15 mg/kg/dose (max. 75 mg/kg/day) every 6 hours regular for 48
hours then PRN
GFR <10mL/min./1.73m2, intermittent peritoneal dialysis: adjust
administration frequency to every 8 hours.
2b Pain management
Opioids IV
First line: HYDROmorphone
i. 0.01 mg/kg IV every 4 hours PRN (For small patient, dilution may be
required for a final concentration of 0.1 mg/mL = 2 mg of
hydromorphone in 19 mL of NS)
Second line: Morphine
ii. Avoid Morphine (active metabolites may increase duration of action and
increases risk of accumulation with renal dysfunction). If used, adjust
interval: e.g. 0.03-0.05 mg/kg every 6-8 hours PRN. Evaluate the effect
and 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.
2c Pain management
Opioids ORAL
>35 kg: HYDROmorphone 0.03 mg/kg PO every 4 hours PRN (tablet) max dose 15 mg
≤35 kg: Morphine 0.15 mg/kg PO every 4 hours PRN (pill or suspension)
Table 2-2: Maintenance Phase for patients not in need of immediate dialysis
Step Procedure Instructions
1 Perform an In/Out exchange
(zero dwell-time)
This will be done by PD nurse, either by manual exchange or using cycler.
i. Once per week (or as assessed by Nephrologist), perform an In/Out exchange (zero dwell-time),
ii. 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 2 weeks to a month for dialysis. The PD nurse should perform an in/out exchange once per week. ADD heparinized 1000 units per liter or 250 units per liter for baby in NICU & PICU to dialysis fluid. We could increase frequency of exchanges if presence of fibrin.
2 Heparinize PD catheter with transfer set extension or catheter adapter
Patients > 15 kg:
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 is attached 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 a proviodine 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 syringe attached at the end of the Baxter transfer set (MMS 068746)
After HepNS injection, close the system with a proviodine Mini Cap (MMS 023005)
NICU & PICU babies: ask nephrologist for heparin concentration
i. Infuse 5 – 10 ml/kg as last cycle volume, (same solution as box1 of this table)
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 nurse
3 Notify the nephrologist for any fibrin strands
For all medications listed above, please refer to their policy for indications, contraindications, dosages
Table 2-3: Maintenance Phase for patients in immediate need dialysis
Step Procedure Instructions
1 Infuse dextrose dialysate containing 1000 Units/Liter of Heparin: (concentration ordered by nephrologist).
Use dialysate with 250 units/Liter of Heparin for the NICU & PICU.
Time Period Volume (ml / kg)
1st 24 hours 10 ml / kg,
2nd
24 hours 15 ml / kg,
3rd
24 hours 20 ml / kg for 4 weeks,
then 25 ml / kg for 1 week,
then 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 6 weeks. 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, then decreased to 500 Units / litre for the 2
nd 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 volume starting at 20 ml/kg
vi. The healing period of the PD catheter exit site may take 6 – 12 weeks.
For all medications listed above, please refer to their policy for indications, contraindications, dosages
This protocol has been developed to describe the possible complications associated with peritoneal dialysis treatments.
3.2 Target audience
Nursing and medical staff responsible for the care of the peritoneal dialysis patient.
3.3 Elements of clinical activity
Executive Summary - The following table (Table 3-0: Summary of PD Complications and Corrective Measures) describes in brief the most well-established complications associated with peritoneal dialysis treatments. This is by no means a comprehensive list, and any signs, symptoms or unanticipated complications should be referred to the nephrologist on-call.
3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK
A peritoneal catheter leak is a consequence of the loss of peritoneal membrane integrity (an opening or a tear in the membrane). This usually becomes apparent in the first weeks or months of use, as the patient becomes more active. There are 2 types of leaks: early (within 30 days of PD catheter insertion) and late leaks.
Table 3-1: Peritoneal catheter leak and Corrective Measures
Subcutaneous swelling, local or generalized edema and/or local pallor
Weight gain
Diminished outflow volume or outflow failure (or “ultrafiltration failure”)
a. Confirm leak with glucose dipstick at exit site. The glucose dipsticks are in the PD cart in the PD teaching room or you may use the UA dipstick in the microscope room.
b. CT scan for peritoneal infusion
Nuclear scan or CT with peritoneal infusion is preferred with a suspected leak. May not be needed if leak is obvious.
The nephrologist will arrange the Nuclear Medicine scan with the radiologist.
c. Ultrasound of abdominal wall may sometimes be useful to document leak.
i. Discontinue dialysis for 7 to 10 days.
If discontinuation is not possible due to the patient’s condition, return to the Break-in Schedule (10–20 ml per kg or 250-500 ml/m2) for 2–3 weeks. Perform dialysis only in the supine position, to minimize intra-abdominal pressure.
If leakage persists, stop PD and switch to hemodialysis for 3–6 weeks.
If the leakage remains refractory, the PD catheter must be
replaced.
Surgery repair needs to be considered in some situations.
3.3.1 Protocol for the Treatment of a PERITONEAL CATHETER LEAK (continued)
CT scan: Computed Tomography with radio contrast material
For all medications listed above, please refer to their policy for indications, contraindications, dosages and precautions.
Table 3-1a: The Nuclear Scan
Procedure to prepare the patient for a Nuclear Medicine scan with a suspected PD catheter leak
i. Empty the peritoneal cavity
The radiologist will come to inject the radioactive dye using a syringe attached to the transfer set prepared by the PD nurse (must do the basic procedure). Ideally to be done by PD nurse. Thus, the dye is being injected into the peritoneal cavity.
As per nephrology recommendations, fill the patient’s regular infusion volume with Physioneal1.36% or Dianeal 1.5% Dextrose.
Make sure patient remains in a supine position. After a 2 hours dwell, the patient will go to Nuclear Medicine to have some images taken.
Drain the abdominal cavity completely, followed by a peritoneal lavage with Physioneal 1.36% Dextrose (PD nurse does this – using twin bag set up). Leave the abdominal cavity empty. Heparinize the PD catheter as per protocol if not used.
Table 3-1b: The CT Scan
Procedure to prepare the patient for a CT scan with a suspected PD catheter leak
i. Empty the peritoneal cavity. Have emergency medications at the bedside (diphenhydramine 1.5 mg/kg, max 50mg IV; hydrocortisone 5 mg/kg, max 200 mg IV; epinephrine SC (1:1000 solution) 0.01ml or 0.01 mg/kg, max 0.5 mg.
Add 50 ml of OMNIOPAQUE 300 (Iohexol 300 mg/ml) in a 2 liter bag. (Add 62.5 ml in 2.5 liter bag).
Note: This is being done using the twin bag set up by the PD nurse. (they are 2L bags)
Infuse the intraperitoneal volume prescribed by the physician. Call 22138 Radiology when the infusion is complete.
Approximatively one hour after the infusion, CT scan can take place.
After the CT, drain the abdomen and perform 2 – 3 In’s & Out’s by manual exchange (can be done with cycler, on the Hi-dose (or OCPD)
b. Rupture of tiny peritoneal capillaries, may be secondary to higher PD solution temperature or activities
c. Possible serious abdominal injury
i. Pink: clears up in 2-3 exchanges w/o treatment. Could do 3 fast in & out exchanges with same volume
Bloody fluid: check BP and HR. Observe patient. Adjust Heparin → to prevent clotting of PD cath. Bloody effluent can lead to clotting of PD catheter. So heparin may be added (decide on patient to patient basis, and only if bleeding not severe), to prevent clots.
Protein loss average protein in effluent: 9 gm/day
Cloudy peritoneal fluid
a. Large amount of protein is lost through the peritoneal membrane
b. Peritonitis can worsen and increase the amount of protein loss
i. Check serum Albumin and Total Protein
ii. Call nephrology & dietician to modify protein diet Protein supplements as ordered by physician can help build and repair tissue and rebuild immunity.
3.3.9 Protocol for ACCIDENTAL DISCONNECTION (Refer to Section 10.4)
Refer to the Accidental Disconnection Protocol section 10.4
3.3.10 Protocol for PAIN DURING DIALYSATE INFLOW
Table 3-10: Pain during Dialysate Inflow and Corrective Measures
Redness, tenderness, and/or discharge at the exit site
a. Patient should be examined by PD nurse and / or nephrologist (patients in outlying regions should be seen by their own pediatrician)
b. Consider obtaining pictures of site from family
c. Do a gram-stain and culture of the catheter insertion site (if discharge). Families have these items in the home. Use the exit site scoring system section 3.3.11 A diagnosis of a catheter exit site infection can be made in the presence of pericatheter swelling, redness, and tenderness (exit site scoring of 2 or greater in the presence of a pathogenic organism and 4 or greater regardless of culture results).
i. Do daily dressing change to assess the exit site or twice-daily dressing if significant discharge.
ii. If the exit site score is low and exit site has only some redness, nephrologist might begin local therapy only (usually BACTROBAN ointment or GENTAMYCIN cream) with every dressing change and to be reassessed regularly.
iii. The decision about whether to initiate therapy or to follow carefully should be based on the combination of clinical judgment and repeated assessment.
iv. Oral antibiotic therapy of uncomplicated catheter exit site infection (refer to c for scoring system) should be initiated upon receipt of culture results and susceptibilities, and that treatment be continued for a minimum of 2 weeks and for at least 7 days after complete resolution of the infection. Treatment for at least 3 weeks is recommended for exit site infections caused by staph aureus or pseudomonas aeruginosa.
v. Successful treatment of catheter ESI is important because failure of therapy may result in catheter removal or peritonitis.
vi. For infections caused by gram positive that fail to improve or resolve promptly, add rifampin to therapy after 3 days.
vii. In patients receiving prophylactic therapy, (by application of an antibiotic ointment or cream at the exit site), slower growth of the causative organism is possible, and the potential for resistance to any prophylactic antibiotic should be considered in the choice of empiric therapy.
viii. Follow ISPD 2012 Pediatric Guidelines (pages S66 to S69) Refer to table 3-3-11
Extension of a skin exit site infection with pain, swelling, nodularity and redness over the subcutaneous portion of the catheter
Systemic signs such as fever or malaise
" Relapsing " peritonitis due to the same organism
a. Patient should be examined by PD nurse and / or nephrologist (patients in outlying regions should be seen by their own pediatrician)
b. Do a gram-stain and culture of the catheter insertion site (if discharge). If exit site dry, If patient is unwell (e.g. fever) ideally obtain blood culture before starting systemic antibiotics.
c. A tunnel infection is defined by the presence of redness, edema and tenderness along the subcutaneous portion of the catheter, with or without purulent drainage from the exit site (exit site scoring of 6 or greater).
i. Most catheter Tunnel infections can be diagnosed by clinical exam alone; ultrasonographic examination of the catheter tunnel may be helpful.
ii. Antibiotic therapy for catheter tunnel infections should be initiated after culture and susceptibility results have been obtained unless signs of severe infection or a history of staph aureus or P. aeruginosa is present, for which initiation or empiric therapy should be considered.
iii. The route of antibiotic administration can be oral, intraperitoneal, or intravenous unless MRSA is the causative agent, in which case IP or IV glycopeptide therapy is indicated. Treatment duration should be 2 – 4 weeks.
iv. Successful treatment of catheter ESI is important because failure of therapy may result in catheter removal or peritonitis
v. Follow ISPD newest Pediatric Guideline 2012 (P S66 to S69). Refer to table 3-3-11
For all medications listed above, please refer to their policy for indications, contraindications, dosages and precautions.
