J Ctuon Dis 1975, Vol. 28. pp. 637-659. Pergamon Press. Printed in Great Britain
COMPLICATIONS
OF ACUTE
PERITONEAL
DIALYSIS*
CARLOS A. VAAMONDE,? ULRICH F. MICHAEL,? ROBERT A. METZGER~ and
KENNETH E. CARROLL, JR.$ Department of Medicine, The University of New Mexico School of Medicine and the Bemalillo County Medical Center, Albuquerque, New Mexico and the Department of Medicine, The University of Miami School of Medicine and the Miami Veterans Administration Hospital, Miami, Florida (Received in revisedform 5 April 1975) Abstract-A detailed analysis was made of the complications of peritoneal dialysis encountered during 184 dialyses performed in 107 severely ill patients at two teaching hospitals where the major responsibility for the dialysis rests outside a specialized renal unit. Only 9.8% of the dialyses were done to maintain patients for renal transpfantation, and no chronic maintenance peritoneal dialyses were performed. Significant mechanical, infectious, cardiovascular, pulmonary, neurologic and metabolic complications occurred in 68 % of the dialyses. Dialysis related peritonitis occurred in 6.3 % of the dialyses and no instance of perforation of an abdominal viscus occurred. In spite of the high incidence of complications 75 % of the dialyses produced significant improvement in the clinical status of the patient. In 32% of the dialyses no or only minimal complications were encountered. Death occurred in 20 patients and was assumed to have been a direct result of the dialysis in 7 or 6.5%. It is apparent that this assumedly safe procedure carries a considerable risk. However, increased knowledge of the mechanics and hazards of peritoneal dialysis, close patient observation and meticulous attention to apparently small details, should decrease the number of complications and preserve the effectiveness of the procedure. PERITONEAL dialysis is an established form of treatment for acute renal failure, for certain water and electrolyte abnormalities and an alternative modality for chronic maintenance dialysis. It is not surprising that this procedure is associated with complications, some quite serious, in a group of patients ill with life-threatening disease. Some of the complications, however, are to varying degrees preventable. Despite its widespread usage, surprisingly few reports have appeared [l-3] describing the types and the frequency of complications seen during peritoneal dialysis. Most of the large series published have not dealt in depth with clinical or management details [4-141. This paper was written in an attempt to report the frequency and type of complica-
*This work was carried out during the tenure of a National Institute of Health Traineeship (5-TI-HE5633) (Dr. Metzger) and during the tenure of a V.A. Traineeship in Nephrology (TP-139) (Dr. Carroll). Present address : tuniversity of Miami School of Medicine and Veterans Administration 33125. *Orlando Artificial Kidney Center, Orlando, Florida 32804. $7 Windsor Lane, N.E., Fort Walton Beach, Florida 32548. 637
Hospital,
Miami, Florida
638
CARL~~A. VAAMONDE et al.
tions observed in 184 peritoneal dialyses performed in 107 patients in two teaching hospitals where the initiation, control and responsibility for dialysis rested with the ward physicians who had ready access to consultation from a renal unit. In many instances, greater ease, efficiency and comfort during peritoneal dialysis can be achieved with meticulous attention to seemingly small details. These will be particularly emphasized. MATERIALS
AND
METHODS
Of 222 peritoneal dialyses (P.D.), complete records were available for 184 performed in 107 patients over a 7 yr period (1963-1969). Therefore, the data in this report were clearly representative of the patient populations and of the incidence and type of complications of P.D. observed during the study period. The mean age of the patients was 45 yr (1.5-83 yr). Seven per cent of the patients were less than 20 and 23% over 60 yr of age. Sixty-four per cent were males. Forty per cent of the patients had two or more dialyses. Multiple dialyses were done for diagnostic evaluation in instances of renal failure of unknown etiology; to maintain previously stable patients with chronic renal disease through episodes of acute illness; and to maintain patients with acute renal failure until kidney function returned or until it became clear that renal damage was irreversible. Except for 18 dialyses in three patients awaiting renal transplantation, none of the patients underwent chronic P.D. Table 1 lists the primary clinical diagnoses and Table 2 the primary indications for dialysis in these patients. From 1963 through October 1967 P.D. was done utilizing the technique of Maxwell et al. [4] modifying only the exchange’s equilibration time (30-60 min) depending on TABLE1. PRIMARYCLINICAL DIAGNOSIS IN 107 PATIENTS UNDERGOING PERITONEAL DIALYSIS 1. Acute Renal Failure (20%)
No. Patients
Acute Tubular Insufficiency Acute Cortical Necrosis Acute Post-streptococcalglomerulonephritis Hepatorenal Syndrome Bilateral Ureteral Obstruction by tumor 2.
