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Pediatric Peritoneal Dialysis

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									Complications of Dialysis

        Presented by :
   Saud Mahmoud RN BScN
Complications of Dialysis
 Infectious


 Non Infectious
         Patient Assessment
 Daily weight
 Blood pressure lying and standing
 Physical assessment observing for signs fluid
  overload /dehydration
 Temperature
 Blood chemistry
 Observe for complications
Patient Assessment cont
           Patient Assessment
 Ask patient about bowel habits
 Check if patient has urine output
 Check exit site on admission
1. Culture if infection suspected


 Check clarity of PD fluid
      Infectious Complications
 Peritonitis


 Exit site infection


 Tunnel infection
Definition:
 Peritonitis is a generalized or localized
   inflammation of the peritoneum.
 This condition most often results from
   contamination and may be a complication of
   one of the following:
1. Diverticulitis
2. Colitis
3. Peritoneal Dialysis
4. Appendicitis
         Causes of Peritonitis
Organisms enter the peritoneum in various
ways namely:

Intraluminal - infections travel to the
peritoneum via the catheter. Touch
contamination or damaged PD systems are
examples of this method of entry.

Per luminal - – bacteria entering the
peritoneum via the peritoneal tract or tunnel,
e.g. exit site infection.
          Causes of Peritonitis
• Tran mural - bacteria enter the peritoneum
  through the bowel wall, e.g. constipation.

• Hematogenous - infections come from the blood
  stream.

• Transvaginal - organisms can travel through the
  reproductive tract.
                      Common Organisms
  Gram Positive:
Organism                     Port of Entry   Information

Diptheroids                  Intraluminal    Normal Skin flora – poor hygiene
                             Periluminal     / break in technique and poor
                                             handwashing

Enterococcus                 Transmural      Fecal organisms, sometimes
                                             hospital acquired – cross
                                             contamination

Staphylococcus Aureus        Intraluminal    Nasal Carrier
                             Periluminal

Staphylococcus Epi           Intraluminal    Due to break in technique (touch
(Coagulase negative staph)   Periluminal     contamination)

Streptococcus                Intraluminal    Found in soil, water, vegetation
                             Periluminal     and dairy products. Normal GI
                             Hematogenous    flora and respiratory tracts
                 Common Organisms
 Gram negative:

Organism               Port of Entry   Information

Acinetobacter          Intraluminal    Found in soil, water and sewage
                       Periluminal
Enterobacteria         Transmural      Indication of fecal contamination



Escherichia (E.Coli)   Intraluminal    Found in nature, animal and
                       Periluminal     human intestinal tract
                       Transmural
Hemophilus             Intraluminal    Organisms from this species are
                       Periluminal     normal of the upper respiratory
                                       tract
                  Common Organisms
  Gram negative:

Organism             Port of Entry   Information

Klebsiella           Intraluminal    Normal flora of the GI tract,
                     Periluminal     colonization of the upper
                                     respiratory tract
Proteus Species      Intraluminal    Found in soil, water and sewage.
                     Periluminal     Normal fecal flora
                     Transmural

Pseudomonas          Intraluminal    Found in soil and water
                     Periluminal


Serratia             Intraluminal    Hospital acquired
                     Periluminal
Common Organisms
 Yeast:
Organism            Port of Entry   Information

Candida Albicans    Intraluminal    Diabetes, those on antibiotics at
                    Periluminal     high risk. Moist exit sites
                    Transvaginal



 Mycobacterium:

 Organism           Port of Entry   Information

 Mycobacterium TB   Hematogenous    Diagnosis: lymphocytes in PD
                                    fluid cell count often elevated.
Peritonitis
         Signs and Symptoms
 Cloudy fluid


 +/- Fever


 Abdominal pain


 Nausea/ vomiting
    Classification of Peritonitis
 Recurrent Peritonitis - an episode that occurs
  within four weeks of completion of therapy of a
  prior episode but with a different organism.

 Relapsing Peritonitis - an episode that occurs
  within four weeks of completion of therapy of a
 prior episode with the same organism or one
 sterile episode.
     Classification of Peritonitis
 Refractory peritonitis - failure to respond to
  appropriate antibiotics within 5 days.
  Recommendation – catheter removal to protect
  the peritoneal membrane for future use.

 Re-infection - new episode 4 weeks after
  completion of treatment.
         Nursing Intervention
 Obtain dialysate effluent from the first bag
    BFH (body fluid hematology) Lavendar tube
    Gram stain & culture ( send whole bag)


 Strict aseptic technique with collection


 Specimens sent to lab       STAT
            Immediate care
 Specimens sent to lab STAT


 Perform 3 quick flushes


 4th bag add the loading dose of antibiotics and
  heparin as prescribed

 The loading dose must dwell for 6 hrs
                  Diagnosis
 BFH - White cell count >100mm3


 Polymorph more than 50%


 Gram stain – positive


 Culture


 Cloudy effluent and abdominal pain
    Effective Culture Technique

1. Solution must dwell in peritoneum for at least 4
   hrs prior to sampling
2. Mix effluent well before sampling
3. Obtain sample aseptically Send a large volume
   to lab > 50ml (for centrifuging and performing a
   gram stain on sediment) preferable to send
   whole bag
4. Inform lab if patient has received any antibiotics
   within the last week
                 Management
 Do not leave patient on extended drain.


 Empirical antibiotic therapy to start
 as soon as possible as per standing order for
 suspected peritonitis


     ISPD recommendations 2005
     Management
 Antibiotic therapy will be adjusted according to
  the organism

 Patient to be taught to add own meds as soon as
 able to do so

 Re-evaluation of technique
                   Exit Site Infection
         Exit site infection


Signs and symptoms

• Inflammation at the catheter exit site

• Redness and pain

• +/-     purulent discharge
EXIT SITE INFECTION
           Risk Factors
•Trauma e.g. excessive manipulation
of catheter

•Cuff extrusion

•Staph Aurous nasal carrier

•Leak at exit site

•Skin breakdown
   Management
•Minimum of twice daily dressing

•Use Normal saline ( no spirit based lotions)

•Topical antibiotic – Gentamicin cream

•IP / Oral antibiotics

•Assess response to antibiotic therapy

•Keep exit site clean and dry ( no showering)

•Shave the cuff if exposed
        Tunnel Infection
Infection in subcutaneous tunnel between
exit site and peritoneum.

Signs and Symptoms:
   •Redness along tunnel
   •Purulent discharge
   •Pain tenderness along tunnel
   •Abscess over tunnel
   •Exit site infection and or peritonitis
    present
 References
 www.ispd.org


 www.pdserve.com

								
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