Manual Acute Peritoneal Dialysis in PICU (using the UTAH Medical / Femcare-Nikomed Dialy-Nate® closed peritoneal dialysis set)

GGC Paediatric Guidelines
NHS GGC

Scope

This standard operating procedure (S.O.P.) is intended for all nursing staff required to set-up (Manual) Acute Peritoneal Dialysis using the Dialy-Nate® closed peritoneal dialysis set within the Paediatric Critical Care Unit at the Royal Hospital for Children (Glasgow).

Audience

All nursing staff involved in caring for infants or children in the Paediatric Critical care unit requiring manual acute peritoneal dialysis, should be familiar with this S.O.P.

Introduction

Renal replacement therapy is an important supportive measure used in paediatric intensive care for the management of Acute kidney injury (AKI). Whilst extracorporeal renal replacement therapies, such as haemofiltration/haemodiafiltration are the more commonly used modality, peritoneal dialysis is still a useful, safe and inexpensive procedure. 1,2,3,4

Advantages:

P/D in paediatrics has several advantages over extracorporeal therapies and includes the following: the peritoneal surface area in paediatric patients is greater than that of adults, thus P/D can result in a more efficient solute clearance than that of P/D in adult patients. 5 P/D is a dynamic dialysis and more physiological process, resulting in less pro-inflammatory consequences than that of Hemodialysis, for example. This continuous process, allows gradual solute and fluid removal, is safe, and is well tolerated cardiovascularly in the critically ill child. 1,4 Finally, P/D is technically far simpler than using extracorporal renal replacement therapies, as it requires minimal infrastructure support and can be performed by the majority of PICU bedside nurses. 2,4

Disadvantages:

There are limitations to using acute P/D in paediatric intensive care, including the following situations: an intact peritoneal cavity is essential for acute P/D therefore it is not a suitable renal support for those children with conditions such as recent abdominal surgeries, diaphragmatic hernia or paralytic ileus. 5  As ultrafiltration and solute removal can be unpredictable in acute P/D, it is also not the ideal choice for those conditions where fluid balance must be precise and controlled, such as multi-organ failure and shock. Children in these conditions will have poor tolerance of increased peritoneal/abdominal volume from the P/D ‘dwell’ volume and decreased splanchnic perfusion. Thus, effective and rapid correction of any life-threatening fluid and electrolyte problems may be difficult with acute P/D. Finally, there are mechanical complications associated with using acute P/D, including catheter leakage and catheter obstruction which can result in reduction in efficiency of dialysis. 1,6

Some other associated problems can include risk of hyperglycaemia (from dialysis fluid used) and hypothermia if fluid not warmed.

The decision about what dialysis modality should be used is based upon the child’s clinical condition, the availability of necessary resources and the expertise and skills of the local staff.

Equipment

Dialy-Nate® P/D Set (x1) (E.g. 400537)

2.5 or 5 litre bag prescribed dialysis solution (E.g. Physioneal 1.36% or 2.27%)

  • Disposable apron
  • Gloves
  • Sterile drape
  • Trolley
  • IV pole / stand
  • Chlorhexidine 2% & Isopropyl Alcohol 70% cleaning swab (E.g. Clinell® wipe)
  • Connector shield with povidone-iodine (Baxter SPC4211)***
  • Extension tubing (Baxter R5C4482)
  • Minicap (Baxter SPC4466)

(***note - due to iodine content check use for infants <1yr)

Preparation of Patient

PROCEDURE

RATIONALE

Provide age appropriate explanation of the procedure.

To ensure that the child understands the procedure and to avoid undue distress.

Positioning infant/child

Ensure unobstructed access to PD catheter connection

Check bloods – glucose,

Monitoring – minimum: ECG, SpO2, BP & +/-

 

Preparation of Equipment

PROCEDURE

RATIONALE

Gather all equipment required and take to bedside

Clean trolley

  

Wash hands thoroughly with appropriate antibacterial skin cleanser then don disposable gloves.7

 

Open drape onto trolley

In order to minimise the risk of cross- infection.

Open outer packaging of Dialy-nate® system set and open onto trolley top (keep packaging for ref no)

Equipment images

Open cleaning wipe, connection shield*** and extension tubing on to drape

 

(*** note-due to iodine content check use for infants <1yr)

Equipment images

Open dialysis solution bag onto trolley top.

 

 

If the solution is in two sections (E.g. Physioneal) (Fig.), break frangible connector inside (Fig..) between ‘top’ and ‘bottom’ bag, and ensure fluid flows into ‘bottom’ bag and solution is well mixed.

Equipment images
 

Equipment images

Hang dialysis solution bag on pole

Equipment images

Priming of Dialy-Nate System

PROCEDURE

RATIONALE

Connect dialysis solution bag to the Dialy-Nate® set, using one of the luer connectors.

