ASA class
Definition
Examples
ASA I
A normal healthy patient
Healthy nonsmoker
ASA II
Mild systemic disease
Mild diseases, smoker, controlled DM(diabetes mellitus or Htn (hypertension) BMI(body mass index) >30 up to 40
ASA III
Severe systemic disease
Moderate to severe diseases ESRD (end stage renal disease) on regular dialysis, COPD, BMI > 40
Poorly controlled Htn or DM
ASA IV
Systemic disease that is a constant threat to life
ESRD not on regular dialysis, recent myocardial infarction, recent cerebrovascular accident, recent transient ischemic attack, coronary artery stent placement less than 3 months prior, ongoing cardiac ischemia
ASA V
Moribund patient not expected to survive without operation
Ruptured abdominal or thoracic aneurysm, ischemic bowel with cardiac or multiorgan system dysfunction
ASA VI
Brain dead organ removal for donor purposes
The majority of peritoneal access surgery patients will be categories ASA III or IV [73, 74]. In patient’s deemed at prohibitive risk for general anesthetic alternative options can be planned. These options include laparoscopic catheter placement under local anesthetic, open surgical insertion under local anesthetic, open surgical insertion under TAPP (transverses abdominis plane block), open surgical insertion under spinal anesthethetic, Y tec peritoneoscopic or percutaneous methods under local anesthetic [75–77].
Pulmonary
Pulmonary patient risk stratification depends on identification of risk factors, use of a pulmonary stratification tool when there is concern, and liberal utilization of perioperative risk mitigative strategies.
The preoperative history and physical can screen for the following pulmonary risk factors. Further more specific testing ordered on basis of elicited findings.
Risk factors for periprocedural pulmonary complication include:
- 1.
Chronic obstructive pulmonary disease (COPD)
- 2.
Age > 60
- 3.
Cigarette smoking
- 4.
Congestive heart failure ( CHF)
- 5.
ASA class ≥ II
- 6.
Functional Dependence (need for device or human assistance with activities of daily living)
- 7.
Obstructive Sleep Apnea Syndrome
- 8.
Pulmonary hypertension (correlates with increased perioperative chf, hemodynamic instability, and respiratory failure)
- 9.
Use of general anesthetic for planned peritoneal access catheter surgery
- 10.
Serum albumin less than 3.5 g/dL
- 11.
Emergency Surgery
- 12.
BUN ≥ 21 mg/dL or Cr > 1.5 mg/dL
Risk Stratification when indicated may utilize 2 accessible pulmonary patient risk indices. The NSQIP (National Surgical Quality Improvement) Surgical Risk Calculator for postoperative pneumonia risk, and ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia). Both tools are extensively validated. The NSQIP Surgical Risk Calculator is demonstrated to have a very high predictive discriminatory correlation for postoperative pulmonary complication [78].
Canet et al. developed the ARISCAT in 2010, an externally validated major perioperative pulmonary risk index. This prognosticator utilizes seven weighted clinical factors. These risk factors are age, history of respiratory infection with a month before surgery, the anatomic site of planned surgery, the duration of the procedure, the operative urgency, and the preoperative oxygen saturation. In a multicenter validation trial 5099 consecutive nonobstetric patients had inpatient surgery under general, neuraxial, or plexus block anesthesia. Patients were followed in this study throughout their postoperative hospital stay for up to 5 weeks. A C statistic of 0.80 was realized, demonstrating a high predictive discrimination for patients having or not having postoperative pulmonary adverse outcome [79, 80].
Pulmonary Risk Mitigative Strategies
1. Smoking cessation for at least 8 weeks prior to surgery. Some data suggest that preoperative smoking cessation for less than 6 weeks may increase perioperative pulmonary risk [81]. 2. Excellent preoperative control of asthma reverses the perioperative asthmatic risk of general anesthesia [82]. Perioperative bronchodilator therapy can be useful in COPD, asthma, and pulmonary hypertension. Inhaled corticosteroid therapy can optimize perioperative asthma and COPD.
