Peritoneal Dialysis



Canberra Health ServicesClinical Procedure Peritoneal Dialysis Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc14350775 \h 1Purpose PAGEREF _Toc14350776 \h 3Scope PAGEREF _Toc14350777 \h 3Section 1 – Peritoneal Dialysis (PD) PAGEREF _Toc14350778 \h 31.1 Post Surgery PAGEREF _Toc14350779 \h 31.2 Weeks 2 to 4 Post Operation PAGEREF _Toc14350780 \h 41.3 Established Exit Site PAGEREF _Toc14350781 \h 41.4 Diagnosis of Exit Site Infections PAGEREF _Toc14350782 \h 51.5 Management of Possible Exit Site Infections PAGEREF _Toc14350783 \h 5Section 2 – Continuous Ambulatory Peritoneal Dialysis (CAPD) PAGEREF _Toc14350784 \h 52.1 Extension Line Change (Fresenius and Baxter) PAGEREF _Toc14350785 \h 52.2 Repair of Tenckhoff catheter (Fresenius and Baxter) PAGEREF _Toc14350786 \h 72.3 PD Fresenius Stay Safe Balance exchange PAGEREF _Toc14350787 \h 82.4 PD Fresenius Stay Safe Balance Drain out PAGEREF _Toc14350788 \h 102.5 PD Baxter Physioneal exchange PAGEREF _Toc14350789 \h 112.6 PD Icodextrin for Fresenius CAPD PAGEREF _Toc14350790 \h 122.7 PD Tenckhoff catheter capping off PAGEREF _Toc14350791 \h 13Section 3 – Automated Peritoneal Dialysis (APD) PAGEREF _Toc14350792 \h 14Section 4 – Infection and Peritoneal Dialysis PAGEREF _Toc14350793 \h 144.1 PD Effluent Collection for Microbiology PAGEREF _Toc14350794 \h 144.2 Adding antibiotics to CAPD bags (Fresenius Balance and Baxter Physioneal) PAGEREF _Toc14350795 \h 164.3 Peritoneal Dialysis Peritonitis (PD Peritonitis) PAGEREF _Toc14350796 \h 174.4 PD Peritonitis Management Plan PAGEREF _Toc14350797 \h 264.5 PD?Exit Site and Tunnel Infection PAGEREF _Toc14350798 \h 27Section 5 – Special Procedures PAGEREF _Toc14350799 \h 285.1 Peritoneal Equilibrium Test procedure PAGEREF _Toc14350800 \h 285.2 Post Laparoscopic revision of Tenckhoff Catheter?PD Exchanges PAGEREF _Toc14350801 \h 315.3 Antibiotic Prophylaxis in PD Patients Undergoing Procedures PAGEREF _Toc14350802 \h 31Implementation PAGEREF _Toc14350803 \h 32Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc14350804 \h 32References PAGEREF _Toc14350805 \h 33Definition of Terms PAGEREF _Toc14350806 \h 33Search Terms PAGEREF _Toc14350807 \h 33PurposeThe purpose of this procedure is to provide staff with the best practice procedures for peritoneal dialysis patients.Peritoneal 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 having Peritoneal Dialysis who are inpatients and are 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 the following Canberra Health Services (CHS) staff working within their scope of practice:Registered and enrolled nurses who are credentialed in performing Peritoneal DialysisRenal Physicians and Advanced Trainee Registrar (ATR) Students under direct supervision.Back to Table of ContentsSection 1 – Peritoneal Dialysis (PD)This Section covers the three stages of exit site care i.e. post-surgery, week one, and thereafter.1.1 Post SurgeryWhen patient returns to the ward post-surgery inspect dressing to ensure that it is dry and intact. If a dressing change is needed then follow the below procedure.? Note:Patients must not shower until week 2 post surgery and only after advice from the Renal Home Therapies teamEquipmentBasic dressing pack.Non- sterile glovesMepilex Border 10cm x 10cmPacket of Gauze squaresSterile gloves Sodium chloride 0.9% 30mL ampouleDetergent wipes to clean tableMethodPerform hand hygiene using alcohol based hand rub (ABHR), as per Healthcare Associated Infection ProcedureClean work surface with detergent wipesOpen dressing pack and prepare equipmentDon non sterile gloves and remove dressingPerform hand hygiene using Triclosan 1% and don sterile glovesClean exit site with sterile saline, dry site with gauze and apply Mepilex dressingDiscard equipment and gloves into appropriate waste bin.1.2 Weeks 2 to 4 Post OperationWeekly dressings will be attended by Renal Home Therapies in ACT. Patients in Southern New South Wales Local Health District (SNSWLHD) will be attended by the Renal Outreach Nurse or community nurse in consultation with the Renal Outreach Nurse.Mepilex dressing is only applied for first week post operation. Week 2 and 3If water gets in under the dressing then patient must come to Renal Home Therapies or contact the Outreach Nurse for dressing change without delayNurse applies mupirocin ointment to exit site and covers with gauze and Tegaderm.? The laparoscopic puncture site dressings are removed and inspected and no further dressing is required for these sites if clean and no signs of infection. Patient can now shower.?Week 4Teach patient how to attend to care of exit site including application of mupirocin Mupirocin ointment should continue to be applied daily.Document condition of the exit site in the patient’s clinical record and notify Advanced Trainee Registrar (ATR)?if any concerns. 1.3 Established Exit Site Once the exit site is healed (this usually takes 3 weeks) the exit site care can be undertaken daily by the patient after training which includes signs and symptoms of exit site infection and the procedure for reporting these.Clean area with warm soapy water then rinse away soap using clean water. Dry body with a towel as normal leaving exit site. Dry exit site with clean gauzeSqueeze a small amount of mupirocin ointment to gauze then apply to exit site, apply dressing if desired before getting dressed.1.4 Diagnosis of Exit Site InfectionsA definite exit site infection has purulent drainage, with or without erythema.? Peri-catheter erythema without purulent drainage is sometimes an early indication of infection but can also be a simple skin reaction.? A positive culture in the absence of an abnormal exit site appearance is indicative of colonization rather than infection.? In this event, more intensive exit-site cleaning is required.? A tunnel infection usually has erythema, oedema or tenderness over the tunnel.Description 0 POINT1 POINT2 POINTSSWELLINGNoExit site only<0.5CM>0.5cmCRUSTNo<0.5CM>0.5cmREDNESSNo< 0.5 CM>0.5cmPAINNoSlightSevereDRAINAGENoSerousPurulentModified Twardowski exit site classification chart1.5 Management of Possible Exit Site InfectionsTwardowski score of 1 is unlikely to need swabbing or treatment?Twardowski score <4 consider observation rather than antibiotic treatment, but ultimate decision is clinical judgement.?? Score as a possible infection for Quality Improvement purposes.Twardowski score ≥4 treat and score as definite exit site infectionProbable tunnel infection requires treatment and usually requires removal of peritoneal dialysis (PD) tube.Discuss findings and treatment plan with ATR or specialist. Back to Table of Contents Section 2 – Continuous Ambulatory Peritoneal Dialysis (CAPD)2.1 Extension Line Change (Fresenius and Baxter)Routine