3.3.11 Protocol for EXIT SITE INFECTION, TUNNEL INFECTION & EXIT SITE SCORING SYSTEM (continued)
Table 3-11b: Exit Site Infection (ESI) and Exit-Site Scoring System 1
Indication Score
2
0 1 2
Swelling No Exit only (<0.5 cm)
Including part of or the entire tunnel
Crust No < 0.5 cm > 0.5 cm
Redness No < 0.5 cm > 0.5 cm
Pain on pressure No Slight Severe
Secretion No Serous Purulent
1 Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 (exit site scoring system p.66)
2 Infection should be assumed with a cumulative exit-site score of 4 or greater regardless of culture results or in the presence of pericatheter swelling, redness, and tenderness (exit site score of 2 or greater in the presence of a pathogenic organism).
3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING
NOTE: Please refer to Prophylaxis of Fungal Peritonitis, to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.
a. Call Nephrologist immediately. Patient should be examined by PD nurse and nephrologist
b. Do a cell count and culture with gram-stain and fungal. Cell count WBC >100 /uL (or >1 X10
9/L),
>50% Polymorphonuclear neutrophil cells (PMN)
i. After taking a specimen for cell count and culture, do 3 in & out exchanges to relieve some pain (you may ask the families to do this at home if pain is severe – but will need guidance from PD nurse – use “bypass” function to do this). You need 10 ml for cell count, 50 ml for culture and
Blood culture bottles 4ml for aerobic (yellow), 5 ml for anaerobic (orange) and 1-3 ml for fungus.
ii. Start IP antibiotics with loading dose as soon as possible. Ensure gram-negative and gram-positive coverage. Allow loading dose to dwell for 6 hours. Add
heparin 1000 units per liter until complete resolution of dialysate cloudiness. Base selection on historical patient and center sensitivities. Refer to section 3.311
iii. When loading dose dwell is completed, set up the cycler for the maintenance dose of IP antibiotics. consider longer dwell time than regular therapy of about 2 hours for 1 to 2 days
iv. Continue assessment of therapy and modification of therapy based on culture and sensitivity results. Consult Pediatric ISPD Guidelines 2012. Guidelines for therapy in table section 3.311
v. Reduce the peritoneal fill volume during the initial 24-48 hours of therapy in patients with significant abdominal discomfort
vi. Assess improvement in therapy at 3 days. Symptoms should resolve and dialysate should clear. Re-evaluate treatment and reassess patient response to therapy.
vii. Send cell count and culture daily.
For all medications listed above, please refer to their policy for indications, contraindications, dosage and precautions.
3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING (continued)
NOTE: Please refer to section 3.3.14 (anti-fungal prophylaxis is recommended), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.
Table 3-12c: Antibiotic Dosing Recommendations for the Treatment of Peritonitis
Therapy type
Continuous b
Antibiotic type Loading dose Maintenance dose Intermittent b
Aminoglycosides (IP)c
Gentamicin 8 mg/L 4 mg/L
Netilmycin 8 mg/L 4 mg/L Anuric: 0.6 mg/kg
Tobramycin 8 mg/L 4 mg/L Non-anuric: 0.75 mg/kg
Amikacin 25 mg/L 12 mg/L
Cephalosporins (IP)
Cefazolin 500 mg/L 125 mg/L 20 mg/kg
Cefepime 500 mg/L 125 mg/L 15 mg/kg
Cefotaxime 500 mg/L 250 mg/L 30 mg/kg
Ceftazidime 500 mg/L 125 mg/L 20 mg/kg
Glycopeptides (IP)d
Vancomycin 1000 mg/L 25 mg/L 30 mg/kg; repeat dosing: 15 mg/kg every 3–5 days
Teicoplanin 400 mg/L 20 mg/L 15 mg/kg every 5–7 days
Fluconazole (IP, IV, or PO) 6–12 mg/kg every 24–48 h (maximum: 400 mg daily)
Caspofungin (IV only) 70 mg/m
2 on day 1
(maximum: 70 mg daily) 50 mg/m
2 daily
(maximum: 50 mg daily)
IP = intraperitoneally; IV = intravenously; PO = orally. a. Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b. For continuous therapy, the exchange with the loading dose should dwell for 3–6 hours; all subsequent exchanges during the
treatment course (including the last fill) should contain the maintenance dose. For intermittent therapy, the dose should be applied once daily in the long-dwell, unless otherwise specified.
c. Aminoglycosides and penicillins should not be mixed in dialysis fluid because of the potential for inactivation. d. In patients with residual renal function, glycopeptide elimination may be accelerated. If intermittent therapy is used in such a setting,
the second dose should be time-based on a blood level obtained 2–4 days after the initial dose. Re-dosing should occur when the blood level is <15 mg/L for vancomycin, or <8 mg/L for teicoplanin. Intermittent therapy is not recommended for patients with residual renal function unless serum levels of the drug can be monitored in a timely manner.
3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING (continued)
a If the center’s rate of methicillin-resistant Staphylococcus aureus (MRSA) exceeds 10%, or if the patient has history of MRSA infection or colonization, glycopeptide (vancomycin or teicoplanin) should be added to cefepime or should replace the first-generation cephalosporin for gram-positive coverage. Glycopeptide use can also be considered if the patient has a history of severe allergy to penicillins and cephalosporins.
Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86
** Montreal Children’s Hospital: Cefazolin or Vancomycin
MCH 1st choice : cefepime
MCH 2nd choice: cefazoline or vancomycin and ceftazidime
3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING (continued)
NOTE: Please refer to section 3.3.14 (prophylaxis of fungal peritonitis), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis.
Table 3-12c: Gram-Positive Bacteria : Recommended IP Antibiotics and Length of Therapya
Organism Recommended antibiotics b Length of therapy
Staphylococcus aureus Methicillin-resistant
Clindamycin or vancomycin (MCH first choice) or teicoplanin
3 weeks
Methicillin-susceptible Cefazolin or cefepime (MCH first choice)
3 weeks
Coagulase-negative staphylococci Cefazolin or cefepime or clindamycin or vancomycin or teicoplanin
2 weeks
Enterococcus species Ampicillin or vancomycin or teicoplanin Consider adding aminoglycoside
2 – 3 weeks
Vancomycin-resistant Ampicillin or linezolid 2 – 3 weeks
Streptococcus species Ampicillin or cefazolin or cefepime 2 weeks
a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b Listed in the preferred order of use, if susceptible. c Prolonged use of linezolid (>2 weeks) can lead to bone marrow suppression.
