Peritoneal Dialysis - | Health



Canberra Hospital and Health ServicesClinical ProceduresPeritoneal Dialysis Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc418607206 \h 1Introduction PAGEREF _Toc418607207 \h 2Scope PAGEREF _Toc418607208 \h 2Section 1 – PD: Catheter Exit Site Management PAGEREF _Toc418607209 \h 2Section 2 – Continuous Ambulatory Peritoneal Dialysis PAGEREF _Toc418607210 \h 5Section 3 – Automated Peritoneal Dialysis PAGEREF _Toc418607211 \h 17Section 4 – Infection and Peritoneal Dialysis PAGEREF _Toc418607212 \h 17Section 5 – Special Procedures PAGEREF _Toc418607213 \h 26Definitions PAGEREF _Toc418607214 \h 30Implementation PAGEREF _Toc418607215 \h 31Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc418607216 \h 31References PAGEREF _Toc418607217 \h 31Attachments PAGEREF _Toc418607218 \h 32IntroductionPeritoneal Dialysis is a Renal Replacement Therapy which is performed by the patient at home. Patients are trained and monitored by the Renal Home Therapies Team. Patients who are admitted and unable to perform their own Peritoneal Dialysis will be assisted by the Renal Home Therapies Team and the ward 8B nurses.Back to Table of ContentsScopeThis document applies to adult patients whose care falls under the clinical governance of the Canberra Hospital and Health Service (CHHS) Renal Network.Back to Table of ContentsSection 1 – PD: Catheter Exit Site Management This procedure covers the three stages of exit site healing, ie post surgery, week one, and thereafter.Post SurgeryWhen patient returns to the ward from surgery inspect dressing to ensure that the whole tube is not underneath the Mepilex dressing as the cap on the end of the catheter can dig into the skin. If the tube is under the dressing proceed as below. Patients must not shower.EquipmentBasic dressing pack.Sterile gloves.Mepilex Border 10cm x 10cmPkt of Gauze squares.Tegaderm 10 x 12cmNon- sterile glovesMethodPerform hand hygiene.Clean work surface with disinfectant.Open dressing pack and arrange equipment on it. Using unsterile gloves, carefully remove the old dressing, taking note of any ooze or odour around the site or on the dressing.Perform hand hygiene and don sterile gloves.Place a new Mepilex dressing over the exit site ensuring Tenckhoff catheter comes out from under the dressing. MepilexCapped catheter out from under MepilexWrap the cap of the Tenckhoff catheter in a piece of gauze to pad it.Place Tegaderm dressing over the gauze wrapped Tenckhoff catheter to hold it securely to the abdomen. New MepilexTegadermGauzeCapped catheterThe Mepilex dressing absorbs a lot of moisture.Remind patients NOT to shower during this period.If in Week 2 the site still has moderate ooze, then continue the Mepilex dressing for another week.B. First three weeksPatients will attend Renal Home Therapies for weekly dressings. Patients in SNSWLHD will be attended by the Renal Outreach Nurse or community nurse in consultation with the Renal Outreach Nurse.Mepilex dressing: Post op for one week.Tegaderm dressing: Replace Mepilex with Tegaderm at end of first week. Patient can now shower. The laparoscopic puncture site dressings are taken down and inspected and no further dressing is required for these sites if clean.Note: If patient is not commencing PD after three weeks PD Catheter should be flushed and heparin locked monthly.EquipmentBasic dressing packSterile NaClBetadine swab sticksNon sterile glovesSterile GlovesGauze squaresTegaderm 10 x 12 cm Appropriate PPEMethodClose door to room to ensure environment and work area is clean.Ask patient to position themselves comfortably and expose dressing.Perform hand hygiene.Clean trolley and set up equipment.Perform hand hygiene.Apply non sterile gloves.Carefully remove old dressing.Observe exit site for any redness, swelling, ooze and take swab if any discharge noted. Perform hand hygiene and don sterile gloves.Check the tunnel for tenderness and ooze by gently palpating along the skin where the catheter passes underneath and in the direction of the exit site. Ensure that care is taken when checking area close to catheter exit site to prevent tissue damage.Check for ooze especially on the underside of the catheter by gently lifting the catheter forward from the exit site.Clean Tenckhoff catheter exit site using NaCl soaked gauze from clean to unclean area in a spiral motion. Repeat twice more and dry with dry piece of gauze.Apply dressing and gauze, ensuring catheter is immobilised by the dressing and is not kinked or twisted. Catheter should come out of the bottom of the dressing so that water from the shower cannot tunnel along the catheter making the dressings wet and thus increasing the risk of infection. If the dressing is wet it must be changed immediately.Discard used equipment and clean trolley.Attend hand hygiene.Document dressing change and condition of the exit site in the medical record and notify Advanced Trainee Registrar (ATR) if any concerns. C. Established exit site Once the exit site is healed (usually 3 weeks) the exit site care can be done second daily by the patient after training, which includes signs and symptoms of exit site infection and the procedure for reporting these.Perform hand hygiene.Clean area with NaCl soaked gauze x 3 in a circular motion from exit site out.Dry with gauze.Clean around the exit site with two betadine swab sticks and use the third swab stick in the pack to clean along the catheter.Allow to dry.Dressing is not necessary. Patients may choose to wear one of a variety of waist bands to secure catheter inside clothing.Management of infected exit sites:Send swab for M/C/S and following RMO review commence on antibiotics as ordered.Increase frequency of dressings to daily as required. Back to Table of ContentsSection 2 – Continuous Ambulatory Peritoneal Dialysis 2.1- PD - Extension Line change (Fresenius and Baxter) Routine extension line changes are scheduled every 6 months.Emergency extension line change is done when there is:Contamination of the extension line.Disconnection of the extension line from the Tenckhoff catheter.Damage to, or leaking from, the extension or Tenckhoff catheter.Patient will need a line change followed by Intra peritoneal Vancomycin cover in the following instances:If the patient has done a bag exchange AFTER contaminating the line. If PD catheter extension line has become disconnected. Damage to the extension line where there is leaking (if no leaking Vancomycin is not required). The PD catheter has to be cut to remove damaged portion which will involve attaching a new luer-lock.EquipmentChlorhexidine 2%/Alcohol 70% solutionDressing packWhite clampUnderpadGauze x 2 pktsDisinfectant for cleaning work