Cardiovascular
Cardiac risk: A 28–41% adult prevalence of ischemic heart disease at initial dialysis is internationally reported [83]. The hemodialysis population has been reported to have a 35 fold higher annual cardiovascular mortality compared to the general population [83]. Left ventricular hypertrophy, diastolic dysfunction, coronary artery disease, and hypertension are very common in end stage renal disease patients. Perioperative cardiac risk markers are categorized as active cardiac conditions or as clinical cardiac risk factors. Active cardiac conditions require cardiovascular investigation, and treatment prior to surgery. These are listed in Table 4.2 below. Clinical cardiac risk factors such as compensated heart failure and diabetes mellitus do not require routine preoperative noninvasive cardiac testing for peritoneal dialysis access surgery [84].
Table 4.2
Preoperative cardiac risk factors
American College of Cardiology/American Heart Association Perioperative Cardiac Risks |
Active Cardiac Conditions |
Unstable coronary syndromes Myocardial infarction (≤30 days) |
Unstable or severe angina (Canadian class III or IV) Decompensated heart failure |
Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias with uncontrolled ventricular rate Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Clinical Cardiac Risk Factors Compensated or prior heart failure Renal Insufficiency History of ischemic heart disease Diabetes Mellitus History of cerebrovascular disease |
Surgical procedures can be classified in terms of their inherent cardiac risk level. The American College of Cardiology and the American Heart Association guidelines stratify noncardiac surgery into low <1%, and high >1% risk levels for 30 day major adverse cardiac events. Major adverse cardiac events being defined to include myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block. Germane factors that influence this stratification include anticipated perioperative blood loss, operative fluid shifts, and duration of surgery. By these criteria peritoneal dialysis access procedures have an inherently low cardiac risk [36].
The overall cardiac risk stratification must not only consider the inherent procedural risk, but also consider the procedural timing urgency, and the cardiac comorbidities of the patient [17, 36]. Any of three preoperative cardiac risk stratification models are recommended by the ACC. These are the RCRI revised cardiac risk index, NSQIP derived MICA myocardial infarction and cardiac arrest calculator, and the NSQIP national surgical quality improvement program broad surgical risk calculator [85].
The Revised Cardiac Risk Index (or Lee Index) counts the preoperative presence of six equally weighted factors: coronary artery disease, heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, high risk noncardiac surgery, and renal insufficiency (Cr > 2 mg/dl). Elevated risk (major adverse perioperative cardiac event >1%) is predicted if two or more risk factors are present [141]. This method overestimates the risk of peritoneal dialysis access surgery.
The NSQIP derived MICA risk model assesses risk of myocardial infarction or cardiac arrest in the 30 day perioperative period. The independent patient variables for this model are ASA (American Society of Anesthesiologist) class, functional status, age, Cr >1.5 g/dl, and type of surgery. This model is derived from data on >400,000 patients [32].
This third risk model applies to cardiac, pulmonary and a broad array of perioperative risk. The American College of Surgeons NSQIP online risk calculator tool uses 20 patient variables built on a database of 2.7 million operations. It predicts perioperative mortality and morbidity modeled for 11 outcomes. As of 2016 this tool includes procedure specific outcome prognostication for laparoscopic, percutaneous, open peritoneal dialysis catheter insertion and catheter removal. The predictions of this calculator correlate very closely with clinically observed patient complication rates [188, 189]. This broad prognosticator is available for pediatric peritoneal dialysis access patients as well [86].
Bleeding
Bleeding risk at time of surgery and postoperatively are a concern given the known platelet dysfunction and common anticoagulant use in chronic kidney disease patients (Table 4.3). Mital et al. retrospectively reviewed 263 consecutive patients after surgically placed Tenckhoff catheters. They evaluated the incidence of perioperative major bleeding complications. Major bleeding was defined as ≥3% decline in hematocrit, or the need for surgical intervention or blood transfusion within 2 weeks of insertion. A 2% rate of major bleeding was identified. A third of the patients with major bleeding were thrombocytopenic preoperatively. Half of the major bleeds were in patients on preoperative warfarin or postoperative heparin [65].