14 2 ; 1
Chronic Renal Disease (71%) Chronic Glomerulonephritis Chronic InterstitialNephritis Diabetic Nephropathy Severe Nephrosclerosis Others (Polycystic kidneys; lupus nephritis; polyarteritis nodosa; renal tuberculosis; rapidly progressive glomerulonephritis; Goodpasture's Syndrome Etiology Unknown
3.
Congestive Heart Failure (2%)
4.
Acute Intoxications (7%) * Barbiturates Salycilate Glutethimide Salt poisoning
*P.D. performed because hemodialysis not available or indicated.
;z 8 7
;:, 2
4 2 1 1
Complications
639
of Acute Peritoneal Dialysis
TABLE 2. PRIMARY CLINICALINDICATIONS FOR PERITONEAL DIALYSIS*(184 DIALYSES)
Indication 1. 2. 3.
Number of Dialyses
Percent of Total
101 25 18
54.9 13.6 9.8
Uremia .: Fluid overload Maintenance for renal transplantation
5. Metabolic acidosis 4. Hyperkalemia 6. Drug overdose f 7. Hepatorenal syndrome 8. Preparation for renal biopsy or instrumentation 9. Severe hypernatremia
11 : 6 :
46.: 4:3 3.3 2.7 0.6
*Only the major clinical indication is listed. tP.D. performed becauseof patients’progressiveclinicaldeterioration despiteadequateconservative
treatment. $P. D. performed becausehemodialysisnot availableor indicated. whether fluid removal or chemical correction was primarily indicated. Thereafter catheter insertion was done using the stylet catheter* as described by Weston and Roberts [15]. Commercially available catheters? and solutions (1.5% glucose dialysate concentration$) were used in all dialyses. To remove fluid or occasionally to test for inadequate drainage a 4.25% glucose dialysate concentration was employed (this concentration was obtained by instilling equal volumes of 1.5 and 7% glucose solutions). On rare occasions the 7% glucose dialysate was utilized for few exchanges. Routinely, 3-4 mEq of K were added per liter of dialysate in all exchanges. Heparin (1000 USP units) was added to the first three or four exchanges in all P.D. Thereafter, heparin was used whenever evidence of bleeding or fibrin formation reappeared in the peritoneal drainage. All P.D. solution bottles were carefully warmed up to 37°C with a water bath or incubator prior to usage. Patients were dialyzed in the medical intensive care unit. The catheter was inserted by a house officer under the supervision of an experienced senior resident or the renal consultant. After complete emptying of the bladder, usually l-2 1. of dialysate were initially instilled into the peritoneal cavity to minimize the risk of perforating a viscus. This fluid can be infused through a long large bore needle but we prefer to remove the needle after passing a flexible plastic catheter through its lumen. When the P.D. catheter is then inserted, rapid return of fluid will signal entry into the peritoneal cavity. The catheter was inserted through the abdominal midline few centimeters below the umbilicus. On rare occasions, because history of previous abdominal surgery or inability to place the catheter into the abdominal cavity through the preferred midline infra-umbilical site, the catheter was successfully inserted at the abdominal midline few centimeters above the umbilicus without complications. However, in those rare instances, it is of particular importance to instill at least 2 1. of dialysate into the peritoneal cavity prior to the insertion of the catheter and to exert extreme *Trocath Peritoneal DialysisCatheter, Don Baxter, Inc. Glendale, California. Vnpersol Catheter, Abbott Laboratories, North Chicago, Illinois; Don Baxter, Inc., Glendale, California. *Peritoneal Dialysis Solution, Don Baxter, Inc., Glendale, California; tories, Inc., Morton Grove, Illinois. F
Dianeal, Travenol Labora-
640
CARL~S A. VAAMONDEet aI.