extension lines changes are scheduled every 6 monthsEmergency extension line change is done when there is:Contamination of the extension line- e.g. cap comes offDisconnection of the extension line from the Tenckhoff catheterDamage to, or leaking from, the extension or Tenckhoff catheterPatient will need a line change followed by Intra Peritoneal (IP) antibiotics in accordance with Section 4 Infection and Peritoneal Dialysis, 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. The PD catheter has to be cut to remove damaged portion which will involve attaching a new Luer-lock.EquipmentChlorhexidine 2% in alcohol 70% swabs x 2Dressing packWhite clampUnderpadDetergent wipes for cleaning work surfaceSterile gloves ABHR 10mL syringe x 1drawing up needle x 1Sodium chloride 0.9% 10mL ampoule x 1Fresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension Line and disinfection capBaxter – Minicap extended life PD transfer set with twist clamp. Extension line and MinicapMethodPerform hand hygiene using ABHRPlace absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connectorPerform hand hygiene using ABHRClean work surface with detergent wipesOpen dressing pack and prepare sterile fieldOpen 10mL sodium chloride 0.9% ampoule and place on the edge of work surfacePerform one minute scrub and ?don sterile gloves, as per Aseptic Technique ProcedureDraw up sodium chloride 0.9% 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/MinicapPick up the Tenckhoff catheter with forceps and place paper drape underHold Tenckhoff catheter close to Luer-lock connector with one piece of gauze and extension line with another piece of gauze, unscrew extension line from the Luer –lock connector and discardStill holding the Luer-lock connector of Tenckhoff catheter clean the hub with alcohol and chlorhexidine swab to remove debris. Clean again with second swab and allow to dry Connect the new extension line to the Luer-lock of the Tenckhoff catheter connector making sure it is not cross threaded. Catheter can now be placed onto drape as key site is protectedRemove the white clamp from the Tenckhoff catheter Discard equipment appropriatelyDocument date of line change and batch number in patient’s clinical record. 2.2 Repair of Tenckhoff catheter (Fresenius and Baxter)This is required when damage to Tenckhoff catheter is above Luer-lock connector.Note:Refer to: Section 2.1 PD extension Line change procedure (Fresenius and Baxter) procedure Section 4.3 Adding antibiotics to PD CAPD bags (Fresenius and Baxter) procedure When notified of the disconnection/damage, advise the patient to clamp off the Tenckhoff catheter with the white emergency clamp. Then wrap in sterile gauze and secure with tape.Advise ACT patients:Treatment is required urgently. The patient should visit Renal Home Therapies or contact the on call nurse. NSW patients:To go to local ED with their emergency pack. They may contact the Outreach Nurse in office hoursIf damage to the Tenckhoff is close to the patients exit site a surgical review may be requiredIP antibiotics will be required, see section 4Nurse to put correct bag on heater: Fresenius 2.3% or Baxter Physioneal 2.27% before doing line change to give it time to warm.Note:Place appropriate glucose strength PD bag with lines on top and writing side down on a heater pad designed for this. It takes 30 minutes to heat.EquipmentCorrect continuous ambulatory peritoneal dialysis (CAPD) bag (Fresenius Balance or Baxter Physioneal)Fresenius Catheter Adaptor Luer-lock with Closure CapSterile scissorsChlorhexidine 2% in alcohol 70% swabDressing packWhite clampUnderpadDetergent wipes for cleaning work surfaceSterile gloves x1Antiseptic hand rub10mL syringe x 1Drawing up needle x 110mL sodium chloride 0.9% ampouleFresenius – Staysafe Catheter Extension Luer-lock 32cm- Extension Line Disinfection capBaxter – Minicap extended life PD transfer set with twist clamp – Extension lineMiniCapMethodPut correct CAPD bag on PD bag warmer (antibiotics will be required as per section 4)Close doors and windowsPerform hand hygiene using ABHRPlace absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connectorClean work surface with detergent wipesPerform hand hygiene using ABHROpen dressing pack and open other equipment onto sterile fieldOpen 10mL sodium chloride 0.9% ampoule and place on the edge of work surfacePerform one minute scrub and don sterile gloves as per Aseptic Technique ProcedureDraw up sodium chloride 0.9% 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 / MinicapOpen the Catheter Adaptor Luer-lock with Closure Cap package. Pick up Tenckhoff catheter with forceps, place paper drape under, drop extension line on paper drape. Hold Tenckhoff catheter with one piece of gauze and cut the Luer-lock connector off just above damaged part of the Tenckhoff catheter with the sterile scissors. Continue to hold the Tenckhoff catheter tubing clean the tubing with Chlorhexidine swab twice and allow to dryPlace blue cone on the catheter then push the tube onto thin end of the blue threaded insert firmly. Screw the cone on to the threaded insert tightly by using the blue spannerConnect the new extension line to the Luer-lock connector making sure it is not cross threadedDiscard equipment appropriately. Document date of Luer-lock and line change in patient record and record the batch numbers of equipment usedLoad correct warmed PD bag with IP antibiotic (as per Section 4). Refer to Adding antibiotics to PD CAPD bags (Fresenius and Baxter) (section 4.2)Attend PD exchange. Antibiotic bag to dwell for minimum 6 hours.2.3 PD Fresenius Stay Safe Balance exchangeEquipment 1 x warmed Fresenius Stay Safe Balance bagOrganiser1 x new disinfection capDetergent wipes to clean tableABHRMethodPerform hand hygiene using ABHR Clean work surface and organiser with detergent wipesCollect new disinfection cap and check expiry datePlace cap, organiser and hand rub on cleaned work surfaceCheck warmed Fresenius PD bag for correct volume, glucose concentration, expiry date, clarity and leaks.? Check that the outer pouch is intactOpen new bag, leave in its package Perform hand hygiene using ABHR Roll bag from side to break middle seam, then roll bag from top to break the triangle completely. Check for leaks or irregularitiesHang the bag and uncoil the lines, place disc into organiser and drain bag downMake patient’s extension line accessible (remove from under clothes)?????????? Place catheter into right side of the organiser.Perform hand hygiene using ABHR. Do not talk or cough ?Remove coloured protection cap from discUnscrew catheter from cap and connect to disc making sure the catheter is not dropped and does not touch anything elsePut the coloured cap from disc onto old cap. Pull out and discardOpen