Core Concepts in Dialysis and Continuous Therapies by Colm C. Magee J. Kevin Tucker & Ajay K. Singh

Author:Colm C. Magee, J. Kevin Tucker & Ajay K. Singh
Language: eng
Format: epub
Publisher: Springer US, Boston, MA

A somewhat controversial aspect of catheter placement is the decision whether or not to routinely perform an omentectomy. A survey of pediatric surgeons indicated that an omentectomy was performed routinely in 53 % of the participating centers at the time of catheter placement [58]. The basis for its performance in children is that catheter obstruction (usually due to omental wrapping) is second only to peritonitis in terms of major catheter complications in this age group [59]. Ironically, most of the data in support of omentectomy come from the adult literature [60]. One retrospective study of children by Cribbs et al. demonstrated a decreased risk of early catheter failure with omentectomy, and Rinaldi et al. noted improved catheter survival with omentectomy, especially in children less than 2 years of age [61, 62]. Additionally, in a retrospective study of 92 pediatric patients (mean age 5 years), Conlin et al. demonstrated that the outflow obstruction rate was 5 % in patients who received an omentectomy versus 10 % in patients who did not [63]. Finally, another single-center retrospective review of 207 patients (median age 10 years) revealed that failure to perform an omentectomy was associated with a higher rate of catheter failure [64] .

One additional unique consideration for catheter placement in the pediatric age group is the timing and location of placement relative to the common need for gastrostomy tube (G-tube) placement in order to accommodate nutritional requirements (see below). As noted above, the catheter exit site should ideally be placed at a distance (often the contralateral side) from the site of a current or potential G-tube to decrease the risk of contamination and possible peritonitis. Likewise, it is recommended that when possible, the PD catheter should be placed either simultaneously or after placement of a G-tube to avoid contamination of the peritoneum from gastric contents [65]. When the catheter placement precedes G-tube placement, the latter procedure should take place under prophylactic antibiotic and antifungal therapy. Whereas percutaneous G-tube placement while on PD should not be performed due to the high risk of infection and mechanical failure; placement via an open Stamm gastrostomy procedure is possible [66]. Conversely, PD catheter placement is possible in the setting of a well-established G-tube with no increased risk of bacterial or fungal peritonitis [67–69] .

Ideally, the use of a PD catheter for chronic dialysis should be postponed until the exit site is completely healed with dressing changes avoided during the first postoperative week, unless they are required because of soiling or bleeding. Generally, a minimum of 2–3 weeks delay is preferred, although the exact timing will vary from patient to patient with complete healing taking up to 6 weeks in some patients [57] .

A quality transformation effort, Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE), is currently examining the impact of standardizing PD catheter care on infectious complications in 29 pediatric dialysis centers in the USA [70].

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