Bleeding Risk Table
Case series authors | Reported bleeding rate | Comments |
|---|---|---|
Case series | Bleeding episodes/total patients | Description |
Fluoroscopic Percutaneous | ||
Vaux et al. (2008) Medani et al. (2012) Moon et al. (2008) | 0/209 0/151 1/134 | No clinically significant bleeding No clinically significant bleeding |
Ozener et al. (2001) | 5/133 | |
Perakis et al. (2009) | 5/86 | |
Reddy et al. (2010) | 4/64 | |
Voss et al. (2012) Jacobs et al. (1992) | 0/51 3/45 | |
Zaman et al. (2005) | 1/36 | |
Maya et al. (2007) Trung et al. (2013) | 0/32 2/30 | No clinically significant bleeding |
Chula et al. (2013) | 2/26 | |
Open Surgical Placement | ||
Rinaldi et al. (2004) Mital et al. (2004) Li et al. (2012) Phan et al. (2012) Robison et al. (1984) Carpenter et al. (2016) Medani et al. (2012) Stone et al. (2013) Yeh et al. (1992) Ozener et al. (2001) Park et al. (2014) Perakis et al. (2009) Gadallah et al. (1999) Radtke et al. (2015) Kim et al. (2015) | 6/503 6/292 20/244 0/214 3/173 0/173 0/162 0/134 4/115 0/82 0/78 2/75 0/72 0/70 7/60 | Hemoperitoneum Minor pericannular bleeds Pediatric series Pediatric series Pediatric series Pediatric series Pediatric series five of the 7 were minor bleeds |
Blind Percutaneous | ||
Medani et al. (2012) Park et al. (2014) Chula et al. (2013) | 0/151 2/89 3/53 | Pericannular bleeding Minor bleeding |
Peritoneoscopic | ||
Asif et al. (2004) Gadallah et al. (1999) | 4/82 0/76 | Blood tinged dialysate |
Laparoscopic | ||
Crabtree et al. (2009) Attaluri et al. (2010) Keshvari et al. (2010) Penner et al. (2015) Voss et al. (2012) | 1/428 1/197 1/175 1/87 0/51 | Port site abdominal wall bleeding Reoperatively controlled Delayed mild bleeding |
Early preoperative interdiction can be initiated at time of consultation when an elevated bleeding complication risk level is prospectively identified. These measures include amelioration of anemia, and a short course of estrogen therapy.
Anemia associated with chronic kidney disease is frequent. Improvement of anemia reduces uremic surgical bleeding through platelet function effects including increased platelet endothelial interaction. Recombinant erythropoietin is a useful agent for optimizing hemostasis. A hematocrit level of 30% is recommended. The benefit of further correction above 30% must be weighed against the increased thrombotic risk [63].
Estrogen administration safely and effectively improves procedural hemostasis in male and female patients with azotemia. Conjugated estrogen can be administered at a dose of 0.6 mg/kg intravenously over 30 min once daily for 5 days. This achieves a procoagulant effect on circulating factor VIII, von Willebrands factor, protein S, endothelial nitric oxide, and platelet ADP and thromboxane A2 levels. A 5–7 day preprocedural course provides maximal effect. Postoperative dosing is not necessary [63, 108–110].
Anti-platelet Therapy
Cardiovascular risk is prevalent among end stage renal disease patients. Among pediatric renal failure patients left ventricular hypertrophy is noted in >80% at initiation of dialysis. Cardiovascular disease is causative in 20–40% of deaths in pediatric end stage kidney failure [47]. Adults with end stage kidney disease have a 20–50 fold increased risk for premature cardiovascular disease compared to the general population [83, 111, 112]. Cerebrovascular risk is also elevated in renal failure patients. A 2015 meta-analysis by Masson et al. included over 30,000 strokes identified a linear relation of GFR and stroke risk. A 7% increased stroke risk was noted for every 10 ml/min/1.73 m2 decrease in GFR [113].
As a result of the prevalence of cardiovascular disease, atrial fibrillation, and cerebrovascular disease among renal disease patients long term antiplatelet and anticoagulation therapy are a frequent issue in preoperative planning. The surgeon or interventionalist in collaboration with consultants must balance the relative perioperative risk of bleeding and the risk of thromboembolism to develop a patient specific optimal strategy. This includes timing of withholding anticoagulants, approaches of coagulopathic reversal, bridging protocols, and timing the resumption of maintenance therapy.