caution to avoid damage to intraabdominal viscus and deep vessels. Alternatively, surgical placement of the catheter or hemodialysis, if available, can be employed. A purse string suture around the catheter was not always utilized, especially since the introduction of the stylet catheter. Antibiotic ointment (polymyxin B, bacitracin, neomycin, Neosporin(R)) was applied around the puncture site and the abdomen was tightly dressed. Cultures of the peritoneal drainage fluid were obtained at the end of the first exchange, every 24 hr of dialysis and at the end of the P.D., or when the suspicion of peritonitis arose. Housestaff and nurses followed a detailed P.D. protocol outlined by the renal staff. Unless complications ensued, the dialysis was supervised by a nurse who had received special training in the procedure. The nurse was responsible for the preparation of the dialysate and kept a flow sheet that included the number of exchanges; the time; the fluid balance per exchange; the accumulated fluid balance; the medications added to the dialysate, and appropriate notes concerning vital signs, changes in the patient’s condition, subjective response of the patient, medications administered during the dialysis and complications with the procedure itself. Prior to January 1967, 25 mg of tetracycline were added to each exchange but since that time no antibiotics were added unless peritonitis was present. The patients were evaluated frequently by the ward physicians and by a renal consultant in many instances. The mean duration of dialysis was 40 hr and no P.D. was prolonged beyond 72 hr. Although this was not a prospective study, the availability of complete and detailed information about the mechanics, results and complications of the P.D., permitted a comprehensive retrospective analysis of the data. RESULTS
The complications of P.D. observed in these patients were divided into the following categories: (1) Mechanical, (2) Infectious, (3) Cardiovascular, (4) Pulmonary, (5) Neurologic, and (6) Metabolic. 1. Mechanical complications (Table 3) Pain was present during 120 or 73% of the dialyses in which the patient was alert enough to respond. It was moderate, requiring the use of analgesics or narcotics during 86 dialyses. These were usually administered prior to infusion of the dialysate and were required only for few exchanges at the beginning of the procedure. Severe pain, requiring deep sedation and cessation of the dialysis was observed on four occasions. Intra-abdominal bleeding with blood persisting in the dialysis drainage after the third exchange was observed in one third of the dialyses. Only in two P.D. was blood transfusion required. Another patient hemorrhaged severely from the site of an open renal biopsy performed 3 days before dialysis and required transfusion. Leakage of dialysate around the catheter occurred in about one third of the dialyses, requiring frequent dressing changes in 24 and contributing to the early cessation of the procedure in 14 dialyses. Inadequate drainage occurred at some time in 38% of the dialyses. In about two-thirds of these it was due to the loss of the siphon effect, and in less than one-third it was related to catheter obstruction. During 39 dialyses insertion of one or more new catheters was required and eight dialyses were inadequate because of drainage problems.
Complications
641
of Acute Peritoneal Dialysis
TABLE 3. MECHANICALCOMPLICATIONS OF PERITONEAL DIALYSIS,184 DIALYSES IN 107 PATIENTS
Complication
Number
Pain 7 Minimal (noted oy patient) Moderate (requiring analgesic or narcotic) Severe (cessation of dialysis)
120 30 86 4
Intra-abdominalhemorrhage Minimal (pink drainage after 3rd exchange) Moderate (bloody drainage) Severe (requiring transfusion)
59 38 19 2
73 * * :: * 2.4* 32 21 10 1
1
Hemorrhage from open renal biopsy site Leakage Mininial(requiring occasional dressing change) Moderate (frequent dressing changes) Severe (persistentsaturation of dressings)
Percent __Total Dialyses
26: :: 69
Inadequate Drainage Loss of siphon effect Catheter obstruction Preperitoneal catheter placement Peritoneal loculation
t; 3 1
Other -_-
15
Intraperitonealcatheter loss
4
Dissection of abdominal v,alland scrotal edema
2
Yound evisceration
2
Catheter removed by patient
5
Post dialysis fluid leakage
1
Hematoma of wall of large intestine
1
*Excludes 20 dialyses in which patients remained comatose throughout
36 ;: 8 37.5 24 11'6 0:5 a.2
the procedure.
On four occasions the catheter broke and was lost into the peritoneal cavity. Dissection of the abdominal wall with formation of scrotal edema occurred twice and laparotomy wounds eviscerated on two occasions. Five patients pulled out their dialysis catheters and one patient had persistent leakage of dialysate through the puncture wound for 48 hr after the dialysis. Although no instances of perforation of an inn-a-abdominal organ occurred in this series a hematoma in the wall of the large intestine was found at autopsy in one patient. 2. Infectious complications (Table 4) A staphylococcal abscess at the puncture site developed following three dialyses, and in one was responsible for contamination of the peritoneal cavity leading to acute peritonitis and death. Peritoneal drainage cultures at the end of dialysis were available in 142 P.D. In 74% of these the drainage fluid was sterile. fn one patient repeated unsuccessful attempts to place the catheter were followed by three days of abdominal pain and rebound tenderness but with repeatedly sterile cultures of the peritoneal fluid (sterilemechanical peritonitis).
642
CARLOSA. VAAMONDE et al. TABLE4. INFECTIOUS COMPLICATIONS OF PERITONEAL DIALYSIS Complication
No. Dialyses
A.
Abscess at puncture site
Y.
