Recommended Approach for Peritoneal Dialysis Catheter Insertions
The recommended approach for peritoneal dialysis catheter insertion is the open surgical technique, which provides the most reliable and secure access with fewer early mechanical complications compared to percutaneous insertion. 1
Insertion Techniques
Open Surgical Technique
- Preferred method due to direct visualization, which reduces the risk of technical failures and early mechanical complications 1
- Particularly advantageous for patients with previous abdominal surgeries 1
- Demonstrates better outcomes with fewer catheter removals due to mechanical complications (1.3% vs 7.9% with percutaneous approach) 1
- Allows for proper positioning of the catheter tip under direct visualization 1
Laparoscopic Technique
- Effective alternative that allows for visualization and adjunctive procedures 2
- Can be performed using nitrous oxide pneumoperitoneum under procedural sedation in suitable candidates 2
- Enables additional procedures such as omentopexy and adhesiolysis to prevent catheter flow problems 2
- Simplified one-port laparoscopic techniques have shown good results with minimal complications 3
Percutaneous Technique
- Associated with higher rates of early mechanical complications (11.2% vs 0% with open technique) 1
- Higher technical failure rates (5.6% vs 0% with open technique) 1
- May be considered in select patients without history of abdominal surgeries 1
- Can be performed under local anesthesia with sedation, avoiding general anesthesia 4
Infection Prevention During Insertion
Maximal Sterile Barrier Precautions
- Use cap, mask, sterile gown, sterile gloves, and sterile full body drape during insertion 5
- Prepare skin with 0.5% chlorhexidine preparation with alcohol 5
- If chlorhexidine is contraindicated, use tincture of iodine, an iodophor, or 70% alcohol 5
- Allow antiseptics to dry according to manufacturer's recommendations prior to catheter placement 5
Post-Insertion Care
- Use either sterile gauze or sterile, transparent, semi-permeable dressing to cover the catheter site 5
- Replace dressings if they become damp, loosened, or visibly soiled 5
- Do not use topical antibiotic ointment or creams on insertion sites except for dialysis catheters 5
- Monitor the catheter site visually when changing the dressing or by palpation through an intact dressing 5
Contraindications and Special Considerations
Relative Contraindications for Peritoneal Dialysis
- Inflammatory or ischemic bowel disease and frequent episodes of diverticulitis increase risk of peritonitis 5
- Abdominal wall or skin infection can lead to contamination of the catheter exit site 5
- Morbid obesity poses challenges in catheter placement, healing, and providing adequate dialysis 5
- Severe malnutrition compromises wound healing and may not tolerate peritoneal protein losses 5
Timing Considerations
- Allow adequate healing time (6-16 weeks) after placement of prosthetic devices or materials to avoid leakage or peritonitis 5
- For patients with vascular grafts, consider the risk of bacterial seeding during hemodialysis 5
Management of Complications
Mechanical Complications
- Monitor for pericatheter/incision leakage, flow obstruction, hernia, hemoperitoneum, and catheter migration 2
- Address catheter migration promptly to prevent dysfunction 2
- Consider revision or replacement if mechanical issues persist 1
Infectious Complications
- Monitor for exit site infections and peritonitis 2
- For Aspergillus peritonitis, removal of peritoneal dialysis catheter and intraperitoneal dialysis with AMB, in addition to IV administration of AMB, are recommended 5
- Promptly address any signs of infection to prevent catheter loss 2