3.3.12 Protocol for PERITONITIS & ANTIBIOTIC DOSING (continued)
NOTE: Please refer to section 3.3.14 (anti-fungal prophylaxis is recommended), to consider whether or not you want to use fungal prophylaxis during treatment of bacterial peritonitis. d
a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86 b The antibiotics are listed in the preferred order of use, if the organism is susceptible. c Emerging resistance to extended-spectrum beta-lactamase has resulted in a wide variety of unique susceptibility profiles; consultation with an infectious disease expert about the antibiotics preferred for treating such organisms is recommended. d. Peritoneal Dialysis International 2016; vol. 36, NO. 5 P. 486 P 493
Table 3-12d: Gram-Negative Bacteria: Recommended Antibiotics and Length of Therapya
Organism Recommended antibiotics b Length of therapy
Escherichia coli, Klebsiella species
Cefepime or cefazolin or ceftazidime or ceftriaxone or cefotaxime
2 weeks
Resistant to third-generation cephalosporins
b
Imipenem or cefepime or fluoroquinolone
3 weeks
Enterobacter, Citrobacter, Serratia, and Proteus species
c
Cefepime or ceftazidime or imipenem
2 – 3 weeks
Acinetobacter species Cefepime or ceftazidime or imipenem
2 – 3 weeks
Pseudomonas species
Cefepime or ceftazidime or piperacillin or ticarcillin or imipenem plus aminoglycoside or fluoroquinolone
3 weeks-4weeks d
Stenotrophomonas maltophilia Trimethoprim– sulfamethoxazole or ticarcillin–clavulanic acid
3.3.13 Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections
Table 3-13: Indications for Catheter Removal for Peritoneal Dialysis (PD)–Associated Infections a
Approach to catheter Indication Reinsertion
Definite removal Refractory bacterial peritonitis
Fungal peritonitis
ESI/TI in conjunction with peritonitis with the same organism (mainly Staphylococcus aureus and Pseudomonas aeruginosa; except coagulase-negative staphylococci)
After 2 – 3 weeks
At least 2 – 3 weeks
After 2 – 3 weeks
Simultaneous removal and replacement
Repeatedly relapsing or refractory ESI/TI (including P. aeruginosa)
Relapsing peritonitis (relapse within 30 days)
Relative removal Repeat peritonitis
Mycobacterial peritonitis
Peritonitis with multiple enteric organisms because of an intra-abdominal pathology or abscess; so-called surgical peritonitis
After 2 – 3 weeks
After 6 weeks
Depends on the clinical course of the patient; 2 – 3 weeks
a Peritoneal Dialysis International 2012; Vol. 32, pp. S32-S86
3.3.14 Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients
Table 3-14: Antifungal and Antibacterial Prophylaxis in Peritoneal Dialysis (PD) Patients
Situation Indication Antimicrobial
Presence of risk factors for fungal peritonitis
High baseline rate of fungal peritonitis in the PD unit
PEG placement or GT (MCH: GT placement)
Nystatin PO 10 000 U/kg daily (MCH: first choice)
Fluconazole 3–6 mg/kg IV or PO every 24–48 hours (maximum: 200 mg)
Touch contamination
Instillation of PD fluid after
Disconnection during PD
(MCH : Cefepime 250 mg/L IP for 3 days)
Cefazolin (125 mg/L IP, recommended by ISPD guideline, however, We use ( MCH) Cefazolin 250 mg/L, or vancomycin (25 mg/L IP) if known colonization with MRSA
Culture result, if obtained, directs subsequent therapy
Invasive dental procedures
Manipulation of gingival tissue or of the periapical region of teeth, or perforation of the oral mucosa
Amoxicillin (50 mg/kg PO; maximum: 2 g) (MCH choice) or ampicillin (50 mg/kg IV or IM, ; maximum: 2 g) or cefazolin (25 mg/kg IV; maximum: 1 g) or ceftriaxone (50 mg/kg IV or IM; maximum: 1 g) or clindamycin (20 mg/kg PO; maximum: 600 mg) (MCH choice if allergic to penicillin) or clarithromycin (15 mg/kg PO; maximum: 500 mg) or azithromycin (15 mg/kg PO; maximum: 500 mg)
Give antibiotic 30-60 minutes pre-procedure
Gastrointestinal procedures
High-risk procedures (esophageal stricture dilation, treatment of varices, ERCP, and PEG/G-Tube)
Other gastrointestinal or genitourinary procedure
Cefazolin (25 mg/kg IV; maximum: 2 g) or clindamycin (10 mg/kg IV; maximum: 600 mg) or, if high risk for MRSA, vancomycin (10 mg/kg IV; maximum: 1 g)
*The PD”1” and “4”: this is simply the company way of naming whether it is the “normal” (1.75 mmol/L) or “low” calcium (1.25 mmol/L) concentration Dianeal dialysate.
Table 4-1b. Composition of Physioneal, Nutrineal and Extraneal peritoneal dialysis solutions
Physioneal Nutrineal Extraneal
*PD2 PD2 PD2 PD4 Dextrose Glucose 1.36% 2.27% 3.86% 1.10% 7.50% iso medium hyper amino acid icodextrin
Goal: To develop a biocompatible PD solution that can replace Dianeal
Requirements:
1. physiological pH 7.4
2. physiological buffer (25 mM bicarbonate)
3. reduced lactate concentration (15nM)
4. reduced glucose degradation products (GDP)
5. improved biocompatibility
Glucose in low pH during heat sterilization maintains low level of GDP's. Calcium and Bicarbonate needs to be in different chambers during sterilisation to prevent precipitation.
Goal: To develop a biocompatible PD solution that can replace Dianeal
Requirements:
1. physiological pH 7.4
2. physiological buffer (25 mM bicarbonate)
3. reduced lactate concentration (15nM)
4. reduced glucose degradation products (GDP)
5. improved biocompatibility
Glucose in low pH during heat sterilization maintains low level of GDP's. Calcium and Bicarbonate needs to be in different chambers during sterilisation to prevent precipitation.
Nutrineal is a PD solution is specially adapted for renal failure patients with abnormal protein metabolism. These patients are at higher risk for malnutrition.
Nutrineal contains 15 different amino acids of which 64% are essential amino acids by weight (1.1 % total amino acids equivalent to 11g/L).
Nutrineal does not contain any glucose, has a pH 6.4 and contains fundamental electrolytes.
The osmolarity of the solution is 365 mOsm/L providing equivalent ultrafiltration to that of a 1.5% dextrose solution.
Each 100 ml of Nutrineal contains :
i. Nutrineal is intended for intraperitoneal administration only, substituting for one or more exchanges.
ii. Nutrineal should be given as a daily exchange, preferably around meal time and dwell for 6 hours.
Table 4-2 :
Composition of Nutrineal PD solution
Adapted for patients with abnormal protein metabolism
Does not contain any glucose; Delivers equivalent UF to 1.5% dextrose
PD4 per 100ml Essential amino acids Nonessential amino acids
Total amino acids 1.1 g Valine 139.3 mg Arginine 107.1 mg
Extraneal is a PD solution designed to increase ultrafiltration with an iso-osmotic solution
i. for PD patients with a decreased residual renal function or
ii. for PD patients with an episode of peritonitis to maintain ultrafiltration.
Extraneal is recommended as a once daily replacement for a single glucose exchange
Recommended for use in the longest dwell period in CAPD or APD regimens for one exchange only (CAPD overnight dwell, APD day time dwell).
Table 4-3 : Composition of Extraneal PD solution
Designed to INCREASE ultrafiltration
Use as a ONCE DAILY replacement for a SINGLE glucose exchange
Description of Extraneal Composition
Extraneal is a PD solution which contains an osmotic agent called icodextrin, a polydispersed glucose polymer.
Icodextrin 75 g/L
The predominant mechanism of action of icodextrin is believed to be colloid osmosis. This can account for the improvement in ultrafiltration and clearance in PD patients.
Sodium 133 mmol/L
Data on absorption of molecules from the peritoneal cavity indicate that the majority of molecules in icodextrin are too large for transfer across the peritoneum and that only small proportion will enter the blood stream via the lymphatic system.
Calcium 1.75 mmol/L
Slow absorption of icodextrin which occurs via the lymphatic system would be in keeping with its prolonged osmotic effect in PD.
Magnesium 0.25 mmol/L
A 7.5 % solution of icodextrin has been shown to be effective as an osmotic agent which results in improved ultrafiltration and clearance as compared to 1.36 % / 2.27 % glucose solutions.
Chloride 96 mmol/L
Icodextrin 7.5 % is iso-osmotic with human serum. Lactate 40 mmol/L
5 ROUTINE PD CARE, PRECAUTIONS & MISCELLANEOUS INFORMATION
5.1 Purpose
This protocol has been developed to prevent Infection.
5.2 Target audience
Nursing and medical staff responsible for the care of the peritoneal dialysis patient.
5.3 Elements of clinical activity
5.3.1 Shower & Bath
Table 5-1a: Shower Considerations and Precautions
Notes The first 6 weeks of PD After 6 weeks of PD
Objective: To prevent infection A shower is permitted only once a week but need to cover the entire exit site and dressing with 4x4 and Opsite or Tegaderm
It is preferred that the PD exit site be covered at all times. A shower is allowed with PD exit site exposed to air when the site is well healed, intact and after being assessed by PD nurse.
This technique is more applicable for the older children / patient
Dressing has to be covered with 4x4 and thenTegaderm or Opsite. Dressing needs to be changed after the shower
The minimum requirement for dressing change is 3 times per week but could be done every day after a shower or bath. Never immerse PD catheter.
Sponge bath is permitted every day When the PD exit site is not intact
(redness, trauma), the exit site should be covered again when showering or bathing with Tegaderm or Opsite
Table 5-1b: Shower Protocol with a PD catheter
Supplies Procedure
Clean face cloth Take a regular shower using the soap pump to wash the body. It is preferred that the PD exit site be covered at all times.
Soap pump. Do not refill the soap container.
At the end of the shower, wet a clean face cloth and clean the area with clear water.
Do not use bar soap Rub area around PD catheter close to the exit site and along the
Shower is preferred. A bath is permitted only once a week. PD exit site has to be covered with 4x4 and then Opsite or Tegaderm.
PD exit site has to be covered at all times with bath care. Water must be shallow and not cover the PD exit site.
i. Shower is preferred. A bath is allowed but PD exit site has to be covered with 4x4 and then Opsite or Tegaderm.
ii. PD exit site has to be covered at all times with bath care. Water must be shallow and not cover the PD exit site.
This technique is more applicable for younger children / patient
PD exit site has to be covered at all times with Bath care. Water must be shallow and not cover the PD exit site.
iii. PD exit site has to be covered at all times with Bath care. Water must be shallow and not cover the PD exit site.
A sponge bath is strongly suggested with younger children
Sponge bath is permitted every day iv. If showering is not possible for the older child and adolescent, a bath may be taken, but the water must be shallow and not cover the PD exit site
Never immerse the PD exit site (even for infant or young child) in the bath tub
The PD exit site dressing must be changed after the bath following the protocol
v. The PD exit site must be changed after the bath following the protocol
refer to the PD exit site care dressing change protocol
vi. refer to the PD exit site care dressing change protocol
5.3.2 Activities & Sports
Table 5-2: Activities & Sports - Special Considerations & Precautions
Notes Activities to avoid Activities considered acceptable
Objective: To minimize physical trauma to the PD catheter and peritoneal membrane
For the first 8 weeks after starting PD, strenuous activities or sports are not permitted
Amusement rides are permitted only when exit site is healed and this is approved by Nephrologist.
Avoid contact sports, weightlifting, gymnastics, parachuting, and bungee jumping
Objective: To minimize physical exposure to organic pathogens dangerous to the PD catheter and peritoneal membrane
Bathing in public pools, rivers and lakes carries a greater risk of inducing peritonitis, so it shouldn't be allowed
Swimming should also be avoided if exit site has been traumatized or infected
Swimming is permitted (after approved by nephrologist) in the ocean or a private swimming pool. The PD catheter and exit site must be covered with waterproof dressing (eg. colostomy bag, Tegaderm or Opsite).
Note: After swimming, refer to Exit Site Care – Dressing Change Protocol.
To maintain an aseptic environment and minimize risk of infection during peritoneal dialysis procedures.