clamp on extension line and commence drainage?????? When drainage complete, close clamp on extension lineTurn 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 fillWhen inflow complete, close clamp on extension lineTurn dial to last position to insert pinOpen new disinfectant cap and place it in left side of organiserPerform hand hygiene using ABHR. Do not talk or cough Unscrew cover from the new capUnscrew catheter and screw onto the new cap making sure the catheter is not dropped and does not touch anything elsePull catheter out of the organiserPut the cover from new cap onto disc to seal it offCheck drained out fluid for clarity, dispose of used equipment, clean up and place a new bag on the heater pad.2.4 PD Fresenius Stay Safe Balance Drain outEquipment required: 1 x Fresenius Drain bagOrganiser1 x new disinfection capDetergent wipes to clean table ABHRProcedure:Perform hand hygiene using ABHRClean work surface and organiser with detergent wipesCollect new disinfection cap and check expiry datePlace cap, organiser and hand rub on cleaned work surfaceOpen drain bag, and uncoil the lines, place disc into organiser, place drain bag downMake patient’s extension line accessiblePerform hand hygiene using ABHR. Do not talk or cough Remove white protection cap from discUnscrew catheter from cap and connect to disc making sure the catheter is not dropped and does not touch anything elsePut the white cap from disc onto old cap. Pull out and discardOpen clamp on extension line and commence drainage??? When drainage complete, close clamp on extension lineTurn dial to last position to insert pin Open new disinfectant cap and place it in left side of organiserPerform hand hygiene using ABHR. Do not talk or coughUnscrew cover from the new cap. Unscrew catheter and screw onto the new cap making sure the catheter is not dropped and does not touch anything else.Pull catheter out of the organiserPut the cover from new cap onto disc to seal it offCheck drained out fluid for clarity, dispose of used equipment, clean up and Wash hands when complete.2.5 PD Baxter Physioneal exchangeEquipment 1 x warmed Baxter Physioneal PD bag 1 x Minicap 2 x Blue port clamp (Physioneal) OR 1 x Blue Port clamp (Dianeal)Detergent wipes to clean work surfaceAntiseptic hand rubPD table with Intravenous (IV) poleMethod Perform hand hygiene using ABHRClean work surface with detergent wipesCheck bag for correct glucose concentration, volume, clarity, expiry date and leaks. Check that the outer pouch is intactOpen outer pouch of PD bag by tearing diagonally down from one of the notches on one end of the packagePerform hand hygiene using ABHRRemove bag from outer pouch and place PD bag on cleaned work surface. Push firmly on bag to check for leaksUncoil and separate lines with the coloured ring cap on it. 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 anythingFlip 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 solutionMake patient’s extension line accessible (remove from under clothes)Perform hand hygiene using ABHRCarefully grasp the bag line and remove the coloured ring-cap, leaving it hanging over the edge of the work surface, make sure nothing touches the exposed end. Do not talk or coughPick up the extension line and carefully remove the Minicap. Protect the end of the line from falling or touching other objectsCarefully connect (screw) the extension line to the PD bag line.Hang the bag of PD fluid up and place the drainage bag on the floor with the shiny side facing upwardsDrain out by opening the twist clamp on the extension line When drainage is complete, close the twist clamp on the extension line. Place blue clamp on Physioneal PD drainage line Flush by breaking the green frangible in the tubing of the new PD fluid bag. Open blue clamp on the drainage line and count to five to flush, then close the blue clamp when complete. Check all air from the line has been expelled. If not, then flush again. Make sure glucose solution in the top chamber has drained completely into the bottom chamber of the PD bagOpen the twist clamp on the extension line to commence fillWhen fill is complete, close the twist clamp on the extension line and place the other blue port clamp on the bag fill line to prevent spillageOpen new Minicap packaging? Perform hand hygiene using ABHR. Do not talk or coughDisconnect PD bag line from the patient’s extension line, making sure nothing touches the exposed end; carefully place the Minicap on patient’s extension line. Secure firmly 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 leakageCheck drainage fluid for clarity. Dispose of PD drainage appropriatelyDispose of used equipment. Clean up and wash hands when completeDocument drainage amount in the patient’s clinical record. 2.6 PD Icodextrin for Fresenius CAPDNote: Patients with diabetes should be informed about the need to source a glucometer that is compatible with Icodextrin use.Patients only instil 2 Litre of IcodextrinEquipmentWarmed Baxter Icodextrin 7.5% single bag Fresenius stay safe Luer-lock setDetergent wipes for cleaning work surfaceABHROrganiserDisinfection capTable with poleMethodPerform hand hygiene?using ABHR Clean the work area surface and organizerCheck bag for correct glucose concentration, volume, clarity, expiry date and leaks. Check that the outer pouch is intactOpen outer pouch of Baxter Icodextrin 7.5% bag and leave on the open packaging Open packaging of Fresenius stay safe Luer-lock setPerform hand hygiene using ABHRCarefully pull purple ring-cap off the bag line making sure nothing touches it. Do not talk or coughCarefully take the blue cap off the Fresenius stay safe Luer-lock set and screw onto the Baxter Icodextrin bagSnap the blue pin and wriggle it to make a gapHang the bag and Uncoil the Fresenius stay safe Luer-lock set lines Proceed as for Fresenius Staysafe exchange.2.7 PD Tenckhoff catheter capping offCapping off applies when patient is off PD temporarily or permanently and PD catheter is still insitu. EquipmentFresenius Catheter Adaptor Luer-lock with Closure Cap Chlorhexidine 2% in alcohol 70% swabs x 2Sterile dressing packBaxter PD catheter clamp (white)UnderpadDetergent wipes for cleaning work surfaceSterile glovesABHR10mL syringe x 1Drawing up needle x 110mL sodium chloride 0.9% ampouleMethod?Perform hand hygiene using ABHRPlace absorbent pad under the catheter and place the white clamp on the catheter above the Luer-lock connectorClean work surface with detergent wipesOpen sterile dressing pack and add Catheter Adaptor Luer-lock with Closure package, syringe and needle onto the draped work surfaceOpen 10mL sodium chloride 0.9% ampoule and place on the edge of another work surfacePerform hand hygiene using ABHR Don sterile glovesDraw up the sodium chloride 