Let us start with the component best known to the surgeon or interventionalist. According to the ACC/AHA (American College of Cardiology and the American Heart Association) operative bleeding risk is now stratified as:
Low <2% 2 day risk of major periprocedural bleed and
High > 2% 2 day risk of major periprocedural bleed.
Low risk procedures include pacemaker or cardiac defibrillator insertion, abdominal hernia repair, axillary node dissection, dental extraction, or cholecystectomy [114]. Peritoneal dialysis access insertion based on broad historical experience has a low operative bleeding risk.
Chronic Oral Anticoagulation
Oral anticoagulant therapy is often encountered in the severe or end stage renal disease patient (gfr < 30). The prevalence of atrial fibrillation in this group has been noted in up to 20% [116]. Preoperative warfarin or novel oral anticoagulants require thoughtful decisions on the need for interruption of therapy, use of parenteral bridging, and postoperative resumption of oral therapy. Interdisciplinary consultation is advisable as there are no large randomized trials that assess the risk benefit of full anticoagulation in severe renal failure patients. Cataract, dermatologic, implantable cardiac device insertion, and dental extractive surgery are safely conducted under full oral anticoagulation [121, 177, 190]. Although PD access surgery is also a low bleeding risk procedure, the potential for hidden intraperitoneal bleeding favors a conservative approach. In the absence of specific studies of PD access surgery on full oral anticoagulant therapy the table below summarizes pharmacologic guidance from available data in renal disease patients with gfr 15–30 (Table 4.4). The nature of the anticoagulant, its antidote, the elimination half life in renal impairment, and options of management based on a patient’s thromboembolic risk. Bridging therapy is discouraged when avoidable due to increased bleeding risk compared to uninterrupted therapeutic anticoagulation.
Oral anticoagulant Therapy alonea | T½ elimination gfr 15–30 ml/min | Low thrombotic risk patient Time from last anticoagulant dose to incision 4–5 t½ | Moderate thrombotic risk patient Time from last anticoagulation dose to incision 2–3 t½ | High thrombotic risk patient Time from last anticoagulation dose to incision |
|---|---|---|---|---|
Warfarin Vitamin K antagonist Reversal vitamin k FFP, PCCb | 35 h | Hold 5–7 days | Hold 3–4 days | Uninterrupted warfarin versus 5–7 day warfarin hold with heparin bridge |
Dabigatran (Pradaxa) Direct thrombin Inhibitor Reversal hemodialysis, or idarucizumab | 27.5 h | 5–6 days | 2–3.5 days | Uninterrupted dabigatran versus 5 day hold with heparin bridge |
Rivaroxaban (Xarelto) Direct factor Xa inhibitor Reversal PCCb Adexanet alfac | 9.5 h | 2 days | 1 day | Bridge usually unnecessary due to rapid onset offset of effect |
Apixaban (Eliquis) Direct factor Xa inhibitor Reversal PCCb Adexanet alfac | 17.3 h | 3 days | 2 days | Uninterrupted dabigatran versus 3 day hold with heparin bridge |
Edoxaban (Savaysa) Direct factor Xa inhibitor Reversal PCCb Adexanet alfac | 17.5 h | 3 days | 2 days | Uninterrupted edoxaban versus 3 day hold with heparin bridge |
Chronic antiplatelet therapy is frequently encountered in preoperative peritoneal access patients. Colette et al. in a multicenter regional study of 502 incident hemodialysis patients found a 61.3% prevalence of chronic antiplatelet therapy [115]. Agents commonly used for antiplatelet therapy include aspirin, P2Y12 receptor inhibitors such as clopidogrel (Plavix) prasugrel (Effient) and ticagrelor (Brilinta) [116].
Aspirin therapy that is indicated for cardiac or vascular indications may be continued perioperatively without interruption for low bleeding risk procedures (2014 American College of Cardiology/American Heart Association Guidelines, 2014 European Society of Cardiology/European Society of Aneaesthesiology Guidelines) [36, 120].
