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 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

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
• 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

• 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.