0.9% into the 10mL syringePick up the extension line with forceps, place paper drape under, drop extension line on paper drapeHold the Luer-lock connector with one piece of gauze and the extension line with another piece of gauze and 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. Clean with chlorhexidine swab twice and allow to dry before attaching the 10mL syringe with 10mL sodium chloride 0.9%.Carefully undo the white clamp and insert 10mL of sodium chloride 0.9% Reclamp the white clamp. Remove the 10mL syringe and attach the white cap to the end of the Luer-lock connector making sure not to cross thread itRemove the white clamp from the Tenckhoff catheterClean up and discard equipment appropriatelyDocument capping off in patient’s clinical record and on the patient care plan.Back to Table of Contents Section 3 – Automated Peritoneal Dialysis (APD)This procedure is not currently performed for inpatients. Patients who are on APD at home switch to CAPD when admitted. Training for APD is given by Renal Home Therapies nurses.Back to Table of Contents Section 4 – Infection and Peritoneal Dialysis Infection in Peritoneal Dialysis carries a high risk of morbidity and suspected instances of infection should be investigated as a matter of urgency.Alert: All local antimicrobial prescriptions must follow local antimicrobial stewardship prescribing procedures with approval of restricted antimicrobials as per Antimicrobial Stewardship Procedure. 4.1 PD Effluent Collection for MicrobiologyEquipmentCloudy PD drain bagDetergent wipes to clean work surface1x pink top(EDTA) (blood tube if requested1 x yellow top container1 x set of blood culture bottles2x 20mL syringe and 1x 10 mL syringe if required for pink tube 3x Blunt fill needle1x Blood transfer device (pink hub) Chlorhexidine 2% in alcohol 70% swabs x 6Pathology formPathology labels Dressing packNon-sterile glovesABHRMethodTo collect sample use the cloudy PD drain bag that patient has brought with them or collect a sample from a wet or dry abdomen as below:Wet abdomen – Do an exchange and use a PD drain bag to fully drain dialysate effluent as normal and disconnect. You will take samples from this drain bag.Dry abdomen – Do an exchange to 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: Effluent cannot be collected from APD drainage bagFresenius: Use Staysafe drainage set (drain bag)Baxter: Use Baxter Physioneal bag for use of drain bag. Confirm patient details as per Patient Identification and Procedure Matching ProcedurePerform hand hygiene using ABHRClean work surface with detergent wipesOpen dressing pack. Add blood transfer device, blunt fill needles and syringes. Open Chlorhexidine 2% in Alcohol 70% swabs on to dressing trayTake lids off culture bottles and yellow top containerLay PD bag on cleaned work surface. Identify and expose sample port on PD drain bag Gently mix contents of bag for at least 30 seconds Perform hand hygiene using ABHRDon glovesScrub each culture bottle access points with Chlorhexidine 2% in Alcohol 70% swab and allow to dry completelyClean PD drain bag sample port with Chlorhexidine 2% in Alcohol 70% swab and allow to dry completelyHold the PD drain bag sample port with sterile gauze and insert 20 mL syringe with blunt fill needle attached, withdraw 20 mL of effluent. Remove blunt fill needle and attach blood transfer device. Insert 10 mL of effluent into aerobic culture bottle (blue top). Inject remaining 10 mL of effluent into anaerobic bottle (purple top). Collect 20 mL of effluent using a blunt fill needle and new 20 mL syringe and place into yellow top container. If requested to collect effluent for pink tube repeat steps above using 10 mL syringeLabel all samples with the patient’s details, as per Patient Identification – Pathology Specimen Labelling procedure, and send to pathology with a request for?white cell count (WCC), Gram Stain, microscopy and culture (MCS). Specifically request urgent cell count to be done from Pink tube (EDTA) if in doubt as to whether the bag is cloudy.Discard equipment and clean up. PD bag is put into a clinical waste binPerform hand hygiene using ABHRDocument procedure in the patient’s clinical record.4.2 Adding antibiotics to CAPD bags (Fresenius Balance and Baxter Physioneal)EquipmentAppropriate CAPD bag (Fresenius Balance 2.3% or Baxter Physioneal 2.27%)Scissors (use for Baxter only)Dressing pack 10mL syringe x 1 2mL syringe x 1 (for gentamicin)4x blunt fill needle Prescribed antibiotics Water for injection 10mL depending on doseChlorhexidine 2% in alcohol 70% swabsDetergent wipes for cleaning work surfaceABHRMedication additive labelNon-Sterile glovesPatient identification labelMethodAll antibiotics need to be checked with another RN or medication endorsed EN before instillation and additive labels signed as per National Standard for User applied Labelling of Injectable Medicines, Fluids and Lines Procedure Check if the patient has any allergies and confirm patient details as per Medication Handling PolicyPerform hand hygiene, and clean work surface with detergent wipesOpen dressing pack add syringes and blunt fill needles. Open chlorhexidine 2% in alcohol 70% swabs on to dressing trayCheck PD bag for expiry date, volume, strength, clarity, and leakage. If packaging is damaged do not use. A pre-warmed bag can be loaded with antibiotics if it is going to be used straight afterFresenius: 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 scissors to cut a slit in back of outer wrapper of Baxter Physioneal bag to identify and expose injection port attached to Physioneal fluid bag. Ensure injection port is attached to Physioneal fluid bag and not the drain bagOpen water for injection and place on edge of work surface Flip the lids off antibiotic vials and open gentamicin ampoule, if requiredPerform hand hygiene using ABHRDon glovesClean injection port on bag with chlorhexidine 2% in alcohol 70% and wait 30 seconds for the surface to dryWipe antibiotic vial with chlorhexidine 2% in alcohol 70% swab. Wait 30 seconds for the surface to dryDraw up water for injection in the 10mL syringe, attach blunt fill needleInject water into vial and mix, then draw up the mixture, attach syringe to new blunt fill needle.Hold the injection port and inject the antibiotics. If gentamycin is required, draw up required dose of gentamycin in 2mL syringe, injecting to PD bag by use of a blunt fill needle.Label PD bag with patient label and additive label as per National Standard for User applied Labelling of Injectable Medicines, Fluids and Lines ProcedureReseal the outer pouch with tapeClean up used equipment and dispose of sharps correctlyPlace 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. The bag needs to warm for at least an hour prior to