surfaceClean gownSterile gloves x 2Masks x 2Antiseptic hand rub10ml syringe x 119G needle x 110ml NaClampouleFresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension Line and disinfection capBaxter – Minicap extended life PD transfer set with twist clamp. Extension line and MinicapMethodClose doors and windows. Perform hand hygiene.Instruct patient and anyone present in room to wear mask. Place absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connector.Clean work surface with disinfectant.Use ABHR.Open dressing pack and open other equipment onto sterile field.Open 10ml NaCl ampoule and place on the edge of work surface.Don mask and gown.Perform one minute scrub and don sterile gloves.Draw up the NaCl into the 10ml syringe. Take the cap off the end of the new line and prime with saline. When primed, clamp line and remove syringe. Screw on new disinfection cap / Minicap.Pick up the patient extension line with a piece of gauze, and scrub the connector with 3 Chlorhexidine 2%/Alcohol 70% soaked gauze swabs and allow to dry.Place sterile paper drape underneath and allow catheter to drop onto sterile field.Remove gloves and perform hand hygiene with ABHR and don sterile gloves.Hold the Luer-lock connector and the old extension line with gauze and disconnect (unscrew) the extension line from the Luer lock connector. Hold the Luer-lock connector very carefully, do not let open end of Tenckhoff catheter touch anything.Connect the new extension line to the Luer-lock of the Tenckhoff catheter connector making sure it is not cross threaded.Remove the white clamp from the Tenckhoff catheter. Remove drape and discard equipment appropriately.Document date of line change and batch number in patient’s medical record.2.2- PD- Cutting the PD catheter (Fresenius and Baxter)This may need to be done if there is damage to the catheterEquipmentSet up as for line changeSterile scissors Fresenius ‘Catheter adaptor Luer-lock with closure cap’. This is the blue connector that is screwed onto the tenckhoff catheter that the Fresenius OR Baxter extension line attaches to.ProcedureRefer to: Attaching a new PD Luer Lock to a Tenckhoff catheter procedureAdd the following to dressing tray: sterile scissorsFresenius “Catheter adaptor luer lock with closure cap”These items can be found in the PD line change box, or emergency pack for home patients in SNSWLHD.Cut back damaged area of Tenckhoff; connect Catheter adaptor luer lock with closure cap as per PD Attaching a new PD Luer Lock to a Tenckhoff catheter. Line change, then load IP Vancomycin into correct PD bag and do PD exchange. Send patient home. Tell the patient that antibiotic must dwell for 6 hours before another regular PD bag can be done by the patient.2.3 PD- Tenckhoff Catheter Luer Lock Connector or Extension Line Accidental Damage Plan of ActionAlert: When notified of the disconnection, advise the patient to clamp off the Tenckhoff catheter with the white emergency clamp. Then swab the end of the catheter with Betadine swab stick, wrap in sterile gauze and cover with a tegaderm. Advise ACT patients:To come to RHT or emergency department ASAP for one of the following treatments including IP Vancomycin PD bag exchange if a bag exchange has been done after contamination of the circuit.NSW patients:To go to local ED department with their emergency pack. They may contact Outreach nurse in office hours.1. PD catheter extension line contamination (Cap has come off end of extension line) Refer to: PD extension Line change (Fresenius & Baxter) procedure (2.1)Perform a line change.Arrange to meet patient at RHT, ROPD or ED after hours. PD line change box can be found 8B storeroom, RHT and ED store room. For SNSWLHD patients, equipment is in Emergency Pack at Moruya Renal Unit.Choose the correct line and cap from the box (Baxter or Fresenius):Fresenius – Stay safe catheter extension luer lock 32cmBaxter – Minicap Extended life PD transfer set with twist clamp2. PD catheter extension line disconnection (Extension line has become disconnected from the catheter)Refer to: PD extension Line change (Fresenius & Baxter) procedure (2.1)Management of Peritoneal Dialysis Peritonitis procedureAdding antibiotics to PD CAPD bags (Fresenius & Baxter)Perform a line change PLUS IP Vancomycin PD bag exchange.Vancomycin is a standing order on our PD Peritonitis protocol. Use IP Vancomycin 30mg/kg body weight up to a maximum of 2.5g.Put correct bag on heater: Fresenius 2.3% or Baxter DIANEAL 2.5% before doing line change to give it time to warm. Do not use Physioneal as stability of antibiotics is not known.Perform a line change first, and then load IP Vancomycin into correct PD bag and do a PD exchange. Send patient home. Tell patient that antibiotic must dwell for minimum 6 hours before another regular PD bag can be done to ensure effectiveness of the antibiotic treatment.3. Damage to the extension line.Depending on where the damage is situated (in relation to the patients peritoneum) change either just the extension line or the connector and extension line. If there is leaking patient will also require IP Vancomycin (30mg/kg body weight.)4. Damage to Tenckhoff catheterRefer to: Attaching Tenckhoff Catheter Luer Lock Connector procedure (2.4)PD extension Line change procedure (Fresenius & Baxter) procedure (2.1) Management of Peritoneal Dialysis Peritonitis procedureAdding antibiotics to PD CAPD bags (Fresenius & Baxter) procedureIf damage to the tenckhoff is close to the patients exit site a surgical review may be required.Tenckhoff catheter may need cutting back to remove damage. You may have to cut off old Luer lock connector and attach a new one.You will also need to do a line change PLUS Vancomycin PD bag exchange.Put correct bag on heater: Fresenius 2.3% or Baxter DIANEAL 2.5% before doing line change to give it time to warm.Set up as for line change.2.4 – PD- Attaching Tenckhoff Catheter Luer Lock ConnectorEquipmentCorrect CAPD bag (Fresenius Balance or Baxter Dianeal)Fresenius Catheter Adaptor Luer Lock with Closure Cap.Sterile scissorsChlorhexidine 2%/Alcohol 70% solutionDressing packWhite clampUnderpadGauze x 2 pktsDisinfectant for cleaning work surfaceClean gownSterile gloves x 2Masks x 2Antiseptic hand rubFresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension LineDisinfection capBaxter – Minicap extended life PD transfer set with twist clamp – Extension lineMiniCap10ml syringe x 119G needle x 110ml NaCl ampouleMethodPut correct CAPD bag on PD bag warmer (antibiotics will be required).Close doors and windows.Perform hand hygiene.Instruct patient and anyone present in room to wear mask. Place absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connector.Clean