PERITONEAL DIALYSIS PROCEDURE IN CHILDREN
Peritoneal dialysis in children is a commonly done procedure in children. There are several indication which includes both renal and non-renal. This post illustrates the procedure of peritoneal dialysis in pediatric patients in simplest way. The prerequisites are to make sure about indication and to rule out contraindication beforehand and off course a written consent.
CHECK:
This is what we require, a surgical tray with gauze, cotton, 2% chlorhexidine with alcohol (AHD), wide bore cannula around 20 F.
Next thing which we require is peritoneal dialysis (PD) catheter. It is available in two standard sizes pediatric and adult. For older children we can use adult catheter.
Patient should be well sedated. we generally use midazolam, ketamine.
Use of local anesthetist, reduces need of more systemic sedation and analgesia and facilitates procedure. Once the site of puncture selected, infiltrate xylocaine locally.
Once sedated the Next step is to select the site of puncture.
1. 2 to3 cm below umbilicus in midline
2. Either of iliac fossa
3. Supraumbilical
We prefer 2 cm below umbilicus in midline . Puncture the site using wide bore IV cannula holding it perpendicular to abdominal wall.
Connect IV cannula to peritoneal dialysis fluid bag and run 20ml/kg PD fluid to create artificial ascites, if there is already ascites this step can be skipped. This is require to avoid injury to bowel and other organ while inserting trocar.
Once artificial ascites created, remove IV cannula make a small incision around 1 cm deep at the same puncture site. Make sure it is not too large as it might cause leak after insertion of PD catheter.
Now hold the appropriate size PD catheter along with stylet perpendicularly and insert in peritoneal cavity through incision made previously. While inserting use screwing / twisting like movements. If incision is nicely made, this step becomes easy. Otherwise the insertion might require unnecessary force. On contrary large incision can cause leak.
Once inside the peritoneal cavity, there will be sudden loss of resistance. Once inside the peritoneal cavity withdraw the trocar's pointed tip inside the catheter (1 or 2 cm), before advancing further. This will prevent internal organs from getting injured.
Start inserting the catheter and direct it towards left pelvic gutter. Make sure all the perforation at the end of catheter are inside the peritoneal cavity. Advance the catheter at a length where free flow of PD fluid is obtained, generally resistance is met after few cm, stop here and check for outflow, don't unduly try force it down.
Remove the stylet and there will be gush of PD fluid, block it with the stopper in L bend. (Described below). There is a small bead with catheter. It also can be used as a marker to avoid too deep insertion. You can fix it at approximate length before insertion of PD catheter.
Connect the PD catheter to to L bend connector which is provided with catheter. If not available we can use 3 way stop cock, however it is always a good practice to get appropriate connectors. Thisavoids leak, prevent the area from soiling and prevents infection. The distal end of L bend is connected to Y connector tubing.
The stem of Y tubing is connected with L bend. One arm of Y connector (Or 3 way) is connected to pediatric micro drip IV set which is connected the the PD fluid bottle hanging above. For acute PD we prefer PD fluid in bottles as it is easy to connect to microdrip set.
The Second end of Y connector ( or 3 way) is connected to urinary bag with urometer, so that the outflow can be measure easily in every cycle. So The microdrip set for measuring the volume of inflow while, Urometer for measuring outflow volume precisely. Use flow regulators in both connection to start/ stop inflow or outflow
PD fluid for CAPD, comes with outflow collecting bag. The bags have individual flow regulators, so you can stop the inflow and start outflow or vise versa. The bags are connected in close ci, so it is good for preventing infection, however for measuring the outflow in collecting bag, we will have to use weighing machine.
Fix the catheter to the abdominal wall with adhesive tape in the fashion shown below, after covering the entry site with sterile gauze. A purse string suture may be put to ensure the catheter position. This is also useful if there is pericatheter leak.
The catheter insertion site should be kept clean and dry at all times. All the handling should be done with sterile gloves or sterile hand care plastic gloves. Place a sterile towel below the catheter and its connections. The connection sites should be handled only when required.