Intraabdominalinfection *
(1.6%)
31184
Sterile Drainage_ (74%)
105/142
Positive Cultures (25.3%)
361142
a)
Asymptomatic
b)
Clinical Peritonitis + (dialysis related) (6.3%)
Sterile
27
(mechanical) peritonitis (0.7%)
9 l/l42
*Data from peritoneal drainage fluid cultures obtained at the end of 142 dialyses. tFour postoperative patients who had clinical peritonitis and positive drainage fluid cultures on the first P.D. exchange were excluded from this data.
TABLE 5. INFEC~OUSCOMPLICATIONSOFPER~TONEALDIALYSIS.ORGANISMSFROM POSITIVECULTURES OBTAINED DURING 142 DIALYSES IN 80 PATIENTS Organism Staphylococcus aureus Staphylococcus epidermidis Streptococcus fecalis Streptococcus non-hemolytic Pseudomonas aeruginosa Klebsiella Aerogenes Proteus Sp. E. coli Clostridium perfringens Bacillus Sp. Serratia (non-pigmented) Candida Sp.
Asymptomatic
Clinical Peritonitis
1
5 0
! 1
: :
3 3
2,
1 3
0 I: 1
20
~ABLE~.CARDIOVASCULARANDPULMONARYCOMPLICATIONSOFPERITONEALDIALYSIS, 184 DIALYSES IN 107 PATIENTS CardiovascularComplication Pulmonary Edema Heart failure Fluid overload Hypotension Arrhythmias Cardiac arrest tiypertension
Rumber of Dialyses
: 6 8 : 2
Pulmonary Complication Gasal atelectasis Aspiration Pneumonia Pleural effusion Respiratory arrest
14 1: 10 1
36
Complications
of Acute Peritoneal Dialysis
643
Positive cultures of bacteria or fungi were grown in 36 P.D., in 27 of these there were no symptoms or signs of peritonitis (asymptomatic positive culture). Positive cultures associated with clinical peritonitis developed during 9 (6.3%) dialyses in 8 patients and were considered dialyses related. The diagnosis of clinical peritonitis in the patient receiving P.D. was based on the development of signs of peritoneal irritation (generalized spasm, rebound tenderness), fever and the appearance of cloudiness (and frequently a foul smell) in a previously clear and sterile peritoneal fluid drainage. Peritonitis contributed to the cause of death in one patient. Table 5 lists the organisms cultured from the asymptomatic and symptomatic patients. Gram negative organisms predominated in the positive cultures from the asymptomatic patients, while Gram positive organisms were as common as Gram negative bacteria in those with clinical peritonitis. Mixed infections were frequent. 3. Cardiovascular complications (Table 6) Acute pulmonary edema occurred during three dialyses complicated by the retention of several liters of dialysate. Evidence of heart failure without pulmonary edema occurred in one patient and six dialyses resulted in fluid overload with peripheral edema. Hypotension developed during 8 dialyses and it was associated with rapid removal of fluid in four. Four patients developed cardiac arrhythmias and electrocardiographic changes consistent with digitalis intoxication and one patient not receiving digitalis, developed frequent premature ventricular contractions during dialysis. Cardiac arrest occurred during four dialyses; two of them followed the aspiration of gastric contents; one occurred during the insertion of the peritoneal catheter; and the fourth occurred in a severely acidotic uremic patient. Two young patients with chronic glomerulonephritis one with and the other without hypertension developed acute increase in blood pressure associated with rapid removal of several liters of fluid. 4. Pulmonary complications
These are listed in Table 6 and only include those instances that were clearly not present prior to dialysis. Basal atelectasis was noted by X-ray or autopsy examination after 14 dialyses. Two patients aspirated during the infusion of dialysate and another aspirated shortly after dialysis; all three died. Pneumonia developed during 13 dialyses and was the cause of death in two patients. Pleural efliion was noted shortly after ten dialyses but was of significance in only one patient who developed a rather large right pleural effusion with some respiratory distress. Transient unexplained respiratory arrest occurred in a comatose patient who had a small subarachnoid hemorrhage at autopsy. 5. Neurologic complications
Mental deterioration and changes in sensorium without convulsions occurred during 12 dialyses. One patient, awaiting renal transplantation, experienced acute hysterical reactions during three dialyses. Generalized convulsions occurred during or within 36 hr following termination of dialysis on 12 occasions (6.5%) in patients who had no history of convulsive disorders. One patient possibly had the dialysis-disequilibrium syndrome.