6.2 Target audience
Nursing and medical staff responsible for the care of the peritoneal dialysis patient. 6.3 Elements of clinical activity
6.3.1 Basic preparation procedure
Table 6-1: Basic Preparation Procedure: the 9 steps
Equipment Procedure
Chlorhexidine 4% (antiseptic solution) or foaming Chlorhexidine 2%
Masks
Alcohol handrub
Sanicloth or Alcohol
To prevent contamination, garbage can, toilet or sink should never be kept close to the area while sterile procedures are in progress.
To prevent contamination, garbage can, toilet or sink should never be kept close to the area while sterile procedures are in progress.
15 seconds hand washing
1. Restrict traffic in area. Close windows, doors, fans, air conditioners.
2. Clean 2 working surface areas with Sanicloth or alcohol
3. Let dry
4. Gather equipment
5. Put on mask
6. Remove jewelry
7. Wash hands with Chlorhexidine solution 4% for 2 minutes.
8. Dry hands well (close faucets with towel)
9. Close faucets with towel when necessary and Alcohol Hand rub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry (20-30 seconds). After handrub, touch only PD supplies. Proceed with desired procedure as per protocol.
Table 7-2: Quick Guide to Basic Aseptic Environment Preparation Procedure
To maintain an aseptic environment and,
To minimize risk of infection during the dialysis procedure
Equipment [4] Procedure
15 seconds hand washing
Chlorhexidine 4% or Foaming Chlorhexidine 2%
1. Close windows, doors and turn off any fans
Masks
2. Wash 2 working surface areas with Sanicloth or alcohol
3. Let dry
Alcohol handrub
4. Gather material
Alcohol
5. Put on mask
6. Remove jewelry
7. Wash hands with Chlorhexidine solution 4% for 2 mins
8. Dry hands well.
9. Close faucets with towel and Alcohol handrub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry (20-30seconds). After handrub, touch only PD supplies.
If hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.
2. Wash 2 working surface areas with Sanicloth or alcohol
3. Let the table dry
4. Gather material
5. Put on mask
6. Remove jewelry
7. 4% Chlorhexidine Wash hands for 2 minutes
8. Dry hands well
9. Close faucets with towel and Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry. (20-30 seconds) After handrub, touch only PD supplies
6.3.2 EXIT SITE CARE – DRESSING CHANGE (continued)
PD Dressing Part 1
PD Dressing
Part 2
Step 1 of 16:
15 seconds hand washing.
Follow Basic Procedure (9 steps).
Apply a palmful of alcohol based sanitizer and rub until dry (20-30 secs).
Open the dressing tray using sterile technique.
Step 5:
Remove old dressing and look for any signs of infection (redness, discharge, tenderness).
Notify nurse/MD
If there is any doubt, take a culture sample (culture swab or alginate).
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Step 2:
Using aseptic technique, open and drop 4 Chlorhexidine 2% green sticks into the sterile tray.
Open sterile 2x2 gauze and drop it into the sterile tray.
Step 6:
Do not pull any crust off – this could worsen and / or damage the skin!
Put on sterile gloves.
If there is crust at the site, use sterile NS to soak the crust in order to soften any crust.
Pulling any crust may increase the patient’s risk for infection.
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Pa
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Step 3:
Add NS prn if there is presence of crust.
You may need a BIOPATCH for the first 6 weeks post-op (except NICU & PICU babies).
Step 7:
Using a gentle pressure, clean the area starting from the catheter site and working outward in a
circular motion.
Clean 2 times using a new Chlorhexidine swabstick each time.
PD
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PD
Dre
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Pa
rt 3 Step 4:
Disinfect your hands with Alcohol handrub. Apply a palmful of alcohol based sanitizer and cover all surfaces of hands. Rub hands until dry. (20-30 seconds).
7.1.1 BAG PREPARATION: Physioneal 5 liters (continued)
Place the bags with the connector facing away from you
Check each bag for the following:
1. Expiry date
2. Solution name
3. Glucose concentration (as per prescription)
4. Volume
Open the over-pouch of all your bags
Put bag on a clean surface.
Press firmly on large chamber to check:
Long seal is intact
Short seal is intact
Check each bag to make sure:
Solution is clear
There are no leaks
Check the connector on each bag for:
Correct position of the wings
Presence of the pull-ring as shown on the picture (left)
If medication is required, it should be added now as prescribed by your doctor. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 seconds). After handrub, touch only PD supplies. Wipe injection port 15 sec. with alcohol chlorhexidine swab.
7.1.1 BAG PREPARATION: Physioneal 5 liters (continued)
To start opening the long-seal, grab each side of the large chamber firmly, turn your hands outwards and push the solution towards the middle of the long-seal or roll one of the side at a time.
Open the short-seal by lifting the large chamber, grabbing the material firmly in both hands and rolling the material towards the connector
Apply pressure, by leaning over the bag, and pushing the solution towards the short-seal to open it
Turn on the HOMECHOICE cycler (the ON/OFF button is on the back right side).
The display will show:
“PRESS GO TO START”
The HOMECHOICE system is ready.
Step 4:
Placing a solution bag or
empty heater bag on the heater cradle
When more than one concentration is used, Place the bag with the highest concentration
on the warming cradle unless using an empty heater bag (Please consult with the physician first).
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Remove all solution bags from their wrap
Put the bags on 2nd
clean surface area.
With the PHYSIONEAL solution bags, break the inner GREEN cones
between the 2 compartment bags.
Hang the bag(s) on a pole to allow the solutions to mix for 2.5 liters. (section 8.3.2liters)
Step 5:
Place an empty heater bag on the warming cradle
or solution bag
The empty heater bag will be needed if:
the patient needs a mixture of different concentration(s)
and
the patient is receiving small volume(s) of solution for each cycle.
Clamp the empty heater bag.
Pa
rt 1
Ma
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Medication
Any medication that needs to be added to the bags must be done in this Step. Use Alcohol handrub and let dry. Wipe in injection port with alcohol chlorhexidine swab for 15 secs and let dry. Use a 23 gauze needle only).
Please refer to the protocol Addition of a Medication 5 liters bag
section 7.1.2 p 52.
Step 6:
Prepare disposable set
CLOSE all 6 clamps on the disposable set.
Open all other material needed. I.e. manifold & clamps, drainage bag, specimen bag…)
CLOSE all the clamps.
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Step 3:
Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of the hands. Rub until dry (20-30secs).
After handrub, touch only PD supplies.
Open all packages, put on second table.
Step 7:
Prepare drainage & effluent sample bag
CLOSE the 2 clamps on the drainage bag.
Recommended: apply blue clamp on
the specimen port of the drainage bag.
Remember to CLOSE the clamp on effluent sample bag.
Make sure that the tubing is not kinked at the exit point of the machine.
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Step 2: LOAD THE SET
The display will show:
“LOAD THE SET”
ou
INSTALLER LES TUBULURES
Step 6 of 6: PLACE ORGANIZER
Place the organizer on
the front of the system.
Careful: Make sure to hold the specimen bag tubing in your hand, which is not attached to the organizer, and place it on the hanger on the side of the cycler‘s table.
Pa
rt 1
Ma
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Step 3: OPEN DOOR
To unlock and open the door, pull the lever UP at the front of the cycler.
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Step 4: LOAD CASSETTE
Remember to orient the cassette with smooth side facing the machine.
7.4.4 CYCLER PREPARATION – Nurses Menu (continued)
Options & Definitions MODE : STANDARD MODE : LOW FILL VOLUME
MODE For patients with
Fill volume > 1000mL
For patients with
Fill volumes from 60mL – 1000mL
Note: You absolutely need to put a value in the option “Minimum drain time” in order for the low-fill volume mode to be saved.
Minim
um
drain volum
e
Minim
um
drain time
MINIMUM DRAIN VOLUME
The minimum volume that the patient needs to drain before the cycler moves on to the next cycle. It is marked in %.
The cycler will alarm if the minimum drain volume % has not been reached.
Setting range: 60–125% of the patient’s fill volume
Default setting: 85% of the
patient’s fill volume
(Unless otherwise specified by the physician)
Setting range: 50% –125% of the patient’s fill volume
Default setting: 85% of the
patient’s fill volume
(Unless otherwise specified by the physician)
Note: for low-fill mode, this option is used in conjunction with the “Minimum Drain Time”
Negative
UF
limit
Positive
UF
limit
Sm
art
dwells
Heater bag
empty
MINIMUM DRAIN TIME
The minimum amount of time a cycle must drain in order for the cycler not to alarm.
When a “low flow” or a “no flow” condition occurs during a drain, the cycler will either alarm or move on to the next fill depending on the settings of the “Minimum Drain Time” and the “Minimum Drain Volume”.
If the «Minimum Drain Volume” percentage is set too low, an incomplete drain could result. This could result in anoverfill. An overfill volume may result in a feeling of abdominal discomfort, and in some circumstances may cause injury to the patient.
+
MINIMUM DRAIN TIME is NOT available in Standard Mode
Setting range: 1 minute [0:01] –1 hour [1:00]
Set at: at least 1 minute [0:01]
** WARNING **
When a patient is in low fill mode, it is MANDATORY to put the minimum drain time. If not, the system will go back to standard.
7.4.4 CYCLER PREPARATION – Nurses Menu (continued)
Options & Definitions MODE : STANDARD MODE : LOW FILL VOLUME
NEGATIVE UF LIMIT
(Overfill alarm)
A negative ultrafiltration indicates that the cumulative amount drained from the patient is less than the cumulative amount filled in the patient’s peritoneum.
The patient is in a state of positive fluid balance.
This limit is set in percentage of the fill volume.
The cycler will alarm when the patient drains less than the set limit.
NEGATIVE UF LIMIT is NOT available in Standard Mode
Setting range: 20% – 60% of the patient’s fill volume
Default setting: 50% of the patient’s fill volume
The negative UF limit can be set higher for patients who absorb fluid so that the therapy can run without generating nuisance alarms.
Minim
um
drain volum
e
Minim
um
drain time
Negative
UF
limit
Positive
UF
limit
Sm
art
dwells
Heater bag
empty
POSITIVE UF LIMIT
(Dehydration alarm)
A positive ultrafiltration indicates that the cumulative amount drained from the patient is more than the cumulative amount filled in the patient’s peritoneum.