work surface with disinfectant.Use ABHR.Open dressing pack and open other equipment onto sterile field.Open 10ml NaCl ampoule and place on the edge of work surface.Don mask and gown.Perform one minute scrub and don sterile gloves.Draw up the NaCl into the 10ml syringe. Take the cap off the end of the new line and prime with saline. When primed, clamp line and remove syringe. Screw on new disinfection cap / Minicap.Pick up the patient extension line with a piece of gauze, and scrub the area to be cut with 3 Chlorhexidine 2%/Alcohol 70% soaked gauze swabs and allow to dry.Place sterile drape underneath and allow catheter to drop onto sterile field.Remove gloves and perform hand hygiene with ABHR and don sterile gloves.Open the Catheter Adaptor Luer Lock with Closure Cap package. Screw the white cap onto the appropriate end of the blue threaded insert.Hold the Tenckhoff catheter and cut the old Luer lock connector off just behind it (or behind damaged part of the Tenckhoff catheter) with the sterile scissors. Continue to hold the Tenckhoff catheter tubing.From the Catheter Adaptor Luer Lock with Closure Cap package, place the blue cone on the catheter.Then push the thin end of the blue threaded insert into the tube lumen firmly as far as it will go. Screw the cone on to the threaded insert as tightly as you can, use the blue spanner to completely tighten it.Remove the white closure cap and connect the new extension line to the Luer-lock of the Tenckhoff catheter connector making sure it is not cross threaded.Remove drapes and discard equipment appropriately.Document date of Luer lock and line change in patient record and record the batch numbers of equipment used.Load correct warmed PD bag with IP antibiotic (see clinical procedure).Attend PD exchange. The antibiotic bag should dwell for a minimum 6 hours to ensure effectiveness of the antibiotic treatment. 2.5 – PD -Fresenius Stay Safe Balance exchangeEquipment 1 x Fresenius Stay Safe Balance bagOrganiser1 x new disinfection capDisinfectant to clean tableAntiseptic Hand rubMethodClose doors and windows.Perform hand hygiene.Clean work surface and organiser with disinfectant. Collect new disinfection cap and check expiry date.Place cap, organiser and hand rub on cleaned work surface.Check warmed Fresenius PD bag for correct volume, glucose concentration, expiry date, clarity and leaks. Check that the outer pouch is intact.Open new bag, leave in its package. Roll bag from side to break middle seam, then roll bag from top to break the triangle completely. Check for leaks or irregularities.Hang the bag and uncoil the lines, place disc into organiser & drain bag down.Make patients extension line accessible (remove from under clothes).Place catheter into right side of the organiser.Perform hand hygiene with ABHRDo not talk or cough Remove coloured protection cap from disc.Unscrew catheter from cap and connect to disc making sure the catheter is not dropped & does not touch anything else.Put the coloured cap from disc onto old cap. PULL out and discard.Open clamp on extension line and commence drainageWhen drainage complete, close clamp on extension line.Turn dial to flush position and count to fiveThen turn the dial to the white circleMake sure there is no air in fill line. Now turn the dial to the blue circle.Open clamp on extension line to commence fill.When inflow complete, close clamp on extension line. Turn dial to last position to insert pin.Open new disinfectant cap and place it in left side of organiser.Perform hand hygiene with ABHR.Do not talk or cough Unscrew cover from the new cap.Unscrew catheter and screw onto the new cap making sure the catheter is not dropped & doesn’t touch anything else.PULL catheter out of the organiser.Put the cover from new cap onto disc to seal it off.Check drained out fluid for clarity, dispose of used equipment, clean up and place a new bag on the heater pad.2.6 – PD-Fresenius Stay Safe Balance Drain outEquipment required:1 x Fresenius Drain bagOrganiser1 x new disinfection capDisinfectant to clean table and Antiseptic Hand rubProcedure:Wash hands as normal in your bathroom, ensuring your hands and nails are visibly clean Ensure hands are thoroughly dried.Go into your PD room and close doors and windows. Use hand rub and allow to dry.Clean work surface and organiser with disinfectant.Collect new disinfection cap and check expiry date.Place cap, organiser and hand rub on cleaned work surface.Open drain bag, and uncoil the lines, place disc into organiser, place drain bag down.Get your catheter out.Get your body in the right position and place your catheter into right side of the organiser.Use antiseptic hand rub. Ensure that all your fingers, thumbs, all surfaces of the hands and wrists are thoroughly cleaned. Allow to dry.Do not talk or cough Remove white protection cap from discUnscrew your catheter from cap and connect to disc making sure the catheter is not dropped & does not touch anything else.Put the white cap from disc onto your old cap. PULL out and discardOpen clamp on extension line and commence drainageWhen drainage complete, close clamp on extension line.Turn dial to last position to insert pin. Open new disinfectant cap and place it in left side of organiser.Use antiseptic hand rub and allow to dry.Do not talk or cough Unscrew cover from the new cap.Unscrew your catheter and screw onto the new cap making sure the catheter is not dropped & doesn’t touch anything else.PULL your catheter straight out of the organiserPut the cover from new cap onto disc to seal it off.Check drained out fluid for clarity, dispose of used equipment and clean up. Wash hands when complete.2.7- PD- Baxter Physioneal or Dianeal exchangeEquipment 1 x Baxter Physioneal or Dianeal PD bag, of appropriate glucose strength warmed on a heater pad designed for this (30 minutes to heat, lines on top, writing side face down).1 x Minicap 2 x Blue port clamp (Physioneal) OR 1 x Blue Port clamp (Dianeal)Disinfectant to clean work surfaceAntiseptic hand rubPD table with IV poleMethod Close doors and windows.Perform hand hygiene with ABHR.Clean work surface with disinfectant.Before use: Check bag for correct glucose concentration, volume, clarity, expiry date and leaks. Check that the outer pouch is intact.Open outer pouch of PD bag by tearing diagonally down from one of the notches on one end. Perform hand hygiene with ABHR.Remove bag from outer pouch and place PD bag on cleaned work surface. Push firmly on bag to check for leaks.Uncoil and separate lines with the coloured ring cap on it. (Close blue clamp on drain bag if Dianeal). Coil up lines with end of lines facing out. Position the end of the line to hang 15-20cm