What are the pre-operative clearance requirements for peritoneal dialysis (PD) catheter placement?

From the Guidelines

Pre-operative clearance for peritoneal dialysis catheter placement should ideally include placement of the catheter at least 2 weeks before the anticipated start of dialysis treatments. This recommendation is based on the clinical practice guidelines for vascular access, as outlined in the American Journal of Kidney Diseases 1. The guidelines suggest that a backup HD access does not need to be placed in most patients, and a PD catheter may be used as a bridge for a fistula in appropriate patients.

When considering pre-operative clearance, the following evaluations and preparations are typically necessary:

• Comprehensive evaluation to ensure patient safety and optimal outcomes
• Complete blood count, comprehensive metabolic panel, coagulation studies (PT/INR, PTT), and electrocardiogram
• Cardiac clearance for patients with significant cardiac history, which could include stress testing or echocardiography
• Screening for nasal Staphylococcus aureus carriage with mupirocin ointment recommended for those who test positive
• Bowel preparation with polyethylene glycol solution the day before surgery to reduce the risk of bowel perforation
• Showering with chlorhexidine soap the night before and morning of surgery
• Discontinuation of blood-thinning medications according to their specific half-lives
• Prophylactic antibiotics, usually a first-generation cephalosporin like cefazolin 1-2g IV, administered within 60 minutes before incision
• Fasting for at least 8 hours before surgery

These measures help minimize infection risk, which is particularly important as infection is the leading complication of PD catheter placement and can compromise the success of peritoneal dialysis therapy. The guidelines from 1 provide a foundation for the pre-operative clearance process, emphasizing the importance of timely catheter placement and appropriate patient preparation.

From the Research

Pre-Operative Clearance Requirements for Peritoneal Dialysis Catheter Placement

• The management of patients on anticoagulant or antiplatelet therapy who require peritoneal dialysis catheter placement is crucial to minimize the risk of thromboembolism and bleeding 2.
• Patients on warfarin, aspirin, or clopidogrel may need to have their therapy interrupted before the procedure, and bridging anticoagulation with low-molecular-weight heparin may be necessary 2.
• The choice of catheter placement technique, whether percutaneous, surgical, or laparoscopic, depends on the patient's condition and the physician's experience 3, 4, 5.
• Percutaneous placement is a well-tolerated and rapidly performed procedure that can be done in patients who are unfit for general anesthesia or hemodialysis 5.
• The use of heparin in peritoneal dialysis is a common practice, but its routine use as an additive to dialysate fluid has been questioned, and its administration should be carefully considered 6.

Catheter Placement Techniques

• Percutaneous placement is a minimally invasive technique that can be done under local anesthesia, but it carries a risk of bowel perforation and catheter malpositioning 3, 4, 5.
• Surgical placement is a more invasive technique that requires general anesthesia, but it allows for correct catheter positioning and adhesiolysis 4.
• Laparoscopic placement is a minimally invasive technique that combines the advantages of percutaneous and surgical placement, but it requires specialized equipment and expertise 4.

Complications and Management

• The major complications of peritoneal dialysis catheter placement include bleeding, dialysate leakage, and catheter malpositioning, which can be managed with appropriate medical and surgical interventions 4, 5.
• Late peritonitis is a major drawback of peritoneal dialysis treatment, and temporary or permanent changeover to hemodialysis may be necessary in some cases 4.