The patient is in a state of negative fluid balance.
The cycler will alarm when the patient drains more than the set limit.
POSITIVE UF LIMIT is NOT available in Standard Mode
Setting range: 0mL – 5000mL
Default Setting: OFF
Note: The system alarms whenever the cumulative drain volumes have exceeded the cumulative fill volumes set the positive UF limit setting. The alarm is informational in nature and will not prevent the therapy from completing.
Options & Definitions MODE : STANDARD MODE : LOW FILL VOLUME
SMART DWELLS PROGRAMMED
If set on “YES”, dwell times can be automatically adjusted Up or Down based on the therapy time programmed and the patient’s actual fill and drain times for each cycle. The therapy will finish on time.
If set on “NO”, the cycler will provide controlled dwell times. Each dwell will last the same time.
Setting range: YES or NO
Default Setting: YES
Setting range: YES or NO
Default Setting: YES
(IDEM to Standard Mode)
Minim
um
drain volum
e
Minim
um
drain time
Negative
UF
limit
HEATER BAG EMPTY
Presence of a heater bag on the heating cradle or not.
If set on “YES”, the cycler will allow therapy to begin with an empty heater bag. System will begin by filling the heater bag with solution connected to the supply lines.
If set on “NO”, the cycler will assume there is solution on the heating cradle at the beginning of therapy. An alarm will be posted if fluid cannot be obtained from the heater bag.
When to use an empty heater bag:
When a patient needs:
a mix of different concentrations of a solution, AND
Have small volumes/cycles.
Setting range: YES or NO
Default Setting: YES, if using an empty heater bag,
NO, if not using an
empty heater bag.
Setting range: YES or NO
Default Setting: YES, if using a empty heater bag,
NO, if not using a empty heater bag. (IDEM to Standard Mode)
Positive
UF
limit
Sm
art
dwells
Heater bag
empty
Tidal full
drains
Language F
lush
TIDAL FULL DRAINS
If set on “YES“, the cycler will ensure that each drain is a full, complete drain.
7.4.4 CYCLER PREPARATION – Nurses Menu (continued)
Options & Definitions MODE : STANDARD MODE : LOW FILL VOLUME
LANGUAGES
Selection of 14 different languages.
Setting range: Various languages
Note: If you are using English US,
HIGH DOSE will show under therapy when you set your program.
If you are using English UK,
OCPD will show.
IDEM to Standard Mode.
Minim
um drain
volume
Minim
um
drain time
Negative
UF
limit
FLUSH
If set on “YES”, during priming, the cycler will automatically flush 100 ml of solution from each bag to the drainage bag. The heater line, supply lines, and final line (if used), are each flushed. This is a preventive measure against infection.
If set on “NO”, the cycler will not flush the lines during the priming.
Setting range: YES or NO
Default Setting: YES
IDEM to Standard Mode.
Positive
UF
limit
Sm
art
dwells
Heater bag
empty
RESET WEIGHT Setting range: YES or NO
PROGRAM LOCKED
To allow user to change or not the therapy settings.
Setting range: YES or NO
Default Setting: NO
IDEM to Standard Mode.
Tidal full
drains
Language
THERAPY LOG
Allows user to review information about the 6 most recently performed therapies, not including therapy in progress. Information also available on the data card.
Flush
Program
locked
ALARM LOG
Allows user to review up to 20 of the most recent user-recoverable alarms. Includes date and time of each alarm.
7.4.5 CYCLER PREPARATION – Connection with a PEDIATRIC Cycler Tubing with Cassette
Basic Procedure Equipment
15 seconds hand washing.
Gather material:
Sterile gauze 4X4
Alcohol chlorhexidine swabs (red swabs)
Alcohol handrub sanitizer
Masks
Homechoice cycler tubing with cassette
SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area
** If the patient is wearing diapers or if the patient has a GT tube, roll a blue pad around the patient extension catheter to protect the connection from body fluids.
Ba
sic
Pro
ce
du
re
1. Close windows, doors and turn off any fans
2. Disinfect or Wash 2 working surface
areas with alcohol, SANICLOTH or disinfecting towelettes or alcohol.
Eq
uip
me
nt 3. Let dry
4. Gather material/ Con
ne
ctin
g
Pe
dia
tric tu
bin
g
5. Put on mask
6. Remove jewelry
Dis
con
nectin
g
Pe
dia
tric tu
bin
g
7. Wash hands with Chlorhexidine solution
4% for 2 mins
8. Dry hands well.
9. Close the faucets with a towel. Alcohol
handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-
30 secs). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.
To prevent contamination, Keep away from garbage cans, sinks and toilets.
7.4.6 CYCLER PREPARATION – Disconnection with a PEDIATRIC Cycler Tubing
Basic Procedure Equipment
15 seconds hand washing.
Gather material:
Sterile gauze 4X4
Alcohol chlorhexidine swabs (red swabs)
MINICAP with Povione-Iodine Solution
Alcohol handrub sanitizer
Masks
SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area
** If the patient is wearing diapers or if the patient has a GT tube, roll a blue pad around the patient extension catheter to protect the connection from body fluids.
Ba
sic
Pro
ce
du
re
1. Close windows, doors and turn off any fans
2. Disinfect or Wash 2 working surface
areas with alcohol, SANICLOTH or disinfecting towelettes or alcohol.
Eq
uip
me
nt 3. Let dry
4. Gather material Con
ne
ctin
g
Pe
dia
tric tu
bin
g
5. Put on mask
6. Remove jewelry
Dis
con
nectin
g
Pe
dia
tric tu
bin
g
7. Wash hands with Chlorhexidine solution
4% for 2 mins
8. Dry hands well.
9. Close the faucets with a towel. Alcohol
handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-
30 secs). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.
To prevent contamination, Keep away from garbage cans, sinks and toilets.
7.4.7 CYCLER PREPARATION – Connection to the child with the ADULT home choice system or CAPD Twin Bag Manual System
Basic Procedure Equipment
15 seconds hand washing.
Gather material:
Sterile gauze 4X4
Alcohol chlorhexidine swabs (red swabs)
Connection shield sysll with poviodine-iodine solution (white protective shield)
Twin bag manual PD set or Homechoice adult disposable set with cassette (according to prescription)
Alcohol handrub sanitizer
Masks
SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area
** If the patient is wearing diapers or if the patient has a GT tube, roll a blue pad around the patient extension catheter to protect the connection from body fluids.
Ba
sic
Pro
ce
du
re
1. Close windows, doors and turn off any fans
2. Disinfect or Wash 2 working surface
areas with alcohol, SANICLOTH or disinfecting towelettes or alcohol.
Eq
uip
me
nt 3. Let dry
4. Gather material Con
ne
ctin
g
Ad
ult s
yste
m 5. Put on mask
6. Remove jewelry
Dis
con
nectin
g
Ad
ult s
yste
m
7. Wash hands with Chlorhexidine solution 4% for 2 mins
8. Dry hands well.
9. Close the faucets with a towel. Alcohol
handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-
30 secs). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.
To prevent contamination, Keep away from garbage cans, sinks and toilets.
9.3.1 CAPD manual set-up with TWIN BAGS (continued)
Part 1 Preparation
15 seconds hand washing
Part 1 Preparation
Step 1 of 6:
Follow Basic Procedure
(9 steps).
Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands.
Rub hands until dry (20-30 seconds). After handrub, touch only PD supplies.
Step 5:
This is what a FISH scale looks like.
Ba
sic
Pro
ced
ure
Eq
uip
men
t
Pa
rt 1
Pre
pa
ratio
n
Step 2:
Remove TWINBAG® solution from its wrap.
Put on 2nd
clean surface
Inspect the bag for expiratory date, etc…
Step 6 of 6:
Pa
rt 2
Co
nn
ectio
n
Pa
rt 3
Dra
in
Step 3:
Disinfect your hands with Alcohol handrub.
Let your hands dry.
After handrub, touch only PD supplies.
Pa
rt 4
Prim
ing
Pa
rt 5
Fill
Step 4:
Break the inner GREEN
cone.
Hang the bag on a pole to allow the solutions to mix.
** If a medication is needed, add it now using #23 gauze needle. Please refer p52 to the protocol: Addition Of a Prescribed Medication in PD Solution section 7.1.2
Pa
rt 6
Dis
co
nne
ctio
n
Hang the FILL bag on a pole equiped with a FISH scale and place the empty bag in the drain position (lower than the patient) on a clean surface.
9.3.1 CAPD manual set-up with Twin bags (continued)
Connect – Drain – Prime – Fill – Disconnect
Part 3 Drain
Part 3 Drain
Step 1 of 5: (UNCLAMP)
Remove the YELLOW clamp (not visible) from the drain line (clear line) to drain the patient.
Step 5 of 5:
Close patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE part clockwise.
If many exchanges are done with the same TWIN BAG set-up, weigh the drainage bag after each drain to determine how much the patient drained after each drainage.
Ba
sic
Pro
ced
ure
Eq
uip
men
t
Pa
rt 1
Pre
pa
ratio
n
Step 2:
Open the patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE
part counter clockwise.
Pa
rt 2
Co
nn
ectio
n
Pa
rt 3
Dra
in
Step 3:
Please note: the GREEN cone near the connection site remains unbroken; this allows the patient’s peritoneum to drain by gravity into the drainage bag.
Pa
rt 4
Prim
ing
Pa
rt 5
Fill
Step 4: (CLAMP)
After draining, place a YELLOW clamp on drain line.
You will notice that the drain phase is finished when the drainage bag stops filling up with effluent.
9.3.1 CAPD manual set-up with Twin bags (continued)
Connect – Drain – Prime – Fill – Disconnect
Part 4 Priming
Part 4 Priming
Step 1 of 7:
Close Patient line.
Break GREEN seal nearest to patient’s connection site.
Ba
sic
Pro
ced
ure
Eq
uip
men
t
Pa
rt 1
Pre
pa
ratio
n
Step 2: (UNCLAMP)
Remove the YELLOW clamp from the fill line.
Pa
rt 2
Co
nn
ectio
n
Pa
rt 3
Dra
in
Step 3: (UNCLAMP)
Remove the YELLOW clamp from the drain line for 5 seconds. This will allow priming of the fill line and of the drain line.