Equipment images

Clamp all 3 luer-connector lines

 

 

 

 

Close the roller clamp (roller clamp is below buretrol chamber and filter)

Equipment images

Check PD extension set attached to ‘Patient’ line on system.

Equipment images

Ensure warming coil loop in circuit is positioned to allow priming of system and air removal

Equipment images

Hang drainage bag / collection system (on trolley) ensuring it is below the height of the buretrol and tubing

Equipment images

Break the frangible inside connector on the bottom of the dialysis solution bag and then open the clamp on that connector line only.

Equipment images

Keeping the buretrol upright, allow 60-80ml of dialysis solution to drain into the buretrol, then clamp that connector.

Equipment images

Keeping the patient line of the Dialy-nate® set on the drape, open roller clamp below buretrol and open stopcock to ‘open’ on patient line and prime to the end of the patient line (including PD extension set).

Equipment images

Once this line is primed, turn the stopcock to ‘closed’ on the patient line and ‘open’ to the drain line. 

Equipment images

Let the remainder of the fluid prime through – but STOP (i.e. close the stopcock at 2 o’clock) when volume in buretrol is 10ml. This is to prevent air entering the circuit.

Equipment images

Once primed, then label all tubing on the system:         -  ‘Fill’

 -  ‘Patient’ and

 -  ‘Drain’.

Equipment images

Make sure buretrol is upright on pole and that all tubing in/out of P/D catheter is not kinked or looped.

  

Connecting PD system to patient

PROCEDURE

RATIONALE

Using Clinell® or similar wipe, clean the connector at end of tubing on child’s PD catheter.

Allow to dry.

Equipment images

Connect white end of PD extension set and connect to patient PD cannula.

Take tubing labelled ‘Patient’, and connect to  PD extension set.

Equipment images

Wrap connection shield around blue end of PD extension set.

 

*Renal staff handy hint: you can connect the Connection shield to the primed system 1st - then connect to the patient PD extension set. It makes it easier to get ‘snug’ fit.

ONLY do this if you confident you have a secure connection.

*Equipment images

Performing manual peritoneal dialysis

PROCEDURE

RATIONALE

Ensure primed system and lines are secured to cot/bed side and not obstructed

Equipment images

Once connected, open the stopcock to the ‘drain’ line and let drain for the prescribed amount of time. Set timer for this – record this initial drainage.

Equipment images

Clamp ‘drain’ line by turning stopcock to 2 o’clock position (this switches off drain, fill & patient lines)

Equipment images

P/D cycle:

a. Fill the buretrol with the desired volume prescribed for child PLUS 10ml.

E.g. dialysis solution fill volume: 40ml PLUS 10ml = total 50ml in buretrol.

 

 

b. Once buretrol filled to prescribed volume (+10ml) - Clamp dialysis solution bag to buretrol

Equipment images

c. Then:

- open stopcock to ‘patient’ line

- unclamp roller clamp (below buretrol and filter)

- let fluid in the buretrol flow into the P/D catheter (N.B. this may be slow)

- once level in buretrol at 10ml*  – CLAMP roller clamp

*do not let buretrol empty as air will then pass down system

Equipment images

Equipment images

d. Close the stopcock to the ‘patient’ and all lines (i.e. 2 o’clock).

 

 

e. Start timer for desired dwell time (E.g. 30 minutes)

Equipment images

f. Once desired dwell time complete, open the stopcock to the ‘drain’ line.

 

 

g. Again set timer to prescribed ‘drain out’ time (E.g. 10 minutes or 15 minutes).

Equipment images

h. At the end of this drain out time, close the stopcock to the ‘drain’ line. (2 o’clock position)

Equipment images

i. Measure amount of drainage in the urimeter, then once amount noted, empty this into the larger collection bag.

 

j. Document amount: This should be the difference between volume of fluid in & volume of drainage out

E.g. 40 ml IN / 52 ml OUT = 12ml drained

 

Repeat steps a to j  for the prescribed time for dialysis.

Equipment images

Discontinuing manual peritoneal dialysis

PROCEDURE

RATIONALE

Wash hands and don apron and non-sterile gloves.

 

Ensure stopcock and all clamps are closed switched off on ‘fill’, ‘patient’ and ‘drain’ lines (i.e. @ 2 o’cock position).

Equipment images

Remove connection shield cap and disconnect Dialy-nate® system from patient P/D catheter connection.

Equipment images

Clean P/D connection with Clinell swab and attach minicap to blue end of PD extension set.

Equipment images

Remove bag of dialysis solution from Dialy-nate® system and clamp/cap off if any solution remaining. Place on trolley top.

Ensure all drainage volumes checked and recorded then place system on trolley also.