CHECK:
- Whether the bladder is emty, catheterise if required. This prevents accidental injury to bladder
- Examine the insertion site for any infection.
- Use complete aseptic precaution
EQUIPMENT:
This is what we require, a surgical tray with gauze, cotton, 2% chlorhexidine with alcohol (AHD), wide bore cannula around 20 F.
Next thing which we require is peritoneal dialysis (PD) catheter. It is available in two standard sizes pediatric and adult. For older children we can use adult catheter.
SEDATION
Patient should be well sedated. we generally use midazolam, ketamine.
Use of local anesthetist, reduces need of more systemic sedation and analgesia and facilitates procedure. Once the site of puncture selected, infiltrate xylocaine locally.
SELECTION OF PUNCTURE SITE
Once sedated the Next step is to select the site of puncture.
1. 2 to3 cm below umbilicus in midline
2. Either of iliac fossa
3. Supraumbilical
We prefer 2 cm below umbilicus in midline . Puncture the site using wide bore IV cannula holding it perpendicular to abdominal wall.
Connect IV cannula to peritoneal dialysis fluid bag and run 20ml/kg PD fluid to create artificial ascites, if there is already ascites this step can be skipped. This is require to avoid injury to bowel and other organ while inserting trocar.
Once artificial ascites created, remove IV cannula make a small incision around 1 cm deep at the same puncture site. Make sure it is not too large as it might cause leak after insertion of PD catheter.
INSERTION OF PD CATHETER
Once inside the peritoneal cavity, there will be sudden loss of resistance. Once inside the peritoneal cavity withdraw the trocar's pointed tip inside the catheter (1 or 2 cm), before advancing further. This will prevent internal organs from getting injured.
Start inserting the catheter and direct it towards left pelvic gutter. Make sure all the perforation at the end of catheter are inside the peritoneal cavity. Advance the catheter at a length where free flow of PD fluid is obtained, generally resistance is met after few cm, stop here and check for outflow, don't unduly try force it down.
Remove the stylet and there will be gush of PD fluid, block it with the stopper in L bend. (Described below). There is a small bead with catheter. It also can be used as a marker to avoid too deep insertion. You can fix it at approximate length before insertion of PD catheter.
Connect the PD catheter to to L bend connector which is provided with catheter. If not available we can use 3 way stop cock, however it is always a good practice to get appropriate connectors. Thisavoids leak, prevent the area from soiling and prevents infection. The distal end of L bend is connected to Y connector tubing.
The stem of Y tubing is connected with L bend. One arm of Y connector (Or 3 way) is connected to pediatric micro drip IV set which is connected the the PD fluid bottle hanging above. For acute PD we prefer PD fluid in bottles as it is easy to connect to microdrip set.
The Second end of Y connector ( or 3 way) is connected to urinary bag with urometer, so that the outflow can be measure easily in every cycle. So The microdrip set for measuring the volume of inflow while, Urometer for measuring outflow volume precisely. Use flow regulators in both connection to start/ stop inflow or outflow
PD fluid for CAPD, comes with outflow collecting bag. The bags have individual flow regulators, so you can stop the inflow and start outflow or vise versa. The bags are connected in close ci, so it is good for preventing infection, however for measuring the outflow in collecting bag, we will have to use weighing machine.
FIXING THE PD CATHETER
Fix the catheter to the abdominal wall with adhesive tape in the fashion shown below, after covering the entry site with sterile gauze. A purse string suture may be put to ensure the catheter position. This is also useful if there is pericatheter leak.
The catheter insertion site should be kept clean and dry at all times. All the handling should be done with sterile gloves or sterile hand care plastic gloves. Place a sterile towel below the catheter and its connections. The connection sites should be handled only when required.
Revised: 09/2017
 | ABOUT AUTHOR: Dr Ajay Agade is a Pediatric Intensivist at Aster Medcity, Kochi, passionate about free online access medical education, acute care and patient safety. He is editor of dnbpediatrics and criticalpediatrics blogs | View Ajay Agade’s posts |  |  |  |  |
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