Pa
rt 4
Prim
ing
Pa
rt 5
Fill
Step 4: (CLAMP)
Replace the YELLOW clamp on the drain line and the fill line.
Pa
rt 6
Dis
co
nne
ctio
n
NOTE: The dialysate does not go into the patient’s peritoneum as the patient extension piece is closed. It only flushes the lines exterior to the patient and flushes any potential bacteria from the tubing into the drainage bag.
9.3.1 CAPD manual set-up with Twin bags (continued)
Connect – Drain – Prime – Fill – Disconnect
Part 5 Fill
Notes
Step 1 of 3:
Weigh bag on scale.
Open the patient extension piece by holding the WHITE end closest to patient and turning the LIGHT BLUE
part counter clockwise.
Remove the yellow clamp on the blue line to allow filling.
The peritoneum is now filling.
Watch the scale’s numbers ↓ to infuse the right amount. See Note.
NOTE: Ensure that it is filling with the right amount of
fluid according to the prescription. The FISH scale displays the total amount of dialysate remaining in the fill bag. Weight of the bag minus fill volume = infused volume
9.3.1 CAPD manual set-up with Twin bags (continued)
Part 7 Final Check
Notes
Step 1 of 1:
Check the drainage fluid bag for clarity.
If only one exchange is needed with the same TWIN BAG® set- up, weigh the drainage bag to know how much fluid was drained from this manual PD exchange.
An accidental contamination is not something to be ignored. When the catheter is accidentally opened, a leak occurs and bacteria can enter and it can lead to a major infection
10.5.1 Basic Rules
1. Clamp the catheter with the Dravon hemostat yellow clamp by using the 2x2 underneath if disconnection is between PD catheter and extension.
2. Close roller clamp of the extension if disconnection is between catheter and tubing.
3. You can close system with cycler tubing or by putting a mini cap.
4. Call nephrologist and PD nurse.
5. Never infuse the abdomen when there is contamination.
6. Need to assess what type of contamination and get history.
7. Need to take a specimen and send for cell count & culture.
8. Need to change the extension. Usually done by PD nurse in hospital.
9. Need to cover with antibiotics with either cefepime 250 mg per liter or cefazolin 250 mg /liter for 3 days depending of contamination history.
10. Need to reassess therapy after results from cell count & culture.
11. If PD is not started yet, no infusion. Drain abdomen and take samples for cell count & culture /
change extension/ start antibiotics with cefepime or cefazolin 250mg/liter. If patient did not start PD yet and can do without a night of dialysis or has some night off, family or nurse can take the samples, disconnect from the cycler using Basic Procedure. The PD nurse will change the extension the following morning depending on the type of contamination.
12. If started PD, Stop dialysis /no more infusion/ take samples cell count & culture / change
extension/ start antibiotics cefepime or cefazolin 250 mg per liter x 3 days and reassess.
10.5.2 Accidental Contamination prior to PD Treatment
1. Make sure the system is closed with either mini cap, or Dravon hemostat yellow clamp with 2x2 underneath. Make sure roller clamp on Baxter PD extension is closed.
2. Never infuse the abdomen when there is a contamination.
3. Assess the situation and type of contamination.
4. Connect to Dialysis cycler if not already done.
5. Make sure specimen bag is connected using basic procedure. If on the cycler, you need to add a specimen bag using the basic procedures (the 9 steps). Wipe the outside specimen connection with alcohol swab 15seconds and let dry. Connect the specimen bag.
6. Drain the abdomen to collect sample for cell count & culture. You need to let drain 20 ml before
taking the samples if pediatric set up or 50 ml if adult set up.
7. Disconnect and apply a mini cap following the Basic Procedures (9steps).
8. Need to change the extension. This is usually done in hospital by the PD nurse.
9. If family can wait without dialysis until the next morning, give them the night off until next morning where PD nurse will change the extension and start antibiotics IP.
10. Cover with antibiotics for 3 days depending on cell count and culture results.
11. Cefepime 250 mg/liter or cefazolin 250 mg/ liter.
10.5.3 Accidental Contamination at the start of PD Treatment
1. Need to stop the dialysis. Make sure roller clamp on Baxter PD extension is closed
2. Make sure the system is closed and add a Dravon hemostat yellow clamp with 2x2 underneath.
3. Never re-infuse the abdomen when there is a contamination.
4. Assess the situation and type of contamination
5. Need to get samples for cell count & culture.
Make sure specimen bag is connected using basic procedure. If on the cycler,you need to add a specimen bag using the basic procedures (the 9 steps). Wipe the outside specimen connection with alcohol swab 15 seconds and let dry. Connect the specimen bag.
6. Drain the abdomen to collect sample for cell count & culture. You need to let drain 20 ml before collecting the samples if pediatric set up or 50 ml if adult set up.
7. Disconnect and apply a mini cap following the Basic Procedures (9steps).
8. Need to change the extension. This is usually done in hospital by the PD nurse.
9. Cover with antibiotics for 3 days depending on cell count and culture results.
10. Cefepime 250 mg/liter or cefazolin 250 mg/ liter.
10.5.4 Accidental Disconnection Between the Extension and Tubing
Goals:
Prevent the contamination of the catheter and reduce the risk for peritonitis.
If the white blood cell count < 100, a 3-day treatment is required.
If the white blood cell count > 100, the medical prescription will continue for a longer period and antibiotics will change according to culture results. The extension should be changed by the dialysis nurse once the white blood cells drop < 100.
Equipment:
Dressing Tray
Mask
Sterile gloves x2
Dravon hemostat yellow clamps
2x2 gauze sponge
4% Chlorhexidine soap, 0.6% Steri-gel
70% Alcohol / 2% chlorhexidine solution
Alcohol swabs
1 or 2 manual dialysis systems twinbag or you can use the cycle
PD solutions
Minicap
Extension
Procedure:
1. Clamp roller clamp on Baxter extension. Clamp the catheter with the Dravon hemostat yellow clamp by using the 2x2 under the clamp; Call the hospital or nephrologist on call.
2. Never infuse if contamination occurs, need specimen, change extension and start antibiotics.
3. Basic procedure;
4. Prepare the dialysis system; cycler or manual CAPD set up. If you are using the cycler, prime the tubing according to protocol; If you are using the twin bag, apply the yellow clamps on fill & drain line, connect the child and drain the abdomen.
5. Connect the dialysis system to the child following the protocol using cycler or CAPD manual system; Apply a white protective connecting shield and wrap around the exposed dark blue area of the extension tubing if using the twin bag CAPD system;
6. Release the yellow clamp and drain the abdomen;
10.5.4 Accidental Disconnection Between the Extension and Tubing (continued)
a. If the abdomen drains:
1. Let the abdomen drain to allow for a complete drainage of the abdominal cavity. After the drainage, take a dialysate sample for cultures and cell count;
2. Change the extension according to protocol (see Changing extension); usually done by PD nurse
3. Connect the child to a new dialysis system with antibiotic as prescribed by nephrologist; (usually
cefepime 250 mg/liter or cefazolin 250 mg/Liter for 3 days depending of contamination history)
4. Refill the child with the daily or night dwell volume depending of nephrologist.
b. If the abdomen does not drain:
1. Change the extension according to protocol (see Changing the extension); usually done by PD nurse.
2. Connect the child to a new dialysis system; use cycler or put protective shield if you use the manual CAPD twin bag.
3. Make 3 rapid exchanges (in & out) with the prescribed volume using PD solution. Take a sample on the first exchange for culture and cell count: Nephrologist will advise you for the duration of dwell time before taking the samples (30 to 90 min).
4. Connect the child to a new dialysis system with antibiotics as prescribed; use cycler or put protective shield if you use the twin bag manual CAPD system (usually cefepime 250mg/liter or cefazolin 250mg/liter for 3 days depending of the contamination history).
5. Refill the child with the daily or night dwell volume depending of situation and nephrologist.
10.6.2 How to change the Transfer Set with a titanium connector when the PD catheter is damaged (continued)
Change Baxter extension transfer set and titanium
15 seconds hand washing
Damaged PD catheter
Step 1 of 18:
Follow Basic Procedure (9 steps).
Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands.
Rub hands until dry (20-30 seconds). After handrub, touch only PD supplies.
Step 5:
Add Chlorhexidine 2% with 70% alcohol in one container of your dressing tray.
Basic
P
rocedure
E
quip
me
nt
Step 2:
Clamp the PD catheter with a YELLOW clamp (Hemostat Dravon) and a 2x2 gauze.
Step 6:
Using aseptic technique, open and drop your sterile materiel in sterile field: sterile scissors, titanium connector, PD Baxter extension set, extra 4x4.
Change B
axte
r
exte
nsio
n tra
nsfe
r set a
nd tita
niu
m
Dam
aged P
D
Cath
ete
r
Step 3:
This is a titanium connector.
Step 7:
Don your sterile gloves.
Take a 4x4 to hold catheter and put the sterile sheet under the PD catheter and use it to make a sterile surface.
Step 4:
Open your dressing tray with an aseptic technique.
.
Step 8 of 18:
Put Chlorhexidine 2% with 70% alcohol on a sterile 4 x 4 gauze.
Clean the catheter with Chlorhexidine 2% with 70% alcohol for 2 minutes where you will cut the PD catheter.
11 PROCEDURE TO COLLECT A DIALYSATE EFFLUENT SAMPLE
11.1 Purpose To maintain an aseptic environment while collecting a dialysate effluent sample
11.2 Target audience Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.
11.3 Elements of clinical activity
Table 11-1 :
Chart of prescribed tests on dialysate and characteristics (Sterile specimens taken from effluent sample bag)
Dialysis specimen:
Always use the 2 sterile containers for cell count and culture (routine and peritonitis). You have to add the blood culture bottles (aerobic, anaerobic and fungus) if suspected peritonitis only. Do not use blood culture bottle for routine cell count and culture.