administering when taking bag from the fridge.4.3 Peritoneal Dialysis Peritonitis (PD Peritonitis)PD Peritonitis: is defined as 100 x 106 white blood cells per Litre effluent following a 2 hour dwell, (usually with > 50% of white cells being neutrophils) or any number of white cells with a growth of bacteria.? If a shorter than 2 hour dwell has been used then a cell count less than 100 white blood cells may still represent peritonitis. If the cell count is being read from the EDTA/Full Blood count type tube, then the reporting units are different and a fluid white blood count of 0.1 x 109 white blood cells per Litre is diagnostic of infection.Initial PresentationA cloudy bag always requires treatment with antibioticsTake culture and commence treatment immediately (before microscopy results are available). Adjust antibiotic treatment when results are known.Culturing Peritoneal EffluentDry abdomen: ?instil 1 Litre of (antibiotic free) dialysate and dwell for 1-2 hours. Then drain out.Wet abdomen: ?fully drain dialysate effluent as normal and disconnect.Method:?Refer to section 4.1 PD Effluent Collection for Microbiology.Empiric Antibiotic TreatmentCommence antibiotic treatment immediately; do not wait for microscopy results.The treating medical team will prescribe antibiotics based on the patient’s individual needs, the Antimicrobial Stewardship procedure and the International Society for Peritoneal Dialysis Peritonitis Recommendations. All initial antibiotic dwells are for a minimum 6 hour period.? The antibiotic combinations of gentamicin/cefazolin and gentamicin/vancomycin can and should be added together in a single dialysate bag for the initial treatment.?There is evidence of stability for gentamicin/cefazolin and gentamicin/vancomycin for at least 48 hours when mixed together and evidence of stability and ongoing sterility for at least 7 days when used as single agents in the dialysate bag 1–3.? The patient should also be commenced on nystatin tablets or fluconazole orally, alternate days, during antibiotic therapy as this may reduce the risk of fungal peritonitis.?? Alert:Due to the risk of causing low intraperitoneal (IP) antibiotic levels, intermittent IP antibiotic dosing must not be used on patients utilising more than 5 exchanges (APD, IPD or CAPD) per day. Therefore for patients that will receive more than 5 exchanges of dialysate per day, a continuous dosing prescription is required. For patients with significant residual renal function a patient specific dosing regimen may be requiredNote: All antibiotics must be prescribed by a physician for each patient on an electronic medication system CV5 Renal Electronic Medical Record or National Inpatient Medication ChartNote: For most patients, cefazolin, rather than vancomycin or ceftazidime, should be selected for empiric Gram positive cover. The loading dose/s of cefazolin cannot be given into a bag of <2L. Discuss correct dosing adjustment for patients receiving vancomycin loaded into incompletely utilised dialysate bags. For Patients weighing <67 kg AND receiving 5 dialysate exchanges/dayDay 0: (day antibiotics are commenced)Refer to the patient’s medication order and load bag with prescribed combination. The following combinations are available to the physician for prescribing:Cefazolin 15mg/kg body weight to maximum 500mg/L dialysate and gentamicin 20mg/L dialysate. Where 15mg/kg cefazolin is more than 500mg/L dialysate, add cefazolin 500mg/L dialysate to the first bag followed by cefazolin 125mg/L dialysate to every subsequent bag (continuous dosing) OR add vancomycin 30mg/kg body weight and gentamicin 20mg/L dialysateOR add ceftazidime 1000mg to 1500mg to the dialysate bag (as most appropriate) to a new dialysate bag.? Add oral metronidazole 400mg 12-hourly, or intravenous metronidazole 500mg 12-hourly, if intestinal perforation suspected. Perform a bag exchange using loaded bag/s.Day 1: (first morning after initial antibiotics)Review peritoneal dialysate result. If white cell count < 100 x 106 per Litre, discuss with nephrologist whether antibiotic therapy requires continuation.If patient received gentamicin, cefazolin or vancomycin then continue as per daily or continuous (for patients prescribed cefazolin that weigh >66kg) doses prescribed. If patient received ceftazidime on Day 0 then continue as prescribed daily dose.Ensure approvals for ongoing antibiotic are obtained if required. Day 2:??? Review peritoneal dialysate result. Discuss result with nephrologist for adjustment of antibiotic therapy. Obtain gentamicin and vancomycin pre-dose serum concentrations if receiving either of these antibiotics? Adjust as per regimen below if ongoing therapy is necessaryContinue cefazolin and/or ceftazidime as per Day 1, if ongoing therapy is necessaryDiscuss treatment course with the Nephrologist or Renal ATRVancomycin resistant Enterococcus (VRE) surveillance should be performed if required as per Healthcare Associated Infections Procedure (generally if on vancomycin therapy). Ensure approvals for ongoing antibiotics are obtained if required. Dose adjustment of gentamicin from Day 2 onwards(target pre-dose blood level 1.5 – 2.5 mg/L):Level < 1: discuss with Nephrologist or delegateLevel 1 – 2: 20mg/L of dialysate, repeat level in 48 hoursLevel 2.1 – 3: 15mg/L of dialysate, repeat level in 48 hoursLevel > 3.1: withhold dose, repeat level in 24 hours and discuss with Nephrologist or delegate Dose adjustment of vancomycin from Day 2 onwards(Target pre-dose blood level > 15mg/mL):Level < 12: 15mg/kg, repeat level in 24 hoursLevel 12.1 – 20: 15mg/kg, repeat level in 48 hoursLevel 20.1 – 25: withhold for 24 hours, then 15mg/kg, repeat level 48 hours after dosingLevel > 25.1: withhold dose, repeat level in 48 hours, discuss with Nephrologist or delegateFor Patients of any weight receiving > 5 dialysate exchanges/day that are prescribed vancomycin/gentamicin or ceftazidime (continuous dosing required)Day 0: (day antibiotics are commenced)Refer to the patient’s medication order and load bag with prescribed combination. The following combinations are available to the physician for prescribing:add vancomycin 30mg/kg body weight to maximum 2.5g and gentamicin 20mg/L dialysate. Follow with vancomycin 1.5mg/kg body weight and gentamicin 4mg/L dialysate to every subsequent bag.OR add ceftazidime 500mg/L dialysate and follow with ceftazidime 125mg/L dialysate to every subsequent bag.? Add oral metronidazole if intestinal perforation suspected. Perform a bag exchange using loaded bag/s.Day 1: (first morning after initial antibiotics)Review peritoneal dialysate result. If white cell count < 100 x 106 per Litre, discuss with nephrologist whether antibiotic therapy requires continuation.Continue Day 0 antibiotics with