over the edge of the work surface making sure it does not touch anything when let go.Flip the bag over so it sits on top of the rest of the coiled lines to secure it in place. Break the frangible in the Physioneal bag to mix the glucose solution.Make patients extension line accessible (remove from under clothes)Perform hand hygiene with ABHRCarefully grasp the bag line and remove the coloured ring-cap, then let the line go. Make sure nothing touches the exposed endDo not talk or coughPick up the extension line and carefully remove the minicap. Protect the end of the line from falling or touching other objects.Carefully connect (screw) the extension line to the PD bag connection.Hang the bag of PD fluid up and place the drainage bag on the floor with the shiny side facing upwards.Drain out by opening the twist clamp on the extension line (open blue clamp on the drain bag if Dianeal).When drainage is complete, close the twist clamp on the extension line. Place blue port clamp on Physioneal PD drainage line. Close clamp on Dianeal PD drainage line.Flush by breaking the green frangible in the tubing of the new PD fluid bag (either Physioneal or Dianeal) open the clamp on the drainage line and count to five to flush the line. Clamp the drainage line when complete. Check all air from the line has been expelled. If not, then flush again. Make sure with the Physioneal bag that the glucose solution has drained completely into the lower chamber of the PD bag before you flush or fill.Fill the peritoneum by opening the twist clamp on the extension line to commence inflow.When inflow is complete, close the twist clamp on the extension line and place a blue port clamp on the bag inflow line.Open new minicap packaging. Perform hand hygiene with ABHR.Disconnect PD bag line from the patients’ extension line and carefully place the minicap on patients’ extension line. Secure firmly. Make sure nothing touches the exposed end. Do not talk or cough.Drop empty PD bag on floor (both bags are now on the floor). Remove blue port clamps. Tie a knot in lines to prevent any leakage.Check drainage fluid for clarity. Dispose of PD drainage appropriately.Dispose of used equipment. Clean up and wash hands when complete.Document drainage amount in medical record.2.8 - PD- Icodextrin for Fresenius CAPDNote: Patients with diabetes should be informed about the need to source relevant glucose testing strips when using IcodextrinEquipmentBaxter Icodextrin 7.5% bag warmed appropriatelyFresenius stay safe Luer –lock setDisinfectant for cleaning work surfaceAntiseptic hand rubOrganiserDisinfection capTable with poleMethodClose door and perform hand hygiene. Clean the work area surface and organizer.Check Baxter Icodextrin 7.5% bag for expiry date, clarity, and leaks. Check outer pouch is intact.Open outer pouch of Baxter Icodextrin 7.5% bag & leave on the open packaging. Open packaging of Fresenius stay safe Luer-lock set.Perform hand hygiene with ABHR.Carefully pull purple ring-cap off the bag line making sure nothing touches it. Do not talk or cough.Carefully take the blue cap off the Fresenius stay safe Luer-lock set and screw to the Baxter Icodextrin bag.Snap the blue pin and wriggle it to make a gap.Hang the bag and Uncoil the Fresenius stay safe Luer-lock set lines. Proceed as for Fresenius Staysafe exchange.2.9- PD -Tenckhoff catheter heparin locking and capping offPatients who do not commence PD three weeks after insertion should have their catheters flushed and heparin locked monthly until they commence on PDNote: Patients allergic to Heparin (HITS) will have a 10ml Saline flush only, before cappingEquipmentFresenius Catheter Adaptor Luer Lock with Closure Cap Chlorhexidine 2%/Alcohol 70% solutionSterile dressing packBaxter PD catheter clamp (white)UnderpadGauze x 2 pktsDisinfectant for cleaning work surfaceClean gownSterile glovesMasks x 2Antiseptic hand rub10ml syringe x 15ml syringe x 119G needle x 210ml NaClampouleHeparin sodium 25000units/5mlMethodClose doors and windows.Perform hand hygiene using ABHR.Instruct patient and anyone present in room to wear a mask. Place absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connector.Clean work surface with disinfectant.Open sterile dressing pack and add Catheter Adaptor Luer Lock with Closure package, sterile gauze, syringe and needle onto the draped work surface. Open 10ml NaCl ampoule and place on the edge of another work surface.Don mask and gown.Perform hand hygiene using ABHR and don sterile gloves.Draw up the NaCl into the 10ml syringe.Draw up correct amount of Heparin in 5 ml syringe depending on catheter length:2.3ml for Swan neck straight catheter3.1ml for Swan neck curled or coiled catheterPick up the extension line with a piece of gauze, scrub the connector with 3x Chlorhexidine 2%/Alcohol 70% soaked gauze swabs. Place sterile drape across the patient's lap and drop the line onto the drape.Change gloves.Hold the Luer-lock connector and the old extension line with gauze and disconnect (unscrew) the extension line from the Luer lock connector. Hold the Luer-lock connector very carefully, do not let open end of Tenckhoff catheter touch anything. Place the 10ml syringe into the end of the Tenckhoff catheter.Carefully undo the white clamp and insert 10ml of Saline. Reclamp white clamp and remove the 10ml syringe and place the 5ml heparin loaded syringe onto the end of the Tenckhoff catheter and insert the correct volume of Heparin.Reclamp the white clamp. Remove the 5ml syringe and attach the white cap to the end of the Tenckhoff catheter making sure not to cross thread it.Remove the white clamp from the Tenckhoff catheter.Remove drape and discard equipment appropriately.Attach medication warning label to catheter (including date and time).Document heparin locking and capping off in patient progress notes and on patient care plan.Back to Table of ContentsSection 3 – Automated Peritoneal Dialysis This procedure is not currently performed for inpatients. Patients who are on APD at home switch to CAPD when admitted Back to Table of ContentsSection 4 – Infection and Peritoneal Dialysis 4.1 Staphylococcus Aureus (S. Aureus) carriers on Peritoneal DialysisMethodPD staff organise routine swabbing to check for MSSA/MRSA & Mupirocin sensitivity following hospital policy Treatment for a positive S. Aureus resultA S. aureus carrier is considered to be any patient in whom the last available nasal swab grew S. aureusNasal Mupirocin should be administered to all S. aureus carriers as soon as carriage is detected in patient, either pre-surgery or with an existing PD catheter.Nasal Mupirocin for current carriers is a self application twice daily for 5 days every calendar