Peritoneal Dialysis Catheter

What is Peritoneal Dialysis Catheter (PD Catheter)?

A peritoneal dialysis catheter is a thin, flexible silicone tube. It has an open end port and several holes on the side for the dialysate (the cleaning fluid) drainage and absorption. The extraperitoneal segment, which is present outside your body, has one or two dacron cuffs. One of these cuffs is placed at the muscle wall of the abdomen, it is referred to as the proximal cuff. The other cuff, referred to as the distal cuff, is placed under the surface of the skin at the exit site of the catheter. The proximal cuff helps to hold the catheter in place, while the distal cuff acts as a barrier to prevent infection-causing germs from entering the body through the opening. 

A PD catheter facilitates the dialysis fluid to be instilled and then removed from the periodontal cavity.

What are The Types Of PD Catheters?

Peritoneal dialysis catheters come in various shapes and sizes. They are also differentiated on various factors like- 

Intra-abdominal segment- Depending on the shape of the portion inside your abdomen-

• Straight catheters
• Coiled catheters

Subcutaneous segment- Depending on the shape of the subcutaneous segments -

• Straight catheters 
• Swan Neck catheters

Depending on the number of Dacron cuffs-

• Single cuffed
• Double cuffed

Depending on the tip-

• Weighted catheters
• Non-weighted catheters

Depending on the material used-

• Silicone catheters
• Polyurethane catheters

Straight catheters are easy to insert but carry a high risk of migration. Coiled catheters can be inserted in various ways, but the coiled end can cause severe abdominal pain if the catheter migrates. The type of catheter to be used is decided prior to the procedure. Most surgeons prefer the double-cuffed, swan-neck, unweighted Tenckhoff catheter with a coiled intra-abdominal segment.

When are PD Catheters Recommended?

Peritoneal dialysis catheters are recommended for use in peritoneal dialysis. This is a procedure that is required when the kidneys are chronically damaged and loses the ability to filter out waste products and toxins from the blood. A PD catheter then acts as an access route for the dialysate (cleaning solution) and the blood vessels. 

Peritoneal dialysis is indicated in the following conditions-

• Intolerance towards hemodialysis
• Congestive heart failure
• Failure to access a blood vessel for hemodialysis
• Children below 5 years of age
• Poor cardiac function
• Peripheral vascular disease
• Bleeding diathesis
• Multiple myeloma
• Chronic infections

Sometimes, people with an active lifestyle, people living far away from a hemodialysis center, and people with needle anxiety may voluntarily opt for peritoneal dialysis.

What are the Pre-procedure Instructions?

A PD catheter is inserted into your body by different techniques. The laparoscopic or open surgical technique is the most common. Here is how you can prepare for the procedure.

• You can ask your surgeon to explain the procedure's details, the necessity of the procedure, and the benefits of getting a PD catheter inserted. You will be asked to sign an informed consent form agreeing to go ahead with the procedure.
• Discuss your medical history with your surgeon and inform him about-
  • All the medications that you are currently taking for your health conditions
  • Any dietary supplements and herbs that you are taking
  • Allergies towards medicines, if any.
• You will be asked to stop medications like blood thinners (to prevent excessive bleeding during and after the procedure) a week before.
• You will be prescribed stool softeners to prevent constipation. Constipation is a common side-effect of the anesthesia used and can lead to severe abdominal pain when the toxins are flushed out via the PD catheter.
• On the day of the procedure, you will be asked to fast for at least 4 hours before the procedure.
• You will be asked to arrange for a friend or relative to drive you home after the procedure.

How Does the Procedure Work?

Peritoneal dialysis catheters may be placed percutaneously, laparoscopically, or by open surgery. The procedure takes about an hour and can be performed by a surgeon, interventional radiologist, or nephrologist. Here is how each procedure works-

Open Surgical Technique 

• This procedure is done under general anesthesia, which means you will be asleep throughout the procedure.
• An IV line is set up, through which antibiotics and fluids are administered.
• You are placed in a supine position (on your back). A straight midline incision is made right below your navel.
• Slicing through the various layers of fat and muscles, the surgeon reaches the abdominal cavity.
• You will now be shifted to a Trendelenburg Position. The head will be lowered by 45°, raising the legs and feet over the edge of the table. This is the position in which most abdominal surgeries are performed.
• Once you are in the Trendelenburg position, the surgeon places the catheter inside the abdominal cavity and secures the proximal (peritoneal) cuff.
• The various layers of muscle and fat that were cut through are now sutured, taking care not to obstruct the catheter.
• An exit tunnel is then carved, with the exit point lateral to the entry point. The distal cuff is placed subcutaneously, 2 cm away from the exit point.
• The incision is then closed.
• The surgeon then tests the catheter by inserting 10 ml of sterile saline solution and then draining it out. Ideally, there should be no leakage at the entry point, and the drained fluid should not contain peritoneal blood.