644
CARLOS
A. VAAMONDE. et ul.
TABLE 7. METABOLIC COMPLICATIONS OF PERITONEAL DIALYSIS, 184 DIALYSESIN 107 PATIENTS
Complications Hyperglycemia (zthan 200 mg%) * Hyperglycemic nonketotic coma Hypoglycemia
Number ofXGi&es 12 *
8.6 *
1*
0.7 *
2*
Hyperkalemia (>than 5 mEq/L)
11
Hypokalemia (
COMPLICATIONS
OF ACUTE
PERITONEAL
DIALYSIS*
CARLOS A. VAAMONDE,? ULRICH F. MICHAEL,? ROBERT A. METZGER~ and
KENNETH E. CARROLL, JR.$ Department of Medicine, The University of New Mexico School of Medicine and the Bemalillo County Medical Center, Albuquerque, New Mexico and the Department of Medicine, The University of Miami School of Medicine and the Miami Veterans Administration Hospital, Miami, Florida (Received in revisedform 5 April 1975) Abstract-A detailed analysis was made of the complications of peritoneal dialysis encountered during 184 dialyses performed in 107 severely ill patients at two teaching hospitals where the major responsibility for the dialysis rests outside a specialized renal unit. Only 9.8% of the dialyses were done to maintain patients for renal transpfantation, and no chronic maintenance peritoneal dialyses were performed. Significant mechanical, infectious, cardiovascular, pulmonary, neurologic and metabolic complications occurred in 68 % of the dialyses. Dialysis related peritonitis occurred in 6.3 % of the dialyses and no instance of perforation of an abdominal viscus occurred. In spite of the high incidence of complications 75 % of the dialyses produced significant improvement in the clinical status of the patient. In 32% of the dialyses no or only minimal complications were encountered. Death occurred in 20 patients and was assumed to have been a direct result of the dialysis in 7 or 6.5%. It is apparent that this assumedly safe procedure carries a considerable risk. However, increased knowledge of the mechanics and hazards of peritoneal dialysis, close patient observation and meticulous attention to apparently small details, should decrease the number of complications and preserve the effectiveness of the procedure. PERITONEAL dialysis is an established form of treatment for acute renal failure, for certain water and electrolyte abnormalities and an alternative modality for chronic maintenance dialysis. It is not surprising that this procedure is associated with complications, some quite serious, in a group of patients ill with life-threatening disease. Some of the complications, however, are to varying degrees preventable. Despite its widespread usage, surprisingly few reports have appeared [l-3] describing the types and the frequency of complications seen during peritoneal dialysis. Most of the large series published have not dealt in depth with clinical or management details [4-141. This paper was written in an attempt to report the frequency and type of complica-
*This work was carried out during the tenure of a National Institute of Health Traineeship (5-TI-HE5633) (Dr. Metzger) and during the tenure of a V.A. Traineeship in Nephrology (TP-139) (Dr. Carroll). Present address : tuniversity of Miami School of Medicine and Veterans Administration 33125. *Orlando Artificial Kidney Center, Orlando, Florida 32804. $7 Windsor Lane, N.E., Fort Walton Beach, Florida 32548. 637
Hospital,
Miami, Florida
638
CARL~~A. VAAMONDE et al.
tions observed in 184 peritoneal dialyses performed in 107 patients in two teaching hospitals where the initiation, control and responsibility for dialysis rested with the ward physicians who had ready access to consultation from a renal unit. In many instances, greater ease, efficiency and comfort during peritoneal dialysis can be achieved with meticulous attention to seemingly small details. These will be particularly emphasized. MATERIALS
AND
METHODS
Of 222 peritoneal dialyses (P.D.), complete records were available for 184 performed in 107 patients over a 7 yr period (1963-1969). Therefore, the data in this report were clearly representative of the patient populations and of the incidence and type of complications of P.D. observed during the study period. The mean age of the patients was 45 yr (1.5-83 yr). Seven per cent of the patients were less than 20 and 23% over 60 yr of age. Sixty-four per cent were males. Forty per cent of the patients had two or more dialyses. Multiple dialyses were done for diagnostic evaluation in instances of renal failure of unknown etiology; to maintain previously stable patients with chronic renal disease through episodes of acute illness; and to maintain patients with acute renal failure until kidney function returned or until it became clear that renal damage was irreversible. Except for 18 dialyses in three patients awaiting renal transplantation, none of the patients underwent chronic P.D. Table 1 lists the primary clinical diagnoses and Table 2 the primary indications for dialysis in these patients. From 1963 through October 1967 P.D. was done utilizing the technique of Maxwell et al. [4] modifying only the exchange’s equilibration time (30-60 min) depending on TABLE1. PRIMARYCLINICAL DIAGNOSIS IN 107 PATIENTS UNDERGOING PERITONEAL DIALYSIS 1. Acute Renal Failure (20%)
No. Patients
Acute Tubular Insufficiency Acute Cortical Necrosis Acute Post-streptococcalglomerulonephritis Hepatorenal Syndrome Bilateral Ureteral Obstruction by tumor 2.