Take both bag & drainage system to sluice and empty drainage into sluice then dispose of bag/system as clinical waste.

  

Appendix 1: Setting up Acute P/D using Dialy-Nate Peritoneal Dialysis set - Flowchart

Acute P/D using Dialy-nate® system in PICU

Gather all equipment & wash hands . Open Dialy-nate® P/D pack & dialysis fluid on to trolley.

Priming system

  • If using Physioneal - break frangible connector inside between ‘top’ & ‘bottom’ bag.
  • Ensure solutions mixed well.
  • Hang bag on pole

Equipment images

  1. Connect bag to the Dialy-Nate® set, using luer connector
  2. Clamp all connectors & roller clamp below bag and above burette
  3. Position looping coil & drainage bag to allow priming of system

Equipment images

  1. Break frangible connector in tubing of the dialysis solution bag
  2. Open clamp on connector line & above burette
  3. Fill burette to 60-80ml then clamp line above burette & dialysis solution bag connection line

Equipment images

  1. Open roller clamp below burette & filter

11 & 12. Open stopcock to ‘patient’ line and prime system (including prime to PD extension)

  1. Once primed, switch stopcock to ‘closed’ to patient & ‘open’ to drainage and prime

Equipment images

  1. Leave 10ml in burette (to avoid air in system)
  2. Switch stopcock to ‘closed’ to all (2 o’clock position) then Close all remaining clamps

Performing manual acute peritoneal dialysis

Before initiation of very 1st PD:

  1. Before connecting primed circuit, open stopcock from ‘patient’ line to ‘drain’ & record this initial drainage in child’s fluid balance
  2. Switch stopcock to closed (2 o’clock position)
  3. Connect P/D system to P/D catheter & attach connector shield

1st cycle and ongoing PD cycles:

  1. Open dialysis solution bag clamp & open clamp above burette.

Fill burette to prescribed P/D volume E.g. 40ml (+10ml) then clamp at bag & above burette

Equipment images

  1. Open roller clamp below filter and burette, and turn stopcock on to ‘patient’ line.
  2. Allow prescribed volume from burette to drain in (E.g. 40ml) leaving @ 10ml in burette chamber.
  3. Close roller clamp below burette and filter, and close stopcock to ‘patient’, ‘fill’ & ‘drain’ line. i.e. 2 o’clock position

Set timer for prescribed ‘dwell’ time for PD cycle.

Equipment images

  1. At end of prescribed ‘dwell’ time, open stopcock to ‘drain’ line to allow PD drainage.

Set timer for prescribed drain out time in cycle.

  1. At end of drain time, close stopcock to all lines i.e. 2 o’clock.

Note volume drained and document.       Repeat timed cycles as prescribed.

Equipment images

Discontinuing Acute Peritoneal Dialysis

Wash hands and don apron and non-sterile gloves.

  1. Ensure stopcock and all clamps are closed i.e 2 o’cock position
  2. Remove connection shield cap, disconnect Dialy-nate® system from patient P/D catheter connection.
  1. Clean P/D connection with Clinell swab and attach minicap to blue end of PD extension set.

Remove all waste and document volumes

Equipment images

Editorial Information

Last reviewed: 30/04/2018

Next review date: 30/04/2020

Author(s): J Grady.

References
  1. Bojam, M  Gioanni, S  Vouhé, PR  Journois, D  Pouard, P (2012)  Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery, is associated with a significant decrease in mortality. Kidney International, Vol. 82, pp. 474-481
  2. Bonilla-Felix, M (2013)  Peritoneal dialysis in the pediatric intensive care unit settings: Techniques, quantitations and outcomes. Blood Purification, Vol.35, pp. 77-80.
  3. Chien, JC  Hwang, BT  Weng, ZC  Meng, LCC  Lee, PC (2009) Peritoneal dialysis in infants and children after open heart surgery.  Pediatric Neonatology, Vol. 50 (6), pp. 275-279.
  4. Cullis, B  Abdelraheem, M Abrahams, Georgi et al (2014) Peritoneal dialysis for acute kidney injury. Peritoneal Dialysis International, Vol. 34 (5), pp. 494-517
  5. Vasudevan, A  Phadke, K  Yap, HK (2017) Peritoneal dialysis for the management of pediatric patients with acute kidney injury. Pediatric Nephrology, Vol. 32, pp. 1145-1156.
  6. Pederson, KR  Hjortdal, VE  Christensen, S  Pederson, J  Hjortholm, K  Larsen, SH  Polvsen, JV (2008) Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congential heart disease. Kidney International, Vol. 73, pp. 581-586
  7. NHS GG&C (2017) NHS Greater Glasgow Prevention and Control of Infection Manual (2017) NHS Greater Glasgow Control of Infection Committee Policy. NHS Scotland