continuous dosing regimen described above.Ensure approvals for ongoing antibiotic are obtained if required. Day 2:??? Review peritoneal dialysate result. Discuss result with nephrologist for adjustment of antibiotic therapy. Obtain gentamicin and vancomycin random serum concentrations if receiving either of these antibiotics? Adjust as per regimen below if ongoing therapy is necessaryContinue ceftazidime as per Day 0 continuous dosing, if ongoing therapy is necessaryDiscuss treatment course with the Nephrologist or Renal ATRVancomycin resistant Enterococcus (VRE) surveillance should be performed if required as per Healthcare Associated Infections Procedure (generally if on vancomycin therapy). Ensure approvals for ongoing antibiotics are obtained if required. Dose adjustment of gentamicin from Day 2 onwards(target random blood level 1.5 – 2.5 mg/L):Level < 1: discuss with Nephrologist or delegate. May require repeat loading dose of 20mg/L dialysate and increase continuous dosingLevel 1 – 3: repeat level in 48 hours, no change to continuous dosingLevel > 3.1: withhold dosing, repeat level in 24 hours and discuss with Nephrologist or delegate Dose adjustment of vancomycin from Day 2 onwards(Target pre-dose blood level > 15mg/mL):Level < 8: Stat dose 30 mg/kg to maximum 2.5g with 6 hour dwell and double previous continuous dosage to 3mg/kg. Repeat level in 48 hours.Level 8 < 12: Stat dose 15 mg/kg to maximum 2.5g with 6 hour dwell and increase continuous dosage to 3mg/kg, repeat level in 48 hoursLevel 12.1 – 20: 15mg/kg, continue current continuous dosing and repeat level in 48 hoursLevel 20.1 – 25: withhold for 24 hours, then resume at 1mg/kg, repeat level in 48 hoursLevel > 25.1: withhold dose, repeat level in 48 hours, discuss with Nephrologist or delegateFor Patients Weighing > 67kg prescribed cefazolin/gentamicin therapy OR for patient of any weight receiving more than 5 exchanges per day prescribed cefazolin/gentamicin therapy (continuous dosing required)Table of Cefazolin/Gentamicin DosingCefazolin/Gentamicin dialysate content in mg/L dialysate per exchange Patient Weight Range67 <80 kg80 <100 kg100 < 134 kgBag no.1st 2nd and subsequent exchanges1st 2nd 3rd and subsequent exchanges1st 2nd 3rd and subsequent exchangesExchanges/day3 or More500mg/L cefazolin & 20mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin500mg/L cefazolin & 20mg/L gentamicin250mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin500mg/L cefazolin & 20mg/L gentamicin375mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin2500mg/L cefazolin & 20mg/L gentamicin125 mg/L cefazolin & 4mg/L gentamicin500mg/L cefazolin & 20mg/L gentamicin250mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin500mg/L cefazolin & 20mg/L gentamicin375mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin1Minimum 2 exchanges/day required500mg/L cefazolin & 20mg/L gentamicin250mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicin500mg/L cefazolin & 20mg/L gentamicin375mg/L cefazolin & 4mg/L gentamicin125mg/L cefazolin & 4mg/L gentamicinDay 0: (day antibiotics are commenced)Refer to the patient’s medication order and load bag with prescribed combination. Loading doses are:Cefazolin 15mg/kg body weight to maximum 500mg/L dialysate and gentamicin 20mg/L dialysate. See Table “Table of cefazolin/gentamicin dosing” for initial and subsequent dosing. Ongoing dosage is at cefazolin 125mg/L dialysate and gentamicin 4mg/L dialysate. Add oral metronidazole if intestinal perforation suspected. Perform a bag exchange using loaded bag/s.Day 1: (first morning after initial antibiotics)Review peritoneal dialysate result. If white cell count < 100 x 106 per Litre, discuss with nephrologist whether antibiotic therapy requires continuation.Continue at cefazolin 125mg/L and gentamicin 4mg/L as above. Day 2:??? Review peritoneal dialysate result. Discuss result with nephrologist for adjustment of antibiotic therapy. Obtain gentamicin random serum concentrations Adjust gentamicin as per regimen below if ongoing therapy is necessaryContinue cefazolin and/or ceftazidime as per Day 1, if ongoing therapy is necessaryDiscuss treatment course with the Nephrologist or Renal ATRVancomycin resistant Enterococcus (VRE) surveillance should be performed if required as per Healthcare Associated Infections Procedure (generally if on vancomycin therapy). Ensure approvals for ongoing antibiotics are obtained if required. Dose adjustment of gentamicin from Day 2 onwards(target random blood level 1.5 – 2.5 mg/L):Level < 1: discuss with Nephrologist or delegate. May require repeat loading dose of 20mg/L dialysate and increase continuous dosingLevel 1 – 3: repeat level in 48 hours, no change to continuous dosing Level > 3.1: withhold dosing, repeat level in 24 hours and discuss with Nephrologist or delegateAntibiotic Recommendations for Culture Positive DiseaseFungi: Notify nephrologist or delegate and arrange for catheter removal with 2 weeks of antifungal treatment post removal. May require systematic antifungal therapy, consult Infectious Diseases team if resistant or Sensitive-Dose-Dependent to fluconazole.Culture negative peritonitis Negative effluent cultures on day 3 warrant a repeat dialysis effluent White Blood Cell count with differential?(2D).If the culture-negative peritonitis is resolving at day 3, suggest discontinuing aminoglycoside therapy and continuing treatment with gram-positive coverage already administered for 2 weeks.If the culture-negative peritonitis is not resolving at day 3, suggest special culture techniques be considered for isolation of unusual organisms.Consult microbiology if unusual organisms suspected.Stenotrophomonas/Pseudomonas spp.– may require oral antibiotic therapy – consult with renal physician Enterococcus faecalis or faecium– will require adjustment based on available susceptibilities. Generally, Enterococcus faecalis will be susceptible to susceptible to ampicillin. Polymicrobial results: Discuss with nephrologist or Infectious DiseasesSourced from: Li, P., Szeto, C., Piraino, B., et al. (2016) International Society for Peritoneal Dialysis Peritonitis Recommendations: 2016 update on prevention and treatment, Perit Dial Int, 36(5):481-508 Available at: accessed on 11/10/18.Sourced from: Li, P., Szeto, C., Piraino, B., et al. (2016) International Society for Peritoneal Dialysis Peritonitis Recommendations: 2016 update on prevention and treatment, Perit Dial Int, 36(5):481-508 Available at: accessed on 11/10/18.Monitoring of PD PeritonitisClosely monitor clarity of the effluent, document and report to Nephrologist or delegate. If the effluent is not clearing catheter removal maybe required. Improvement should be obvious within 48 hoursMaintain close contact with microbiology to seek culture