month for six months, then stop for a month and re swab. If negative, stop the application of nasal Mupirocin. In NSW this drug is not PBS. Ensure patient has a relevant script.Nasal swabs are routinely attended every 6 month for all PD patients, but no sooner than 3 weeks after last administration of nasal Mupirocin.If there is an allergy to Mupirocin, or presence of known S. aureus resistance to Mupirocin, then discuss with Advanced Trainee Registrar.4.2 - PD Effluent Collection for MicrobiologyEquipmentCloudy PD drain bagDisinfectant to clean work surfaceFoam Falcon tube holder2 x falcon tubes2 x blood culture bottles1 x 20ml syringe1 x 50ml syringe5 x 19g needles Gauze x 1 PktChlorhexidine 2%/Alcohol 70% solution Pathology formPatient Labels x 5Dressing packSterile glovesAntiseptic hand rubMethodTo collect sample use the cloudy PD drain bag that the patient has brought with them or collect a sample from a wet or dry abdomen as below:Abdomen wet –Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Abdomen dry – Instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Note:Fresenius: Use Staysafe drainage set (drain bag)Baxter: Use Baxter Physioneal bag for use of drain bag (as the Ultraset CAPD Disposable Disconnect Y-set (drain bag) does NOT have a port.)Close door.Perform hand hygiene using ABHR.Clean work surface with disinfectant.Perform hand hygiene using ABHR.Open dressing pack. Add needles, syringes & gauze. Pour Chlorhexidine 2%/Alcohol 70%solution into dressing tray.Take lids off culture bottles and falcon tubes (Falcon tubes need to sit in white foam holder).Lay PD bag on cleaned work surface. Identify and expose sample port on PD drain bagPerform hand hygiene and don sterile gloves.Using forceps swab each culture bottle with Chlorhexidine 2%/Alcohol 70% solution soaked gauze and allow to dry before it is penetrated.Wash PD drain bag sample port with Chlorhexidine 2%/Alcohol 70% solution soaked gauze and allow to dry before it is penetrated.Hold the PD drain bag sample port with sterile gauze and collect 20mls of peritoneal effluent. Change needles. Use a square of gauze to hold culture bottles and change needles in between each bottle. Insert 10mls of peritoneal effluent into each bottle starting with blue top- aerobic bottle.Hold the PD drain bag sample port with sterile gauze and collect 2 x 50 ml samples of PD effluent from sample port. Use a new needle to collect each sample. Remove needle to deposit sample into falcon tube.Label all samples and send to pathology for WCC, Gram Stain, M/C/S.Discard equipment and clean up. PD bag is emptied into sluice and then put into a clinical waste bin.Perform hand hygiene using ABHR.Do a PD exchange with antibiotics loaded bag (Refer to: “Adding Antibiotics to CAPD bags”).Document in medical record4.3 - Adding antibiotics to CAPD bags (Fresenius Balance & Baxter Dianeal)EquipmentAppropriate CAPD bag (Fresenius Balance 2.3% or Baxter Dianeal 2.5%)Sterile scissors (use for Baxter only)Dressing pack10ml syringe x 1 2ml syringe x 1 (for Gentamycin)4 x 19G needlesGauze x 1 packetRequired Antibiotic(s)Water for injection 10mls depending on doseChlorhexidine 2%/Alcohol 70%solutionDisinfectant for cleaning work surfaceAntiseptic hand rubMedication additive labelSterile glovesPatient identification labelMethodAll antibiotics need to be checked with another RN or medication endorsed EN before instillation and additive labels signed. Check patient antibiotic allergies.Close door, perform hand hygiene, and clean work surface with disinfectant.Perform hand hygiene using ABHR.Open dressing pack; add needles, syringes & gauze. Pour Chlorhexidine 2%/Alcohol 70% solution into dressing tray.Check PD bag for expiry date, volume, strength, clarity, and leakage. If packaging is damaged do not use. For Baxter bag, make sure you have a Dianeal bag NOT a Physioneal bag. A pre-warmed bag can be loaded with antibiotics if it is going to be used straight after.Fresenius: Peel back enough outer wrapper of PD bag to expose left blue injection port. Tape wrapper back. (Blue Injection port attached to Fluid bag, NOT the blue port on the drain bag)Baxter: Using sterile scissors to cut a slit in back of outer wrapper of Baxter Dianeal bag to identify and expose injection port attached to Dianeal fluid bag. Ensure injection port is attached to Dianeal fluid bag and not the drain bag.Open Water for injection and place on edge of work surface. Flip the lids off antibiotic vials.If Gentamycin is required - Open Gentamycin ampoule. Open sterile gloves. Perform hand hygiene using ABHR.Don sterile gloves.Assemble needles and syringes. Draw up Water for injection in the 10 ml syringe. If Gentamycin is required - Draw up required dose of Gentamycin in 2ml syringe and change needles. Wipe antibiotic vial (ie: Vancomycin) with Chlorhexidine 2%/Alcohol 70% soaked gauze swab. Wait 30 seconds for the surface to dry before it is penetrated.Holding antibiotic vial with sterile gauze, inject water into vial and mix, then draw up the mixture and change needles.Wash injection port on bag with Chlorhexidine2% /Alcohol 70% soaked gauze and wait 30 seconds for the surface to dry before it is penetrated.Hold the injection port with sterile gauze and inject antibiotics into the PD Fluid bag taking care not to puncture the bag. (Make sure you are not injecting Antibiotics into the Drainage bag). Label PD bag with patient label and additive label which includes date and time of administration.Reseal the outer pouch with tape.Clean up used equipment and dispose of sharps correctly.Place bag on heater pad to warm if for use within the hour or place it in the medication fridge if it is not being used straight away. Needs to warm for at least an hour when taking bag from the fridge.4.4- PD- PERITONITIS Peritoneal Dialysis Peritonitis: 100 WBC/ mL effluent of which > 50% are neutrophilsInitial PresentationA cloudy bag always requires treatment with antibioticsTake culture and commence treatment immediately and before microscopy results are availableCulturing Peritoneal EffluentAbdomen dry: instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours.Drain outAbdomen wet: fully drain dialysate effluent as normal and disconnect.Method:gently mix contents of bag for at least 30 secondsUsing sterile technique, swab port aspirate two 50 mls of effluent and place each sample into separate falcon tubeaspirate 20 mls of effluent and inject 10ml into each of a set of blood culture bottles (aerobic then anaerobic) label all bottles and tubes send straight to microbiology . Needs to be analysed ASAPAntibiotic TreatmentCommence antibiotic treatment immediately; do not wait for microscopy resultsAll