View source for Austere peritoneal dialysis

==Overview==
*Improvised PD has been done in resource-limited settings such as the earthquakes in Turkey in 1999 and Haiti in 2010
*Indications in the austere setting are the same in non-austere settings
*Consider contacting a nephrologist via telemedicine if available
*Effective for [[hyperkalemia]], though much slower than hemodialysis
**Relatively ineffective for [[uremia]] and eliminating BUN

==Indications==
*See indications in [[AKI]]
*However, there are certain situations that are more likely in disaster or combat situations:
**[[Rhabdomyolysis]] from crush injuries
**Severe pediatric [[dehydration (peds)|dehydration]] and AKI
**Toxin clearance

==Contraindications==
*No absolute contraindications
*Relative contraindications include:
**Recent abdominal surgery
**Diaphragmatic injury with communication into thoracic space
**Overlying diffuse abdominal wall infection
**Known severe peritoneal adhesions
**Patients with severe respiratory failure that may not do well with intraperitoneal fluid

==Equipment Needed==
*Types of possible peritoneal catheters:
**Flexible Tenckhoff catheter is gold standard, but not available in austere setting
**Rigid trocar, non-tunneled catheter
**Improvised: NGTs, suprapubic catheters, pediatric chest tubes, large bore central venous catheters ("Cordis"), pigtail catheters, 8-10 Fr Foley catheters
*Scalpel
*Lidocaine
*Sterile preparation, sterile equipment
*Ultrasound

==Procedure==
*Consider giving preprocedural antibiotics such as ertapenam before start
**Fungal coverage where suspected to be an issue
**Ensure sterile technique in creating dialysate
**Additionally, antibiotics such as cephalosporins can be added to each PD bag
*Improvised flexible
**Local anesthesia, then midline incise 2 cm below umbilicus
**Blunt dissect to linea alba, then puncture through linea alba with rigid catheter, and insert a small volume of dialysate under US guidance
**Insert a guidewire through the initial catheter, then dilate using Seldinger technique to final catheter
*Rigid catheter
**Local anesthesia to area just lateral to umbilicus
**Advance pointed trocar, directed caudal toward iliac fossa
*See reference for dedicated tunneled PD catheter insertion

==Dialysate==
*Lactated Ringer's is the most readily available IVF and most similar to commercial dialysate fluid, but dextrose must be added to produce an osmotic dialysate
*Increasing dextrose concentration increases volume removal for hypervolemic patients
**Commercial dialysates usually have 1.5-4.25% dextrose
**Generally, dextrose concentrations increase 1% for every 20 mL of D50 per liter
*500 units of heparin per liter can prevent PD catheter obstruction
      [[File:peritoneal dialysate.jpg|400px]]

==Dialysis Process==
*Attach threeway stop-cock to improvised catheter
*Infuse 1-2 L of dialysate in an adult, with dwell time of 2-4 hours, four times per day
**Smaller volume dwells of 500-1000 mL with 2-4 hours of dwell time may be more appropriate in the austere combat setting
**In pediatrics, give 10-20 mL/kg of dialysate, with total exchange time of 60-90 minutes, with 30-40 minutes of dwell time\
**Volume usage per day may range from 4 all the way to 70 L per day depending on targets of therapy
*Drainage is done by gravity or aspiration
*Frequently measure electrolytes and BUN/Cr, alongside collecting daily EKGs

==Complications==
*Hemorrhage, bowel or solid organ injury
*[[Peritoneal dialysis-associated peritonitis|Peritonitis]], including fungal peritonitis not otherwise covered by prophylactic antibiotics
*Dialysate leakage, especially in abdominal surgical patients with newly healing abdominal wounds
*Hydrothorax
*Catheter obstruction

==References==
<references/>
*Gorbatkin C, Bass J, Finkelstein F, Gorbatkin S. Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management. West J Emerg Med. 2018 May;19(3):548-556.

[[Category:Procedures]]
[[Category:Renal]]