The POISE-2 trial randomly assigned 10,010 noncardiac preoperative patients at risk for vascular complications to low dose perioperative aspirin or placebo. The 30 day death or nonfatal MI rate was statistically not different at 7% for both groups. The major bleeding rate in the aspirin treated group was higher (4.6% versus 3.8%, p = 0.04, [117].
Shpitz et al. prospectively evaluated the effect of low dose aspirin (mostly 100 mg daily) on postoperative bleeding in end-stage renal disease patients. These patients underwent 52 consecutive open surgical peritoneal dialysis catheter placements or removals. Twenty-nine patients were on aspirin and this was continued perioperatively without interruption 23 control patients were not on chronic aspirin therapy. There was a 17.2% minor bleeding rate in the aspiring group and a 13% bleeding rate in the control group. Only one major bleed occurred and this was in the control group. 2/3 of the bleeding observed occurred with catheter removal. From this data the authors conclude that PD catheter insertion or removal can be safely performed with uninterrupted conventional low-dose aspirin therapy [118].
Large trials on perioperative aspirin use in renal failure patients are lacking. In Summary, the cardiology society guidelines, POISE 2 trial results, Shpitz data, and the low bleeding risk of peritoneal dialysis access surgery suggest safety in perioperative continuation of chronic aspirin therapy when medically indicated [36, 117, 119–121].
Surgeons and Interventionalists have been even more reticent to continue P2Y12 platelet aggregation inhibition therapy periprocedurally. Among end stage renal disease patients clopidogrel (Plavix) tends to have less bleeding risk than prasugrel or ticagrelor [122–124] Combined aspirin clopidogrel use without perioperative interruption demonstrated a 6.8 fold increased pocket hematoma risk in meta-analyzed cardiac implantable electronic device insertions [119].
In the largest retrospective trial of major noncardiac surgery involving 2154 patients, Strosberg et al. demonstrated no increased periprocedural bleeding with clopidogrel alone continued within 5 days prior to incision [125]. Furthermore, Chu et al. performed the largest prospective randomized controlled trial of noncardiac surgical patients, and administered single agent clopidogrel perioperatively. In 39 patients they observed no difference in perioperative bleeding with uninterrupted versus a 7 day preoperatively held clopidogrel [126]. A 5–7 day preoperative hold of clopidogrel is historically recommended. There is now sufficient data to suggest that low bleeding risk procedures such peritoneal dialysis access can safely be performed without interruption of single agent clopidogrel. Dual agent aspirin and clopidogrel perioperative use still requires careful consideration of thromboembolic proclivity, duration of need for dual antiplatelet therapy, bleeding risk, and alternative options for dialysis access.
Office Preoperative Preparation
Preoperative Mapping and Planning of Insertion and Exit Site
PD catheter mapping is the most important preoperative step unique to peritoneal access placement by the surgeon or interventionalist. Omission of adequate mapping predisposes to a litany of demonstrated complications including: Drain or infusion pain, catheter dysfunction, peritonitis, catheter tip migration, superficial cuff extrusion, injury during subsequent operations. Increased risk of tunnel infection and exit site infection, as well as catheter kinking and patient discomfort at the exit site.
The primary objectives of mapping are to establish optimal catheter tip position, optimal catheter tunnel, and optimal exit site positioning. The catheter tip should be positioned in the pelvis sufficiently deeply to allow good dependent drainage, and decreased omental wrapping, as outflow dysfunction is a most common cause of catheter failure [103]. Drain pain is most commonly observed when the catheter tip is too deeply positioned in the pelvis. Clinically significant drain pain occurs in 13–25% of patients. This estimate does not include patients who tolerate the pain, convert to manual exchanges, or convert to hemodialysis because of the pain [127]. Drain pain occurs by a siphoning effect against deep cul de sac fenestrated catheter tip apposition to sensitive parietal pelvic peritoneum [128–131].