antibiotic dwells are for a 6 hour period.Vancomycin see Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A )Gentamycin: see Medication Standing Order: Intraperitoneal Gentamycin for Empiric Treatment of Peritoneal Dialysis Peritonitis (Attachment B)If necessary for polymicrobial infections, cephalosporins or vancomycin can be mixed with aminoglycosides in the one dialysate bag. Contact the pharmacy department for stability information.Day 0: (day antibiotics are commenced)Add Vancomycin and Gentamycin as per the medication standing orders to a new dialysate bag.Perform a bag exchange using this loaded bag.Day 1: (first morning after initial antibiotics)Continue IP Gentamycin as per the medication standing order once a day.Day 2 Obtain Gentamycin and Vancomycin pre-dose blood levels. Adjust if necessary as per the medication standing orders.Discuss treatment course with the Nephrologist.Treatment Adjustment Based on Gram Stain/ CultureNote: All changes to be discussed with the NephrologistGram stain available and peritonitis not substantially improved at 48hours.Gram negative bacilli: Change IP Vancomycin to IP Cefepime 1g daily; continue IP Gentamycin after discussion with the Nephrologist.Fungi: Notify Nephrologist and arrange catheter removal by a General Surgeon.Culture available.Pseudomonal Peritonitis: Treat with 2 antibiotics for a minimum of 3 weeks,Recommended antibiotic combination is either:IP Cefepime 1g daily and daily Gentamycin until clinical improvement. This is usually followed by IP Cefepime 1g daily and oral ciprofloxacin to complete three full weeks of treatment.Gram positive cocci sensitive to cephazolin:Discuss cessation of Gentamycin and possible change of Vancomycin to Cephazolin with the Nephrologist.Other bacterial peritonitis organisms: Antibiotics are based on sensitivity patterns and drug dosing convenience.Enterococci:Treat with IV ampicillin 1g TDS, together with Gentamycin (if not high level resistance) after discussion with the Nephrologist, Discuss length of Gentamycin therapy with the Nephrologist.Fungi: Arrange for urgent catheter removal by general surgeon.Treatment Adjustments Based on Antibiotic LevelsVancomycin:Target (pre-dose blood level) is 12.1 – 20?g/mL.Take first level on day 2.Adjust as per the Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).Gentamycin:Target (pre-dose blood level) is 1.5 – 2.5 mg/L.Take first level on day 2.Adjust as per the Medication Standing Order: Intraperitoneal Gentamicin for Empiric Treatment of Peritoneal Dialysis Peritonitis (Attachment B).Monitoring of PD PeritonitisClosely monitor clarity of the effluent, document and report to Nephrologist. If the effluent is not clearing catheter removal may be required. Improvement should be obvious within 48 hours.Maintain close contact with microbiology to seek culture information.Closely monitor clinical status of patient, attention to MEWS, consider NBM if abdomen distended.Antibiotic treatment should continue for 2-3 weeks, determined by Nephrologist.Outlying patients at regional hospitals to have follow up dialysate effluent cell count on day 3 – PD staff to monitor.Outlying patients at regional hospitals that have not improved at 48 hours will require urgent transfer to The Canberra Hospital. Renal Registrar / Nephrologist to arrange.Failure of dialysate effluent to clear by day 5 is a strong indication for catheter removal.All results and any treatment changes to be discussed with treating NephrologistVRE status should be monitored according to hospital policyStability of Antibiotics in PDIt is recommended that all dialysate containing admixed antibiotics are stored in a refrigerator at 4 degrees Celsius. If made up as the only antibiotic in the bag in pharmacy, and stored at 4 degrees Celsius, then Vancomycin, Gentamycin, Cephazolin and Cefepime have adequate stability for at least 7 days. Stability for these antibiotics is adequate for 4 days at room temperature. In special cases it may be possible to store admixed fluid for longer or at room temperature. (Although Cephalosporins or Vancomycin and Gentamycin can be added to the same bag, they may not be stable for long periods after being mixed.) Contact the pharmacy department for advice.IcodextranVancomycin, cephazolin, Ampicillin, Ceftazidime, Gentamycin and Amphotericin are compatible with Icodextran containing dialysate. There is limited data on long term stability except for Vancomycin.Catheter RemovalCatheter removal in all CAPD peritonitis is performed by the general surgeons by means of a mini laparotomy with washout.4.5 - PD peritonitis management planIn ACT: Suspected Peritonitis of non admitted patients is handled by the staff of Renal Home Therapies:during office hours 0700- 16301630-0700 (Ring switch and ask for second on call) Information Required.Establish whether patient is well or unwellSend patient to Emergency department if symptomaticPD peritonitis is initially treated by local ED department in SNSWLHDAsk patient to come to Renal Home Therapies or contact Renal Outreach nurse (will depend on availability)if they are completely symptom freePD fluid in situ or abdomen empty?Do they have the cloudy bag? They need to bring it with themSample is required for culturesIf empty – tell patient to fill before coming in. Ideally fluid should have dwelled for 1-2 hours before draining for a sample.Current weightRequired for Vancomycin dosage (see Peritonitis protocol)AllergiesIf patient is allergic to Vancomycin use Cephazolin (see Peritonitis protocol).If patient is allergic to Gentamycin use Cefepime (see Peritonitis protocol).If patient has known VRE continue current protocolBaxter or Fresenius Choose the correct PD bag to load. For Baxter you must use a DIANEAL bag to load antibiotics (NOT a Physioneal bag). PD bags can be found at Renal Home Therapies or ward 8B.PD volume 2L/ 2.5LRequired for Gentamycin dosage (see Peritonitis protocol).ACT or NSW patientFollow directions below depending on where the patient livesACT PATIENT For the patient with peritonitis in the Emergency Department equipment can be found in ward 8B or emergency dept store roomantibiotic Loaded bag drain bag silver PD table with pole hand rub Fresenius – Disinfection cap, white organiser, Fresenius: Staysafe drainage set (drain bag)Baxter – Mini cap, 2 blue port clamps, Baxter: Ultraset CAPD Disposable Disconnect Y-set (drain bag)How to obtain a specimen if the patient does NOT bring their cloudy bag with them.Abdomen wet –Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Then, you can attend to the PD exchange with antibiotics loaded.Abdomen dry – Instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Then, you can attend