14 2 ; 1
Chronic Renal Disease (71%) Chronic Glomerulonephritis Chronic InterstitialNephritis Diabetic Nephropathy Severe Nephrosclerosis Others (Polycystic kidneys; lupus nephritis; polyarteritis nodosa; renal tuberculosis; rapidly progressive glomerulonephritis; Goodpasture's Syndrome Etiology Unknown
3.
Congestive Heart Failure (2%)
4.
Acute Intoxications (7%) * Barbiturates Salycilate Glutethimide Salt poisoning
*P.D. performed because hemodialysis not available or indicated.
;z 8 7
;:, 2
4 2 1 1
Complications
639
of Acute Peritoneal Dialysis
TABLE 2. PRIMARY CLINICALINDICATIONS FOR PERITONEAL DIALYSIS*(184 DIALYSES)
Indication 1. 2. 3.
Number of Dialyses
Percent of Total
101 25 18
54.9 13.6 9.8
Uremia .: Fluid overload Maintenance for renal transplantation
5. Metabolic acidosis 4. Hyperkalemia 6. Drug overdose f 7. Hepatorenal syndrome 8. Preparation for renal biopsy or instrumentation 9. Severe hypernatremia
11 : 6 :
46.: 4:3 3.3 2.7 0.6
*Only the major clinical indication is listed. tP.D. performed becauseof patients’progressiveclinicaldeterioration despiteadequateconservative
treatment. $P. D. performed becausehemodialysisnot availableor indicated. whether fluid removal or chemical correction was primarily indicated. Thereafter catheter insertion was done using the stylet catheter* as described by Weston and Roberts [15]. Commercially available catheters? and solutions (1.5% glucose dialysate concentration$) were used in all dialyses. To remove fluid or occasionally to test for inadequate drainage a 4.25% glucose dialysate concentration was employed (this concentration was obtained by instilling equal volumes of 1.5 and 7% glucose solutions). On rare occasions the 7% glucose dialysate was utilized for few exchanges. Routinely, 3-4 mEq of K were added per liter of dialysate in all exchanges. Heparin (1000 USP units) was added to the first three or four exchanges in all P.D. Thereafter, heparin was used whenever evidence of bleeding or fibrin formation reappeared in the peritoneal drainage. All P.D. solution bottles were carefully warmed up to 37°C with a water bath or incubator prior to usage. Patients were dialyzed in the medical intensive care unit. The catheter was inserted by a house officer under the supervision of an experienced senior resident or the renal consultant. After complete emptying of the bladder, usually l-2 1. of dialysate were initially instilled into the peritoneal cavity to minimize the risk of perforating a viscus. This fluid can be infused through a long large bore needle but we prefer to remove the needle after passing a flexible plastic catheter through its lumen. When the P.D. catheter is then inserted, rapid return of fluid will signal entry into the peritoneal cavity. The catheter was inserted through the abdominal midline few centimeters below the umbilicus. On rare occasions, because history of previous abdominal surgery or inability to place the catheter into the abdominal cavity through the preferred midline infra-umbilical site, the catheter was successfully inserted at the abdominal midline few centimeters above the umbilicus without complications. However, in those rare instances, it is of particular importance to instill at least 2 1. of dialysate into the peritoneal cavity prior to the insertion of the catheter and to exert extreme *Trocath Peritoneal DialysisCatheter, Don Baxter, Inc. Glendale, California. Vnpersol Catheter, Abbott Laboratories, North Chicago, Illinois; Don Baxter, Inc., Glendale, California. *Peritoneal Dialysis Solution, Don Baxter, Inc., Glendale, California; tories, Inc., Morton Grove, Illinois. F
Dianeal, Travenol Labora-
640
CARL~S A. VAAMONDEet aI.