Test Minimum amount of
effluent needed Type of requisition
Type of specimen container
Other specifications
C & S and gram smear
Take both specimens if suspected peritonitis
9 mL*+3ml for fungus
50ml
(always for routine and suspicion of
peritonitis)
Microbiology requisition
specify “PD effluent” on the requisition
Aerobic blood culture bottle (4 mL) YELLOW]
Anaerobic blood culture (5 mL) ORANGE]
50 ml in a sterile container with
orange lid
Do not store in the refrigerator (only orange container could go in the fridge)
Send to the lab STAT if suspect
peritonitis.
Fungus
To do only when peritonitis suspected 1 to 3 mL**
50 mL from above (same specimen but
add fungus on requisition)
Microbiology requisition
specify “PD effluent” on the requisition
send only if peritonitis
Fungus bottle (1-3ml)
Sterile specimen container same as
above (ORANGE LID 50 ML)
If amount of dialysate is less than 50 ml, send as much as possible with one cycle.
2 requisitions and 1 specimen for 50 ml. Use a separate microbiology requisition from the C & S test.
11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag with cycler
Basic Procedure 15 seconds hand
washing. Equipment
1. Close windows, doors and turn off any
fans
Gather material:
Effluent sample bag
Alcohol swabs (red) with chlorhexidine
60 mL syringe depending on kind of test
23 Gauge needle (18 if patient not connected to the dialysis system).
Sterile specimen container(s) x 2
Blood culture bottles (only if suspect peritonitis)
Appropriate laboratory requisition
Gloves and Masks
Alcohol handrub sanitizer
Refer to the Home Choice Quick Reference Guide protocol to know when to connect the effluent sample bag to the PD cassette tubing during the set-up (section8.3.4 and section12.3.1).
Basic
Pro
cedure
2. Disinfect or Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes E
quip
me
nt
3. Let dry
4. Gather material
Part 1
: Connect
Sam
ple
bag
5. Put on mask Part 2
: Positio
n
& F
ill Sam
ple
Bag
6. Remove jewelry
7. Wash hands with Chlorhexidine
solution 4% for 2 mins
Part 3
: Colle
ct
Sam
ple
8. Dry hands well.
Part 4
: Dis
card
Efflu
ent
9. Close the faucets with a towel. Alcohol
handrub. Apply a palmful of alcohol based sanitizer and rub until dry
(20-30 secs). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use Alcohol handrub or Chlorhexidine 4% solution for 15 seconds.
Connect the effluent sample bag just before the drainage bag is connected to the drain line of the PD cassette when setting up see Part 1 (section 8.3.1 8.3.4 and 12.3.1)
To prevent contamination, Keep away from garbage cans, sinks and toilets.
11.3.1 How to collect a sterile effluent sample via the EFFLUENT sample bag (continued)
Part 2: Position & Fill Sample Bag
Part 2: Position & Fill Sample Bag
Part 2:
All sterile samples are collected from the effluent sample bag at the beginning of the last drain of a PD
therapy (routine culture) unless otherwise specified by the physician or if peritonitis. The effluent sample bag is then detached from the PD set-up at the end of therapy, after the patient is disconnected from the PD set-up.
If you need a sterile specimen STAT during the course of the therapy:
i. Follow step 1 at the beginning of the drain of any cycle.
ii. KEEP THE EFFLUENT SAMPLE BAG ATTACHED
to the PD set- up (skip step 2).
iii. Follow Basic Procedures.
iv. Go to step 3.
v. Call the porter to take the specimen STAT to the lab
Step 3:
Once the effluent sample bag is full, close the 2 clamps.
Reopen the drain bag to complete the dialysis.
Basic
P
rocedure
E
quip
me
nt
Step 4:
Make sure the patient is disconnected from the PD set-up. Use # 23 needle if patient still connected to set-up
Disinfect hands with Steristat 0,5%.
Let them dry.
Part 1
: Connect
Sam
ple
bag
Step 1 of 6:
When the drain phase start, the effluent sampling bag must be closed at the beginning. You need to first drain the dead space before collecting the sample.
This is to prevent collecting fluid fro-m the previous fill (dead space).
Part 2
: Positio
n
& F
ill Sam
ple
Bag
Step 5:
Don clean gloves (the effluent sample is a biological waste).
Part 3
: Colle
ct
Sam
ple
Step 2:
If using a PEDIATRIC set, let drain a minimum of 20 mL of the last
drain into the drainage bag and then open the clamps on the effluent sampling site and effluent sample bag.
If using an ADULT set, let drain a minimum of 40 mL of the last drain
into the drainage bag and then open the clamps on the effluent sampling site and effluent sample bag
Part 4
: Dis
card
E
ffluent
Step 6 of 6:
Disconnect the effluent sample bag from the Y-junction line.
Collecting an Effluent Sample via the PD Baxter Cycler System
11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE
Table 12-2 : Chart of prescribed test on dialysate and characteristics
Test & Purpose Minimum amount of
effluent needed Type of requisition
Type of specimen container
Other specifications
Creatinine clearance and urea
(24-hour collection)
Purpose:
To monitor patient’s status and the efficiency of the PD treatment.
50 mL Yellow biochemistry requisition
1. In Oasis or the requisition Biochemistry section, under “URINE”, cross-out “URINE” and write “PD EFFLUENT”.
2. Write the total amount of dialysate
contained in the drainage bag on requisition:
*Add up the drains from the “OUT” column on your
IN/OUT sheet, including the 1st drain
OR
*Calculate: Volume/Cycle x # of Cycles + Initial Drain + cumulative UF written on the cycler.
3. Write duration, time of start and end of collection.
4. Check “CREATININE”, “CREATININE
CLEARANCE”, “PROTEIN TOTAL”,
lytes and write UREA beside
“OTHER”.
5. Write the patient’s dry weight and height.
Non sterile specimen container (yellow lid)
In the program, put dextrose to same. Do not use extraneal or the blue line for that evening only.
**You should empty the drainage bag before the therapy starts to remove the accumulated fluid from the flushing of the tubing (this fluid may alter the results of the test).
If 2 drainage bags are attached to the system, place them at the same level from the start of the therapy so that the effluent dialysate can equally spread in the 2 drainage bags for the duration of the PD. You may take a sampling from each bag in equal amount in same container.
Mix the drainage bag contents before taking the sample. Take the
sample at the end of therapy when patient is disconnected.
Draw a BLOOD
specimen at the same time for urea and creatinine.
11.3.3 How to collect an effluent sample via the DRAINAGE bag for CREATININE CLEARANCE (continued)
Collect effluent sample from drainage bag
Collect effluent sample from drainage bag
Step 9 of 11:
Close white and blue clamps.
Co
llect e
ffluen
t sa
mp
le fro
m
dra
inag
e b
ag
Step 10:
Close specimen container tightly.
Co
llect e
ffluen
t sa
mp
le fro
m th
e
Pe
dia
tric S
etu
p
Step 11 of 11:
Use printed label from Oasis
or Label container as “PD effluent”. Clearly mark the patient’s name, hospital number and total drained volume for the night on the label.
Complete appropriate requisition
Note: Remember to draw a BLOOD sample at the same time (urea and creatinine) and send PD effluent for urea, creatinine, protein and write the total amount of effluent drained.
11.3.4 How to collect an effluent sample via the PEDIATRIC SETUP
Collect effluent sample from the Pediatric Setup
15 seconds hand washing
Collect effluent sample from the Pediatric Setup
Step 1 of 4:
Effluent procurement with the Pediatric set up use the sampling port below the drainage soluset.
Follow Basic Procedure
Disinfect your hands with Alcohol handrub.
Let your hands dry.
Step 3:
Drain some effluent from the patient into the drainage soluset.
Do not overfill the soluset to prevent the vent from getting wet and causing a system malfunction.
Co
llect e
ffluen
t sa
mp
le fro
m
dra
inag
e b
ag
Step 2: (old version)
Clean sampling port with alcohol swab with chlorhexidine (red swab) for 15 secs. and let dry.
Step 4 of 4:
Clean sampling port with alcohol chlorhexidine swab (red swab) for 15 secs. and let dry.
Use a 60 ml syringe and 23 gauge needle.
Puncture the sampling port with the needle and draw approximately 60 mL or as much as you can if small volume: 5 mL for cell count and 50 mL for culture (as much
as you can) and put in 2 orange sterile containers.
Send orange containers and blood culture bottle (if enough PD fluid) as well if peritonitis is suspected otherwise use the orange containers for routine culture and cell count
12.4.1 How to set-up the pediatric manual CAPD system
Basic Procedure
15 seconds hand washing
Equipment
1. Close windows, doors and turn off any
fans
Gather material:
PD-Paed system (# 5895) (including 4 liters drainage bag)
Solution bags: Physioneal : 1.36% (72099),
2.27% (72098)
3.86 % (72094) Dianeal : 0.5% 7110
SAFE LOCK APD LUER-LOCK CONNECTOR 4 inch 72092
STAY SAFE CAP 72101
DRAVON hemostats (YELLOW clamps) # 5876
Chlorhexidine with 70% Alcohol swabs (red swab)
Syringe for heparin / Needle 23 gauge
Alcohol handrub hand sanitizer
Masks
SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area
Basic
Pro
cedure
2. [Disinfect] Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes and let dry
Equip
me
nt
3. Let dry
4. Gather material
Part 1
:
PD
PA
ED
S
ET
5. Put on mask
Part 2
:
PD
PA
ED
SE
T
6. Remove jewelry
Part 3
:
PD
PA
ED
S
ET
7. Wash hands with Chlorhexidine solution 4% for 2 mins and dry hands well. (Close the faucets with a towel)
8. Dry hands well
9. Close the faucets with a towel. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 seconds). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use SteriGel+ 0.5% or Chlorhexidine 4% solution for 15 seconds.
To prevent contamination, Close the faucets with a towel, keep away from garbage cans, sinks and toilets.
12.4.1 How to set-up the pediatric manual CAPD system (continued)
Part 3: PD PAED SET
Part 3: PD PAED SET
Step 1 of 10 :
Install solution bag and 2 solusets on an IV pole.
A= Soluset receives solution for dialysis.
B= Soluset receives
drainage from dialysis.
Step 2:
Step 4 :
Open blue clamp below solution bag to partially fill soluset “A” then close when done.