to the PD exchange with antibiotics loadedOrganising AntibioticsVancomycin & Gentamycin administration for peritonitis are covered in a STANDING ORDER. You do not need a registrar to write them up. Standing order Approval Number for Vancomycin – CHHS 13/597Standing order Approval Number for Gentamycin – CHHS 13/596Standing order approval number for Cephazolin – TCH CHHS13/595 TCH Loading IP (Intraperitoneal) AntibioticsLoad IP antibiotics as per PD RHT Adding Antibiotics to PD CAPD bagsNB Consider antifungal prophylaxis Taking cultures from cloudy bagTake cultures as per PD Effluent collection for Microbiology.You will require a Pathology form with: WCC, Gram Stain, M/C/mence antibiotic treatment immediately; do not wait for Microscopy results.All antibiotic dwells are for a minimum six (6) hour period.NSW PATIENT Gather information required as per procedure to get all relevant information from PD patient.Tell patient to go their local hospital and find out which hospital they are going to and report to Outreach nurse if available.Tell PD patient to take the cloudy bag with them.Tell the patient they will need to take ALL their PD supplies with them. It is very likely the hospital they go to will not have PD supplies.A box of green (2.3% Fresenius or 2.5% Baxter DIANEAL). Extra equipment depending on system used:Fresenius – Disinfection caps, white organiser if Baxter – Mini caps, 2 blue port clampsBag warmer (Heater pad).Does the patient have a copy of the peritonitis protocol to take to the local hospital?Yes – Take it with them.No – Tell the patient to advise the local doctor to phone the Renal Physician on call at the Canberra Hospital.Outlying PD Patients at Regional hospitals need to have follow-up dialysate effluent white cell count (WCC) on Day 3.Outlying PD Patients at Regional hospitals that have not improved at 48hrs (bag clearing) will require urgent transfer to TCH. Renal Registrar / Nephrologist to arrange.4.6- PD exit site and tunnel infectionInfection is determined in the following way:Exit site infection Either purulent discharge or 2 or more of the following:Erythema ?13 mm at exit siteInduration at exit siteTenderness at exit site Tunnel infection Presence of two or more of the following:Induration of the tunnelTenderness of the tunnelRadiographic evidence of a collection along the tunnelNote: It is unusual for there to be a tunnel infection in the absence of an exit site infectionExit site surface swabsA positive culture in the absence of an abnormal appearance is indicative of colonization rather than infection. The appropriate treatment for this is intensified local cleaning rather than antibiotics. Concomitant catheter related infection and peritonitis is often due to pseudomonas species.Empiric treatment of mild exit site infectionsInfections with S. aureus must always be covered. Treatment duration continues 5-7 days after all the infection has resolvedPseudomonas may need to be covered if the patient has a history of pseudomonal infections Known colonisation in the patient:Non MRSA: Dicloxacillin 500 mgs orally tdsNon Multi MRSA:Clindamycin (based on results of sensitivity)MRSA:IP Vancomycin as per Peritonitis protocol or alternatively oral fusidic acid + rifampicin Back to Table of ContentsSection 5 – Special Procedures5.1 - Peritoneal Equilibrium Test procedure (PET)The purpose of the Peritoneal Equilibrium Test (PET) is to establish the transport characteristics of the peritoneal membrane. It defines the membrane clearance and ultrafiltration rates by measuring dialysate to plasma ratios of creatinine and glucose. Usually done 4 weeks after commencement on PD EquipmentPatient input form (PET form) Pathology form x 2Labels x 10DisinfectantAntiseptic hand rubChlorhexidine 20% & Alcohol 70% solutionSterile gloves x 3Red top blood tubes x 3Gauze x 310ml syringe x 319G needle x 3For Fresenius include:Fresenius Balance 2.3% bag for PET, warming on heater pad.Fresenius Balance bag of patient choice for after the test warmedFresenius Staysafe drainage set. (drain bag)Disinfection Caps x 3For Baxter include:Baxter Physioneal 2.27% bag for PET, warming on heater pad.Baxter Physioneal bag for mid test (for use of drain bag)Baxter Physioneal bag of patient choice for after the test warmedMinicaps x 3MethodA PET involves a PD Adequacy which requires the patient to bring in a 24 hour urine collection and three PD effluent bags from the day before. The patient will have been given a date to collect the urine and PD bags pre PET. It is preferred to use a 2.27% or 2.3% or 2.5% (green) PD bag for the overnight bag and for the PET test. The patient is asked to note what time the overnight bag was infused.Check patient has brought in 24 hour urine and correct PD effluent bags; otherwise there is no point in continuing the test.Measure patient’s sitting and standing blood pressure.Close door, wash hands and clean work surface.Set up for PD exchange using correct warmed PD bag. (See PD RHT Fresenius Balance bag change procedure SOP or PD RHT Baxter Physioneal or Dianeal bag change SOP).Attach patient to PD exchange and drain out overnight dwell. Work out the time in minutes that the overnight bag was in for and record it as Dwell time on PET form. Record % glucose and volume infused in Overnight exchange.Note the time in minutes that it takes to drain out the overnight bag completely and record it as Drainage time on PET form. Weigh patient.Flush then Fill. Infuse the PD solution with the patient supine, getting them to roll side to side halfway through filling and again when the infusion is complete. This will mix the solution around the abdomen. Note the time in minutes that it takes to infuse the solution and record it as infusion time on PET form. Record % glucose and volume infused in Four-hour Equilibrium test.PET 1. Sit the patient up. Make sure the DRAIN line is clamped! Now drain approximately 200ml from the abdomen into the PD fluid (FILL) bag (NOT the drain bag that has the overnight PD drainage fluid in it). Close the extension line clamp.Open syringe, needle, gauze and sterile gloves in their packets onto cleaned work surface. Pour Chlorhexidine 20% & Alcohol 70% solution onto gauze.Perform hand hygiene using ABHR and don sterile gloves.Wash sample port with Chlorhexidine 20% & Alcohol 70% solution soaked gauze. Wait 30 seconds for the surface to dry before it is penetrated.Assemble 10ml syringe and needle. Withdraw 10mls from sample port and inject sample into red top tube. Label sample as PET1 with patient name, ID number, date and time. Dialysate sample 1 (PET1) is recorded as 0 minutes on the PET Form.Reinfuse any solution left in the fill bag back into the