caution to avoid damage to intraabdominal viscus and deep vessels. Alternatively, surgical placement of the catheter or hemodialysis, if available, can be employed. A purse string suture around the catheter was not always utilized, especially since the introduction of the stylet catheter. Antibiotic ointment (polymyxin B, bacitracin, neomycin, Neosporin(R)) was applied around the puncture site and the abdomen was tightly dressed. Cultures of the peritoneal drainage fluid were obtained at the end of the first exchange, every 24 hr of dialysis and at the end of the P.D., or when the suspicion of peritonitis arose. Housestaff and nurses followed a detailed P.D. protocol outlined by the renal staff. Unless complications ensued, the dialysis was supervised by a nurse who had received special training in the procedure. The nurse was responsible for the preparation of the dialysate and kept a flow sheet that included the number of exchanges; the time; the fluid balance per exchange; the accumulated fluid balance; the medications added to the dialysate, and appropriate notes concerning vital signs, changes in the patient’s condition, subjective response of the patient, medications administered during the dialysis and complications with the procedure itself. Prior to January 1967, 25 mg of tetracycline were added to each exchange but since that time no antibiotics were added unless peritonitis was present. The patients were evaluated frequently by the ward physicians and by a renal consultant in many instances. The mean duration of dialysis was 40 hr and no P.D. was prolonged beyond 72 hr. Although this was not a prospective study, the availability of complete and detailed information about the mechanics, results and complications of the P.D., permitted a comprehensive retrospective analysis of the data. RESULTS
The complications of P.D. observed in these patients were divided into the following categories: (1) Mechanical, (2) Infectious, (3) Cardiovascular, (4) Pulmonary, (5) Neurologic, and (6) Metabolic. 1. Mechanical complications (Table 3) Pain was present during 120 or 73% of the dialyses in which the patient was alert enough to respond. It was moderate, requiring the use of analgesics or narcotics during 86 dialyses. These were usually administered prior to infusion of the dialysate and were required only for few exchanges at the beginning of the procedure. Severe pain, requiring deep sedation and cessation of the dialysis was observed on four occasions. Intra-abdominal bleeding with blood persisting in the dialysis drainage after the third exchange was observed in one third of the dialyses. Only in two P.D. was blood transfusion required. Another patient hemorrhaged severely from the site of an open renal biopsy performed 3 days before dialysis and required transfusion. Leakage of dialysate around the catheter occurred in about one third of the dialyses, requiring frequent dressing changes in 24 and contributing to the early cessation of the procedure in 14 dialyses. Inadequate drainage occurred at some time in 38% of the dialyses. In about two-thirds of these it was due to the loss of the siphon effect, and in less than one-third it was related to catheter obstruction. During 39 dialyses insertion of one or more new catheters was required and eight dialyses were inadequate because of drainage problems.
Complications
641
of Acute Peritoneal Dialysis
TABLE 3. MECHANICALCOMPLICATIONS OF PERITONEAL DIALYSIS,184 DIALYSES IN 107 PATIENTS
Complication
Number
Pain 7 Minimal (noted oy patient) Moderate (requiring analgesic or narcotic) Severe (cessation of dialysis)
120 30 86 4
Intra-abdominalhemorrhage Minimal (pink drainage after 3rd exchange) Moderate (bloody drainage) Severe (requiring transfusion)
59 38 19 2
73 * * :: * 2.4* 32 21 10 1
1
Hemorrhage from open renal biopsy site Leakage Mininial(requiring occasional dressing change) Moderate (frequent dressing changes) Severe (persistentsaturation of dressings)
Percent __Total Dialyses
26: :: 69
Inadequate Drainage Loss of siphon effect Catheter obstruction Preperitoneal catheter placement Peritoneal loculation
t; 3 1
Other -_-
15
Intraperitonealcatheter loss
4
Dissection of abdominal v,alland scrotal edema
2
Yound evisceration
2
Catheter removed by patient
5
Post dialysis fluid leakage
1
Hematoma of wall of large intestine
1
*Excludes 20 dialyses in which patients remained comatose throughout
36 ;: 8 37.5 24 11'6 0:5 a.2
the procedure.
On four occasions the catheter broke and was lost into the peritoneal cavity. Dissection of the abdominal wall with formation of scrotal edema occurred twice and laparotomy wounds eviscerated on two occasions. Five patients pulled out their dialysis catheters and one patient had persistent leakage of dialysate through the puncture wound for 48 hr after the dialysis. Although no instances of perforation of an inn-a-abdominal organ occurred in this series a hematoma in the wall of the large intestine was found at autopsy in one patient. 2. Infectious complications (Table 4) A staphylococcal abscess at the puncture site developed following three dialyses, and in one was responsible for contamination of the peritoneal cavity leading to acute peritonitis and death. Peritoneal drainage cultures at the end of dialysis were available in 142 P.D. In 74% of these the drainage fluid was sterile. fn one patient repeated unsuccessful attempts to place the catheter were followed by three days of abdominal pain and rebound tenderness but with repeatedly sterile cultures of the peritoneal fluid (sterilemechanical peritonitis).
642
CARLOSA. VAAMONDE et al. TABLE4. INFECTIOUS COMPLICATIONS OF PERITONEAL DIALYSIS Complication
No. Dialyses
A.
Abscess at puncture site
Y.
Intraabdominalinfection *
(1.6%)
31184
Sterile Drainage_ (74%)
105/142
Positive Cultures (25.3%)
361142
a)
Asymptomatic
b)
Clinical Peritonitis + (dialysis related) (6.3%)
Sterile
27
(mechanical) peritonitis (0.7%)
9 l/l42
*Data from peritoneal drainage fluid cultures obtained at the end of 142 dialyses. tFour postoperative patients who had clinical peritonitis and positive drainage fluid cultures on the first P.D. exchange were excluded from this data.