Laparoscopic Technique

• This is a minimally invasive procedure that is performed under general anesthesia.
• An (intravenous line) IV line is set up to administer antibiotics and fluids.
• A laparoscopic inspection of the abdominal cavity is performed first to rule out any abdominal adhesions.
• The surgeon now inserts a special instrument called the trocar through the various layers of your abdomen till it reaches the peritoneal membrane.
• A double-cuffed, curved PD catheter is now inserted up to the pouch of Douglas (an extension of the peritoneal cavity) in such a way that the distal cuff remains outside the peritoneal cavity, usually between the rectus sheaths.
• The trocar is now removed, and the catheter is directed to its exit location. A subcutaneous tunnel is created, and the catheter is brought out through it. The proximal cuff remains within the tunnel.
• The catheter is tested by inserting and draining 10 ml of sterile saline water. 

Percutaneous Placement

• This technique can be done under local anesthesia. It is usually done at the bedside or as an outpatient procedure.
• The surgeon makes an incision just below the navel and inserts an 18 gauge blunt needle through it.
• After confirming that the needle has been positioned correctly, a guide wire is threaded through the needle, and the needle is removed.
• A dilator and a peel-away sheath are advanced into the abdominal cavity over the guidewire.
• The PD catheter is next advanced through the sheath. It is advanced until the proximal cuff is in the pre-peritoneal sheath, after which the peel-a-way sheath is removed.
• A tunnel is created for the exit of the catheter. The distal cuff is placed subcutaneously 2 cm away from the exit site.

After the catheter has been inserted by any of the above techniques, a sterile gauze is placed over the exit site to prevent the catheter from moving. 

What are the Post-Procedure Instructions?

Taking good care of the catheter insertion and exit site is very important to keep the catheter working well and to reduce the chances of infection. After the procedure, you will be moved to a recovery room where your vitals, like your pulse rate, respiratory rate, temperature, and blood pressure, will be monitored. Once your vitals are stable, you may go home. Some instructions to be followed:

• Do not touch or move the catheter a lot.
• For the first 7 days, do not touch the sterile bandage on the exit site, as this can increase the risk of infection.
• The skin around the insertion and exit point of the catheter will be red and bruised. This is a normal phenomenon that subsides gradually. A scab will form around 10 to 14 days after the procedure.
• If the skin has become very dark and is painful to touch, contact your doctor immediately, as this could be a sign of an infection.
• Keep the skin around the catheter dry at all times. Avoid swimming, long baths, and sauna baths. 
• Avoid lifting heavy weights, bending forwards, and strenuous exercises.
• Avoid constipation by taking the prescribed stool softeners and eating foods rich in fiber. Constipation lowers the efficiency of the peritoneal dialysis. Straining for stools can cause a hernia to develop (a condition where the contents of the abdomen push out through an abnormal opening in the abdominal wall).

What are the Potential Complications?

All procedures, however minor, carry a certain risk of complications. PD catheter insertion, too, has potential complications that you should be aware of.

• Bleeding- This is a common problem after PD catheter placement. The bleeding usually occurs from the exit site.
• Wound infection- This is a rare complication that can be treated with antibiotics and drainage if required.
• Bowel perforation- There is a good chance of bowel perforation when the catheter enters the peritoneal cavity.
• Outflow failure- This can happen due to a variety of reasons. The lumen of the catheter can get clogged with fibrin deposit, adhesions may develop around the catheter, or the catheter may have been placed incorrectly - all these are conditions that block the outflow of fluid during the dialysis procedure.
• Dialysate Leak- This presents as leakage at the exit site or a bulge under the entrance site. Late leaks present as edema, weight gain, swelling around the genitals, or hernia. These signs appear more after than 30 days of catheter placement.
• Peritonitis- This is an infection of the peritoneal cavity. It manifests as abdominal pain.
• Catheter migration- This is a serious complication that may lead to peritoneal dialysis failure and the need for catheter removal and transfer to a hemodialysis procedure.

What are the Advantages of PD Catheter?

A PD catheter has the following advantages-

• Since it is placed in a single procedure, there is no need for multiple needle pricks.
• The blood remains inside your body while getting cleaned. This reduces the chances of blood-borne infections.
• There is no machine dependence. A PD catheter allows you to perform peritoneal dialysis in the comfort of your own home.

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