The key to an optimal catheter tip placement is distal cuff abdominal wall mapping. Historically a number of landmarks have been used for deep cuff mapping. The anterior superior iliac spine, specified distance superior to planned exit site [6], some distance relative to umbilicus [43, 100, 132–134], and pubic symphysis [43, 107]. An anthropometric anatomic study by Crabtree et al. found a 21 cm variation in the distance of the umbilicus to the symphysis pubis in 200 adult patients. There was wide variation in the distance of the anterior superior iliac spine to the symphysis pubis making it an unreliable anatomic marker also. The pubic symphysis has been confirmed laparoscopically to be a consistent externally identifiable landmark to catheter tip placement in the true pelvis [135].
Mapping of the deep cuff location is performed in the office with the patient supine. A sample straight tip catheter can be used by positioning the first side hole of a straight catheter on the upper border of the symphysis pubis. If a curled tip catheter insertion is planned, the upper or proximal border of the coil can be placed over the pubic symphysis. The deep cuff location is then marked on the skin as the catheter is extended along the planned tunnel course. Some catheter manufacturers provide plastic marking stencils designed for this purpose also [1, 128, 135, 136]. The deep cuff position should be moved more laterally to coincide with the rectus muscle position in patients with diastasis. Bilateral mapping may be considered in patients anticipated to have extensive lower abdominal adhesions [25].
The patient’s clothing or work tool belt line, nonvisible or inaccessible areas of the abdominal skin, cutaneous intertriginous, inframammary, or surgical scar folds, chronic dermatitis, incontinence susceptible skin, planned sites of postoperative bath tub or whirlpool water exposure, bra lines, thicker portions of breast, gastrostomy or ostomy placement areas should be identified with the patient seated and supine. The belt line is best identified with patient dressed. Once these hazard zones are marked, a catheter configuration and exit site is selected that best avoids them. The catheter tunnel should eschew contact with existing or planned prosthetic abdominal wall mesh, a ventriculoperitoneal shunt, breast implants, midline abdomen or midline sternum( risk of laparotomy or sternotomy operative catheter damage) [8, 22, 29, 55, 128, 137–140, 142–146].
Informed consent in peritoneal access procedures includes good doctor patient communication in review of indications, risks, benefits, and alternatives. Setting rational expectations of outcome, and explaining adjunctive procedures that may become indicated at laparoscopic exploration is valuable. These include selective omentopexy, abdominal wall herniorraphy, adhesiolysis, epiploic appendage resection, ovariopexy, and fallopian tubopexy [8, 49, 165].
Infection Prevention
Infection is a common early postoperative peritoneal dialysis access complication. It is an overwhelming and often avertable cause of catheter loss and peritoneal dialysis interruption. Tunnel, exit site, and peritoneal infection early after peritoneal dialysis procedures are usually caused from endogenous microbes [5, 147, 148]. Staphylococci are the most frequently cultured organism. Selective preoperative nasal Staphylococcus aureus decolonization in peritoneal dialysis access may be prudent.
The close correlation between endonasal S.aureus colonization and exit site infection has been known for greater than 20 years [43]. Lye et al. in a 4 year trial with 146 chronic PD patients found higher rates of exit site infection, peritonitis, and catheter loss in nasal S. aureus carriers (p < 0.01) [149].
In prevalent peritoneal dialysis patients a broad genomic heterogeneity of S. aureus nasal colonization is consistently demonstrated. Clinical S. aureus infections during a 6 month trial by Aktas et al. found a 90% genomic concordance with identified endonasal S. aureus [150]. Many earlier studies also confirm autologous origin of PD related peritonitis and exit site infections [151–153].
Two large studies in broad populations demonstrate reduction in clinical early postoperative infection when nasal and cutaneous staphylococcal decolonization is administered. Bode et al. in a randomized double blind placebo controlled trial, PCR rapidly screened general hospital admissions for nasal S. aureus colonization. 808 nasal S. aureus colonized patients had surgical procedures acutely after admission. The nasal mupirocin and chlorhexidine bath treatment group had a 79% reduced risk of deep surgical site infection compared to placebo [154].
Schweitzer et al. conducted the pragmatic STOP SSI multicenter trial with 38,000 cardiac, knee and hip arthroplasty surgical patients. Despite a low (39%) protocol full compliance for nasal and cutaneous decolonization, treated subjects demonstrated a 40% reduction in staphylococcal complex surgical site infections [155].