patient, and disconnect as usual.Weigh the overnight bag and record it in PET form. Label this bag as overnight bag. Label the other PD bags as PD effluent 1, 2, & 3. Label 24hr urine, date and time. Put all bags and urine together in PD fluid lab samples box.PET 2. At 2 hours, attach a drain bag and drain out 200ml. For FRESENIUS use a Fresenius Staysafe drainage set. (drain bag). For BAXTER use a Baxter Physioneal bag for (for use of drain bag). Then close extension line clamp.Follow steps 8 through 12 to collect sample PET 2. Label sample 2 as PET 2 with patient name, ID number, date and time and record as 120 min on the PET formAfter collecting the 2 hour dialysate sample, send patient straight down to Pathology to get bloods done.Pathology Form 1: Urea, Creatinine, Glucose, Albumin.PET 3. At 4 hours the patient can prepare their warmed PD bag of choice, and at the allotted time drain the abdomen of PD effluent completely. This will be their lunchtime bag exchange. Follow steps 8 through 11 to collect sample PET 3. Label sample 3 as PET 3 with patient name, ID number, date and time. Record as 240 min on the PET formPatient then completes PD bag exchange as usual. Patient can go home once bag exchange is complete.Weigh the drain bag and record it on PET form under Four-hour equilibration test: Volume drained. Discard into a yellow infectious waste bin.Make sure ALL tubes and bags are correctly labelled, dated and timed before sending to pathology.Pathology Form 2: PET, 24 hr Urine, 24hr dialysate, Volume, urea, creatinine, glucose, albumin.5.2 Post Laparoscopic revision of Tenckhoff Catheter PD Exchanges The purpose is to recommence Peritoneal Dialysis slowly and safely after a Laparoscopic review so as to prevent leakage of dialysis fluid into the abdominal tissuesEach surgeon has their own preference for Tenckhoff catheter use post revision:Surgeons request 24 – 48 hours of NOT using the catheter Surgeons request it be used straight awayIf catheter is not for use; check on surgical report to see if the surgeon has heparin locked the catheter, otherwise clots and blockages can occurIf the Tenckhoff catheter has not been heparin locked then the Tenckhoff catheter will need to be heparin locked and a new PD extension line attachedMethodRESUMING PD EXCHANGES (may not be day one post op)DAY 1:BED REST 24 HOURS with toilet privileges (if patient needs to get up for toilet, they need to be drained out first)1000 ML EXCHANGES X 5 Monitor laparoscopic sites for leaking, moisture. If leaking evident, drain patient out and for medical reviewDAY2: 1000 ML EXCHANGES X 5Patient should be able to mobilise to shower & toilet with fluid in situ.Monitor laparoscopic sites for leaking, moisture. If leaking evident, drain patient out and for medical reviewDAY 3: 1500 ML EXCHANGES X 4Patient can mobilise freely with fluid in situ.Monitor laparoscopic sites for leaking, moistureDAY4:1500ML EXCHANGES X 4Patient can mobilise freely.Monitor laparoscopic sites for leaking, moisture.DAY 5: Review laparoscopy sites:Sites not healing well, to do 1500ML EXCHANGES X4Sites healed well, to do 2000ML EXCHANGES X4Please ensure that you do a telephone handover to PD staff on discharge5.3 Antibiotic Prophylaxis in PD Patients Undergoing ProceduresPD catheter extension line disconnection (unintended contamination):IP Vancomycin as per Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).High Risk Procedures:The abdomen should be drained at the time of the procedureColonoscopy:ISPD guidelines recommend ampicillin 1g IV plus Gentamycin 120mg IV plus Metronidazole 400mg orally immediately pre-procedure. This may be impractical in privately performed procedures.Consult Nephrologist.Significant dental work (anything more than scale and polish)Consider ampicillin alone 2g PO.Consult Nephrologist.Prophylaxis before PD tube insertionAll patients should have an intranasal swab 5 days to 14 days pre-procedure.Intranasal Staph carriers MRSA or MSSA : Mupirocin 2% nasal ointment twice daily for 3 days before, and 2 days post procedure.Intranasal MRSA carriers: Admit day before procedure for IV Vancomycin as per the Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion (Attachment A).Intranasal carriers of sensitive SA MSSA: DOSA admission with IV cephazolin in theatreBack to Table of ContentsDefinitions Peritoneal Dialysis Peritonitis: 100 WBC/ microlitre effluent of which > 50% are neutrophilsMEWS: Medical Early Warning System NBM: Nil by mouthCAPD: Continuous Ambulatory Peritoneal DialysisISPD: International Society for Peritoneal DialysisMRSA: Methicillin Resistant Staphylococcus aureusMSSA: Methicillin Sensitive Staphylococcus aureusBack to Table of ContentsImplementation PD procedures are carried out by Peritoneal Dialysis trained and credentialed nurses in Renal Home Therapies and 8B. SNSWLHD Renal Outreach Nurses are also trained and credentialed in Peritoneal Dialysis. These skills are taught to all new staff members who perform the procedures under the guidance of trained staff until credentialed. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationHand Hygiene SOP (CED11-50)Antimicrobial prescribing Policy (CHHS13/386)Aseptic non touch technique SOP (CHHS12/347)Medication Standing order SOP (CHHS13/295)Medication Management Policy (DGD12-035)Patient Identification – correct patient, correct site, correct procedure Policy (CED11-26)Management of Peritoneal Dialysis Peritonitis Medication standing order: Intraperitoneal Vancomycin for MRSA, Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion(TCHM11-008)Medication standing order: Intraperitoneal Gentamycin for Empiric Treatment of Peritoneal Dialysis Peritonitis (TCHM11-07)Adding Antibiotics to PD CAPD bagsPD Effluent collection for Microbiology Back to Table of ContentsReferencesAntimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Strippoli GF; Tong A; Johnson D; Schena FP; Craig JC. Am J Kidney Dis 2004 Oct;44(4):591-603.Praino B, et al. ISPD Guidelines/Recommendations. PD Internat. 2010; 30: 393-423AttachmentsAttachment A: Medication Standing Order: Intraperitoneal Vancomycin for MRSA Peritoneal Exit Site and Tunnel Infection, Empiric Treatment of Peritoneal Dialysis (PD) Peritonitis, and Prophylaxis for PD Catheter Extension Line Disconnection Contamination and PD Tube Insertion.Attachment B: Medication Standing Order: Intraperitoneal Gentamycin for Empiric Treatment of Peritoneal Dialysis Peritonitis, Gram negative Bacilli Peritonitis, Pseudomonal Peritonitis, Enterococci Peritonitis.Attachment C: Antibiotic Dosing in PD FluidDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By ................
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