**Do not overfill soluset “A”. This is to prevent the vent from getting wet. Should the vent get wet it can cause a system malfunction**
Basic
P
rocedure
E
quip
me
nt
Step 5 :
Fill the soluset with the amount prescribed.
Fill the drip chamber partially by squeezing it. (The drip chamber contains exactly 10 ml if fully filled) • Ensure that the ball of the safety valve is floating.
Part 1
: P
D P
AE
D S
ET
P
art 2
: P
D P
AE
D S
ET
Step 2 :
Use the holder if available
Step 6 :
PRIMING:
Need to put a YELLOW
clamp on the patient end after the Y (fill and drain line join).
Prime tubing from soluset “A” (fill soluset) to the soluset “B” (drain soluset).
Part 3
: P
D P
AE
D S
ET
Step 3 :
This is a clamped system.
Open clamp and break the cone
Step 7 :
When finished priming fill and drain line, close the clamps.
Make sure not to fill soluset “B” with any dialysis solution or empty the drain soluset each time for accurate reading.
SANICLOTH, disinfecting towelettes or alcohol to disinfect and wash the working surface area
Masks
Basic
Pro
cedure
2. [Disinfect] Wash 2 working surface areas with alcohol, SANICLOTH or disinfecting towelettes and let dry
Equip
me
nt
3. Let dry
Change S
tayS
afe
Cath
ete
r
4. Gather material
5. Put on mask
Dam
aged
Tra
nsfe
r Set
6. Remove jewelry
7. Wash hands with Chlorhexidine solution 4% for 2 mins and dry hands well. (Close the faucets with a towel)
8. Dry hands well
9. Close the faucets with a towel. Alcohol handrub. Apply a palmful of alcohol based sanitizer and rub until dry (20-30 secs). After handrub, touch only PD supplies.
If your hands become contaminated, remember to use SteriGel+ 0.5% or Chlorhexidine 4% solution for 15 seconds.
To prevent contamination, Close the faucets with a towel, keep away from garbage cans, sinks and toilets.
Disinfect your hands with Alcohol handrub. Apply a palmful and cover all surfaces of hands. Rub hands until dry (20-30 secs). After handrub, touch only PD supplies.
This is the STAY SAFE CAP
Step 5 of 7:
Put a YELLOW clamp
on the PD catheter with a 2x2 underneath to protect and close catheter
Basic
P
rocedure
E
quip
me
nt
Step 2:
Wipe outside Stay safe patient connection with alcohol chlorhexidine swab for 15 secs. Let dry
Put a 2x2 underneath the catheter
Step 6 of 7:
Open the stay safe cap.
You will see the blue pin that closed the catheter
Put the stay safe cap. The pin will perforate the stay safe cap to release proviodine.
Part 1
Connectio
n
Pro
cedure
Part 2
Connectio
n
Pro
cedure
Step 3 of 7:
Turn and push.
Turn clockwise the blue push button situated closest to the catheter connection tubing
Step 7 of 7:
You can remove the yellow clamp
Part 3
Dis
connectio
n
Pro
cedure
Part 4
Dis
connectio
n
Pro
cedure
Step 4 of 7:
Push to the end the blue pushbutton to introduce the pin in the extension of the patient.
Make sure the clamp is not on when you push the pin because it will create a pressure that could make the pin fall
15 PROCEDURE TO SAFELY DISPOSE OF BIOLOGICAL DIALYSATE EFFLUENT
15.1 Purpose
To properly dispose of anatomical biological dialysate effluent using universal precautions.
15.2 Target audience
Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.
15.3 Elements of clinical activity
Dialysis effluent is a non-anatomical biological waste.
It is a body fluid for which universal precautions apply.
The effluent measured from the drainage bag must be discarded into the toilet or in the unit’s drain in utility room (or where bed pans are emptied on your unit).
To monitor and keep a record of the patient’s fluid balance.
16.2 Target audience
Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.
16.3 Elements of clinical activity
Table 16.1 Guidelines for charting dialysis exchanges
1. Write the name of the patient and his / her unit number or stamp with a card on Peritoneal Dialysis Record flowsheet
2. Enter patient`s weight before starting PD and post dialysis ( with last fill volume ).
3. To detect any signs of dehydration: every morning post-dialysis,
Take a postural BP and heart rate ( lying and standing ) 60 seconds apart.
If the patient has already gotten up in the morning, make him/her lie down for 10 minutes first.
If there is a decrease of 20 mmHg for BP and/or increase beats/min for HR( between lying and standing ), advise the physician.
4. Use time or time intervals when recording exchange, e.g.: write 15:00 – 15:50 for Infusion / Dwell, 15:50 – 16:00 Drain, mainly for CAPD, time CCPD.
5. Number of cycles according to infusion, e.g. first infusion write « 1 ». The number of cycles does not become « 0 » at midnight. They add up for the length of the overnight treatment. For 6S and 6N: if 24 hours dialysis restarts at midnight.
6. Write volume infused (in mL).
7. Write type of solution, e.g. Dianeal 2.5% or Physioneal 2.27% .
8. Write any added medications, e.g. : Heparin 500u /L
9. Use a different line to record drainage / output using time intervals.
10. Record volume drained (in mL).
11. Calculate balance for the cycle, indicate clearly if balance is positive (+) or negative (-). i.e. Balance is ( + ) if volume infused > drained Balance is negative ( - ) if volume infused < drained.
12. Enter cumulative balance.
13. Describe quality of the effluent, e.g.: clear, cloudy, presence of fibrin, blood, clots, sediment.
14. The daily PD record is kept at the bedside. Use a new sheet daily.
Table 19.1 How to perform a PET test 15 seconds hand washing
1. Basic Procedure (9 steps). Apply a palmful of Acohol handrub and cover all surfaces of hands. Rub hands until dry (20-30 seconds).
2. Prepare 2 dialysis set ups (one to drain the patient and the other to fill and do PET test).
3. Infuse approximatively 1100 cc / SAM2 of 2.5 % dialysis solution on the evening prior to the PET and allow to dwell for 8 to 12 hours or the patient’s prescription fill volume. Note time of last infusion at home.
4. The following day, go to your scheduled appointment for the PET.
5. Connect a dialysis system and drain abdomen over 20 minutes. Record volume and send samples for cell
count and culture ( hematology and culture ) and for urea, creatinine, glucose , sodium ( write total volume drained ).
6. Prime and connect a new dialysis system with connective shield following the basic procedure and re-infuse 1100 cc /SAM2 or usual home cycling fill volume of a new 2.5% or 2.27% dialysis solution over exactly 10 minutes. Ask the patient to roll intermittently from side to side. Zero dwell time is the time the infusion is completed.
7. At 0, 1, 2 and 4 hours, obtain dialysate samples and blood sample at 2 hours as follows :
a. Basic procedure (mask, wash hands and dry them well…) before each sampling.
b. Drain dialysate samples (approx. 5 mL / Kg) into drainage bag.
c. Mix sample in the drainage bag.
d. Rub injection port with red alcohol swab x15 seconds and let dry. This cleaning is to be done before and after each sample is taken.
e. Obtain 5 mL sample through injection port of drainage bag with needle # 23 and syringe.
f. After each sample is taken, re-infuse remaining dialysate from drainage bag to the patient.
8. Send the dialysate samples to the biochemistry lab for sodium, glucose, creatinine, urea and protein to the nephrology lab. Write the total volume on first overnight sampling and on the last drain.
9. Draw a single serum for sodium, glucose, creatinine and urea at 2 hours dwell time. Send to biochemistry lab.
10. After 4 hours, drain the patient completely over 20 minutes. Record the volume drained. Mix sample in the drainage bag. Obtain a 5 ml dialysate sample and send to biochemistry lab for sodium, glucose, creatinine and urea to the nephrology lab.
11. Infuse his regular day volume with the appropriate solution.
19 PROCEDURE TO PERFORM AN INTRAABDOMINAL PRESSURE MESUREMENTS (IPP)
19.1 Purpose
IPP should be measured in all PD patients in an effort to optimize clearance and ultrafiltration.
Pressures above 18 cm H2O are associated with discomfort and must be avoided.
Increase volume slowly accommodating 1 to 3 weeks.
Maximum tolerable IPV that results in an IPP of 15 to 18 cm H2O. Aim for 14.
IPPs in children need to be done in recumbent position. IPP should be performed in patients when: we need to increase the intraabdominal volume faster than protocol, or when the volume is reaching 1100 mL/m
2 or for clinical assessment of the patient.
19.2 Target audience
Nursing and medical staff responsible for the care of the patient on peritoneal dialysis.
19.3 Elements of clinical activity
Table 19.1 Guidelines for preparation for a IPP test
1. Make sure the bladder is empty.
2. Heat the dialysis bag for comfort.
3. Zero level of the column (on graduated scale) is set at the center of the abdominal cavity i.e. Medial axillary line.
4. You could use the Pain Scale to assess comfort and volume tolerance.
5. Patient needs to be in a supine position
6. Recommended to use a neutral Ph solution: reduces IPP (physioneal)
7. Never go higher than 18 cmH2O. Aim for 14 cmH2O.
Make sure patient uses the bathroom prior to the test
Table 19.2 Procedure for preparation for a IPP test 15 seconds hand washing
1. Basic procedure (9 steps).
2. Patient is at rest, lying completely flat.
3. Set up 2 manual systems (twinbag CAPD manual set up is preferred) physioneal 1.36%.
4. Connect patient and drain the abdominal cavity completely.
5. Connect to the 2nd set up and fill the abdomen with regular volume – minus 50 mL.
6. Put the drain line on manometer and hang the drain bag on the pole.
7. Open the drain line assess the PD fluid
8. With a manometer, measure the level of PD solution with the zero at mid-abdomen. Take the level of pressure on inspiration and expiration, calculate the mean pressure generated.
9. Level of the column of dialysis fluid in the PD line is read with the scale graduated in cm after the height of the column stabilises, firstly after inspiration, secondly after expiration.
10. Mean IPP = IPP insp + IPP exp 2
11. Zero level of the column, on the graduated scale, is set at the center of the abdominal cavity, on the medial axillary line.
12. Repeat the same procedure by adding 50 mL at each cycle up to maximum of 1400 mL/m2