informationClosely monitor the clinical status of patient, attend to vital sign monitoring as per Vital Signs and Early Warning Score Procedure.Consider making the patient nil by mouth (NBM) if abdomen distendedAntibiotic treatment should continue for 2-3 weeks, determined by Nephrologist or delegate.? Current ISPD guidelines recommend 3 weeks’ therapy for gram negatives, Enterococci and for Staphylococcus aureus.? Two weeks is generally adequate for other organismsPatients are to have follow up dialysate effluent cell count on day 3 if they are not clearly improving – PD staff to monitor.? A white cell count >1000 x 106 per Litre dialysate or > 1 x 109 white blood cells per Litre at Day 3 is a risk factor for subsequent treatment failure and must be notified to the nephrologist or delegateOutlying patients at regional hospitals that have not improved at 48 hours will require urgent transfer to The Canberra Hospital.? Renal Registrar/Nephrologist or delegate to arrangeFailure 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 Nephrologist or delegateVancomycin resistant Enterococci (VRE) status should be reviewed if surveillance was performed on Day 2 according to Healthcare Associated Infections Procedure.Stability and microbiological purity of Antibiotics in PDAntibiotics should not be stored for more than 48 hours after addition to the PD bag.? Icodextranvancomycin, cefazolin, ampicillin, ceftazidime, gentamicin and amphotericin are compatible with Icodextrin containing dialysate3? There is limited data on long term stability except for vancomycinCatheter RemovalCatheter removal in all CAPD peritonitis is performed by general surgeons in operating theatre by means of a mini laparotomy with washout.4.4 PD Peritonitis Management PlanEstablish the following:Is the patient well or unwell?Send patient to Emergency Department if febrile or has abdominal painPD peritonitis is initially treated by local Emergency department in SNSWLHDAsk patient to come to Renal Home Therapies or contact Renal Outreach nurse (will depend on availability) if they are completely symptom freeIs the PD fluid in situ or abdomen empty?Does the patient have the cloudy bag? Instruct the patient to bring it with them so it can be sampled for culturesIf the patient does not have a cloudy bag and their abdomen is EMPTY – tell patient to fill before coming in. Ideally fluid should have dwelled for 1-2 hours before draining for a sample.The patient’s current weight?Required for antibiotic dosage If the patient has any allergies?Prescribe the patient PD antibiotic treatment as per Section 4.3If patient has known VRE continue current protocol.Does the patient use Baxter or Fresenius? In the ACT PD bags can be found at Renal Home Therapies or ward 8B.What is the patient’s PD volume? 2L/ 2.5LRequired for gentamicin dosage Is the patient an ACT or NSW resident?Follow directions below depending on where the patient lives?????????? ACT Patients Suspected peritonitis of non-admitted patients is managed by the staff of Renal Home Therapies:during office hours 0800- 16301630-0800 (Ring switch and ask for second on call dialysis nurse)For the patient with peritonitis in the Emergency Department equipment can be found on the renal ward EquipmentAntibiotic and PD bag Drain bagPD table with poleABHRFresenius – 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)Management Refer to PD Effluent Collection for Microbiology (section 4.1)Refer to HYPERLINK \l "_4.2_Adding_antibiotics" Adding antibiotics to CAPD bags (Fresenius Balance and Baxter Physioneal) (section 4.2)NSW Patients Tell patient to go to their local hospital and find out which hospital they are going to and report to Outreach nurse if availableTell the patient to advise the local doctor to phone the Renal Physician on call at CHS.Tell PD patient to take the cloudy bag with themTell 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 : Heater pad for PD bagsA box of green (2.3% Fresenius or 2.27% Baxter Physioneal)? Extra equipment depending on system used:Fresenius – Disinfection caps, white organiserBaxter – Mini caps, 2 blue port clampsOutlying PD Patients at Regional hospitals will be followed up by the NSW Renal Outreach Team and need to have follow-up dialysate effluent white cell count (WCC) on Day 3. Where there is no improvement at 48 hrs (bag clearing) the patient is to be transferred to the Canberra Hospital. Nephrologist or delegate or ATR to arrange transfer as per Admission to Discharge Procedure.4.5 PD?Exit Site and Tunnel Infection Refer to Section 1.3 Established Exit Site Exit 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 and continuation of topical mupirocin rather than oral antibiotics. Concomitant catheter related infection and peritonitis is often due to Pseudomonas species.Empiric treatment of mild exit site infectionsInfections with Staphylococcus aureus must always be covered. Treatment duration continues 5-7 days after all the infection has resolvedPseudomonas spp may need to be covered if the patient has a history of pseudomonal infections Known colonisation in the patient:No MRSA: flucloxacillin/dicloxacillin 500 mg orally three times dailyNon Multiresistant MRSA:?clindamycin if susceptible. If not, as per Multiresistant MRSA Multiresistant MRSA: IP vancomycin or alternatively oral fusidic?acid and rifampicin 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 infectionBack to Table of ContentsSection 5 – Special Procedures5.1 Peritoneal Equilibrium Test procedure 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. ?A PET 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 and instructions, by Renal Home Therapies, 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.EquipmentPatient input form (PET form) Pathology form x 2Patient identification labels x 10DisinfectantAntiseptic hand rubChlorhexidine 20% in alcohol 70% swabSterile gloves x 3Red top blood tubes x 3Gauze x 3For Fresenius include:Fresenius Balance 2.3% bag for PET, warming on heater padFresenius Balance bag of patient choice for after the test warmedFresenius Staysafe drainage set (drain bag)Disinfection Caps x 3Blood transfer device x3Luer lock access devicex3For Baxter include:Baxter Physioneal 2.27% bag for PET, warming on heater padBaxter Physioneal bag for mid test (for use of drain bag)Baxter Physioneal bag of patient choice for after the test warmedMinicaps x 310mL syringe x3drawing up needle x3MethodCheck patient has brought in 24 hour urine collection and correct PD effluent bags; if the patient has not brought in the correct samples then the test will need to be rebooked.Note: Specimens must be labelled as per Patient Identification – Pathology Specimen Labelling ProcedureConfirm patient’s details as per Patient Identification and Procedure Matching Procedure Measure patient’s sitting and standing blood pressureClose door, Perform hand hygiene using ABHR and clean work surfaceSet up for PD exchange using correct warmed PD bag (section 2)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 % of bag and volume infused in “overnight exchange” on PET formNote 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 and record weight on PET formFlush 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” on PET formPET 1. Make sure the drain line is clamped. Sit the patient up. 