TABLE 5. INFEC~OUSCOMPLICATIONSOFPER~TONEALDIALYSIS.ORGANISMSFROM POSITIVECULTURES OBTAINED DURING 142 DIALYSES IN 80 PATIENTS Organism Staphylococcus aureus Staphylococcus epidermidis Streptococcus fecalis Streptococcus non-hemolytic Pseudomonas aeruginosa Klebsiella Aerogenes Proteus Sp. E. coli Clostridium perfringens Bacillus Sp. Serratia (non-pigmented) Candida Sp.
Asymptomatic
Clinical Peritonitis
1
5 0
! 1
: :
3 3
2,
1 3
0 I: 1
20
~ABLE~.CARDIOVASCULARANDPULMONARYCOMPLICATIONSOFPERITONEALDIALYSIS, 184 DIALYSES IN 107 PATIENTS CardiovascularComplication Pulmonary Edema Heart failure Fluid overload Hypotension Arrhythmias Cardiac arrest tiypertension
Rumber of Dialyses
: 6 8 : 2
Pulmonary Complication Gasal atelectasis Aspiration Pneumonia Pleural effusion Respiratory arrest
14 1: 10 1
36
Complications
of Acute Peritoneal Dialysis
643
Positive cultures of bacteria or fungi were grown in 36 P.D., in 27 of these there were no symptoms or signs of peritonitis (asymptomatic positive culture). Positive cultures associated with clinical peritonitis developed during 9 (6.3%) dialyses in 8 patients and were considered dialyses related. The diagnosis of clinical peritonitis in the patient receiving P.D. was based on the development of signs of peritoneal irritation (generalized spasm, rebound tenderness), fever and the appearance of cloudiness (and frequently a foul smell) in a previously clear and sterile peritoneal fluid drainage. Peritonitis contributed to the cause of death in one patient. Table 5 lists the organisms cultured from the asymptomatic and symptomatic patients. Gram negative organisms predominated in the positive cultures from the asymptomatic patients, while Gram positive organisms were as common as Gram negative bacteria in those with clinical peritonitis. Mixed infections were frequent. 3. Cardiovascular complications (Table 6) Acute pulmonary edema occurred during three dialyses complicated by the retention of several liters of dialysate. Evidence of heart failure without pulmonary edema occurred in one patient and six dialyses resulted in fluid overload with peripheral edema. Hypotension developed during 8 dialyses and it was associated with rapid removal of fluid in four. Four patients developed cardiac arrhythmias and electrocardiographic changes consistent with digitalis intoxication and one patient not receiving digitalis, developed frequent premature ventricular contractions during dialysis. Cardiac arrest occurred during four dialyses; two of them followed the aspiration of gastric contents; one occurred during the insertion of the peritoneal catheter; and the fourth occurred in a severely acidotic uremic patient. Two young patients with chronic glomerulonephritis one with and the other without hypertension developed acute increase in blood pressure associated with rapid removal of several liters of fluid. 4. Pulmonary complications
These are listed in Table 6 and only include those instances that were clearly not present prior to dialysis. Basal atelectasis was noted by X-ray or autopsy examination after 14 dialyses. Two patients aspirated during the infusion of dialysate and another aspirated shortly after dialysis; all three died. Pneumonia developed during 13 dialyses and was the cause of death in two patients. Pleural efliion was noted shortly after ten dialyses but was of significance in only one patient who developed a rather large right pleural effusion with some respiratory distress. Transient unexplained respiratory arrest occurred in a comatose patient who had a small subarachnoid hemorrhage at autopsy. 5. Neurologic complications
Mental deterioration and changes in sensorium without convulsions occurred during 12 dialyses. One patient, awaiting renal transplantation, experienced acute hysterical reactions during three dialyses. Generalized convulsions occurred during or within 36 hr following termination of dialysis on 12 occasions (6.5%) in patients who had no history of convulsive disorders. One patient possibly had the dialysis-disequilibrium syndrome.
644
CARLOS
A. VAAMONDE. et ul.
TABLE 7. METABOLIC COMPLICATIONS OF PERITONEAL DIALYSIS, 184 DIALYSESIN 107 PATIENTS
Complications Hyperglycemia (zthan 200 mg%) * Hyperglycemic nonketotic coma Hypoglycemia
Number ofXGi&es 12 *
8.6 *
1*
0.7 *
2*
Hyperkalemia (>than 5 mEq/L)
11
Hypokalemia (