There is evidence to suggest decreased infection rates with the institution of maintenance antistaphyloccal prophylaxis among prevalent PD patients. A 2004 Cochrane review found nasal mupirocin reduced exit site and tunnel infections in patients being dialyzed peritoneally [156]. Blowey et al. in a randomized controlled trial demonstrated a higher incidence of dialysis related infection among pediatric nasal S. aureus carriers. This was rendered equivalent to noncarriers during the month following decolonization therapy [157]. In a multicenter double blind randomized placebo controlled trial the Mupirocin Study Group demonstrated a significant reduction in staphyloccal exit site infections with nasal mupirocin nasal decolonization in nasal carrier adult PD patients. Crabtree et al. carried out a 2 year surveillance and nasal mupirocin treatment of S. aureus carriers. The rates of peritonitis (p = 0.0002) and catheter loss (p = 0.01) were reduced in the treatment group compared to historic controls [158]. The nasal carriage rate of S. aureus is 20% in the general population and higher among dialysis patients [154, 155]. S. aureus nasal carriage confers a five to tenfold increased risk of staphylococcal surgical site infection [148]. The Italian Society of Nephrology Peritoneal Dialysis Study Group recommends bid nasal mupirocin prophylaxis for 3 days preoperatively and 3 days postoperatively. The International Society of Peritoneal Dialysis is ambivalent about the need for preoperative nasal decolonization due to lack of data on this specific indication. Preoperative nasal S. aureus screening and preoperative prophylactic treatment of carriers can be recommended on the basis of the information so far reviewed [8 ].
Preoperative Training
Preoperative training helps optimize outcomes following PD access insertion. Hall et al. in a longitudinal multicenter trial, assigned 620 incident patients to conventional versus enhanced peritoneal dialysis training. The enhanced training patients demonstrated significantly improve procedural compliance (p < .0001), lower exit site infection rates 18.5/1000 patient months vs 31.8/1000 patient months (p = .00349), and lower infection related drop out rates from peritoneal dialysis 1.6% vs 5.6% (p = .0069) [161].
In an International Society of Peritoneal Dialysis 76 center survey, longer pre-dialysis training times for families were associated with the lowest pediatric peritoneal dialysis related infection rates (p < 0.05) [162].
Bordin et al. in a retrospective analysis of peritonitis rates at 120 dialysis centers found a strong correlation of improved peritoneal infection free duration with pre-dialysis education. A rate of 1 peritonitis episode/26 months improved to 1 peritonitis episode/32 months with pre-dialysis education (p < 0.05) [163].
Pre-dialysis PD training time was noted to vary from 6 to 96 h in an international multicenter survey [164]. ISPD guidelines advise thorough training of patients and participating family members. Motor skills, concepts, procedures and problem solving in peritoneal dialysis home care must be assured through a standardized teaching plan [29, 161].
PD Team Coordination
Collaboration within a team facilitates successful timing, fulfilling social supportive needs, and optimal delivery of care. The Renal Association UK, and the International Society for Peritoneal Dialysis recommend that each center establish a dedicated team involved in the implantation and care of peritoneal catheters [8, 166]. In addition, care coordination for optimal timing of PD catheter placement improves the rate of successful peritoneal dialysis start [167]. The team consists of Nephrologist, Primary care physician, medical specialists, nurses, social workers, perioperative staff, dialysis unit team, and interventionalist or surgeon. Nephrologists are the primary drivers of this team. When the decision is made a patient will begin PD, Education is begun at the dialysis unit, either by nurse or nurse practitioner and the patient is referred to surgeon or interventionalist. If the patient is to have surgical placement, an expedited process must take place of pre-op risk stratification and optimization. This is in combination with surgeon, primary care physician and appropriate medical specialist. Finally, the procedure is accomplished with carful coordination with outpatient nephrology and the operating room team. Postoperatively the nephrologist and dialysis unit continue support for the patient, with the surgeon on standby in case there are complications. It should be noted that a surgeon and operating room team with interest, experience and skill in dealing with these complex patients is paramount to a successful process [168].
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