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 clampFor Fresenius: open blood transfer device, Luer-lock access device, gauze and sterile gloves in their packets, put chlorhexidine 20% in alcohol 70% swabs onto gauze. For Baxter: open syringe and drawing up needle, gauze, sterile gloves leaving in their packets, put chlorhexidine swabs onto gauzePerform hand hygiene using ABHR and don sterile glovesHold sample port with gauze and clean sample port with chlorhexidine 20% in alcohol 70% swab. Wait 30 seconds for the surface to dryFor Fresenius: assemble blood transfer device to Luer-lock access device. Attach blood transfer device to sample port, attach red top tube to Luer-lock access device, PD fluid sample will be sucked into red top tubeFor Baxter: attach syringe to drawing up needle and withdraw 10mL from sample port Label sample as PET 1 with patient name, identification 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 usualWeigh 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, and 3.? Label 24 hour urine, date and time. Put all bags and urine together in PD fluid laboratory 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 clampFollow steps 8 through 11 to collect sample PET 2. Label sample 2 as PET 2 with patient name, ID number, date and time and record as 120 minutes on the PET formAfter collecting the 2 hour dialysate sample, send patient straight down to Pathology with request form to get bloods taken or attend in Renal Home Therapies.Pathology request Form 1: Urea, Creatinine, Glucose, AlbuminPET 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 completeWeigh the drain bag and record it on PET form under Four-hour equilibration test: Volume drained. Discard into a yellow clinical waste binMake sure ALL tubes and bags are correctly labelled, dated and timed before sending to pathologyPathology request Form 2: PET, 24 hour Urine, 24 hour 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 tissues.Each surgeon has their own preference for Tenckhoff catheter use post revision: Some request 24 – 48 hours resting of the catheter. Others allow immediate use. Please check the patient’s notes for the surgeon’s postoperative instructions.MethodResuming PD exchanges (may not be day one post operation)DAY 1:1000 mL EXCHANGES X 5 BED REST 24 HOURS with toilet privileges (if patient needs to get up for toilet, they need to be drained out first)Monitor laparoscopic sites for leaking and moisture. If leaking evident, drain patient out and request a medical review.DAY 2: 1000mL EXCHANGES X 5Patient should be able to mobilise to shower and toilet with fluid insituMonitor laparoscopic sites for leaking and moisture. If leaking evident, drain patient out and request a medical review.DAY 3: 1500mL EXCHANGES X 4Patient can mobilise freely with fluid insituMonitor laparoscopic sites for leaking and moisture. If leaking evident, drain patient out and request a medical review.DAY 4:1500mL EXCHANGES X 4Patient can mobilise freely with fluid insituMonitor laparoscopic sites for leaking and moisture. If leaking evident, drain patient out and request a medical review.DAY 5: PD nurse review of laparoscopy sites:Sites not healing well : keep volume at 1500mL exchanges X 4Sites healed well: increase the volume to 2000mL exchanges X 4Please ensure that you do a telephone handover to Renal Home Therapies when the patient is discharged home.5.3 Antibiotic Prophylaxis in PD Patients Undergoing ProceduresPD catheter extension line disconnection (unintended contamination):IP cefazolin unless MRSA risk factors. If MRSA risk factors then IP vancomycin as per Section 4.3High Risk Procedures:The abdomen should be drained at the time of the procedure.Colonoscopy:ISPD guidelines recommend ampicillin 1g IV plus gentamicin 120mg IV plus metronidazole 400mg orally immediately pre-procedure? This may be impractical in privately performed proceduresConsult Nephrologist or delegate.Significant dental work (anything more than scale and polish)Consider ampicillin alone 2g orallyConsult Nephrologist or delegate.Back to Table of ContentsImplementation PD procedures are carried out by Peritoneal Dialysis trained and credentialed nurses in Renal Home Therapies and Ward 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.This procedure will be available to all staff on the Policy Register. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesMedication Handling Patient Identification and Procedure Matching Consent and Treatment ProceduresHealthcare Associated Infections Antimicrobial Stewardship Aseptic Technique Patient Identification and Procedure Matching Admission to Discharge Patient Identification – Pathology Specimen Labelling Pathology Requests and Specimens Urine Specimen Management Venepuncture Blood Specimen Collection International GuidelinesInternational Society for Peritoneal Dialysis Guidelines Back to Table of ContentsReferencesLi, P. K.-T. et al. Peritoneal Dialysis-Related Infections Recommendations: 2010 Update. Perit. Dial. Int. 30, 393–423 (2010).Roberts, D. M. et al. Antibiotic stability in commercial peritoneal dialysis solutions: influence of formulation, storage and duration. Nephrol. Dial. Transplant. 26, 3344–9 (2011).Li, P. K. et al. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit. Dial. Int. J. Int. Soc. Perit. Dial. (2016). doi:10.3747/pdi.2016.00078Back to Table of ContentsDefinition of Terms Peritoneal Dialysis Peritonitis: 100 White Blood Cell count/microlitre effluent of which > 50% are neutrophilsMEWS: Modified Early Warning Score NBM: Nil by mouthCAPD: Continuous Ambulatory Peritoneal DialysisISPD: International Society for Peritoneal DialysisMRSA: Methicillin Resistant Staphylococcus aureusVRE: Vancomycin resistant enterococciBack to Table of ContentsSearch Terms Peritoneal, Dialysis, tunnel, exit site, PD, CAPD, peritonitisDisclaimer: This document has been developed by Canberra 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 Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 17/07/2019Complete ReviewED, MedicineCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHS18/244Peritoneal Dialysis ................
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