Ultrasound Guided Placement of a PD Catheter

Peritoneal dialysis (PD) was introduced nearly a century ago but did not become a primary method for dialysis until 1959. It wasn't until 1968 that the first indwelling PD catheter was developed, initially through an open surgical procedure. Despite significant advancements in PD technology, delivery methods, and cost-effectiveness in countries that produce their own dialysate, PD is still less commonly used than hemodialysis (HD). Comparing surgical techniques to percutaneous fluoroscopic methods shows no significant difference in 1-year catheter survival rates. However, surgical methods can provide additional procedures, like omentopexy or omentectomy, which help manage omental-related issues affecting PD catheters. On the other hand, fluoroscopic techniques offer the benefits of being less invasive and providing precise real-time imaging of catheter placement, along with a lower incidence of infections and mechanical problems.

Presentation

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Anatomy

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Indications

End-stage kidney disease (ESKD)
Acute kidney injury
Chronic cardiorenal syndrome

Contra Indications

Unsuitable peritoneal cavity due to extensive adhesions
Fibrosis
Irreparable abdominal wall defects
Active inflammatory or ischemic bowel disease
Frequent diverticulitis
Malignancy

Workup

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Preproduceral

DRUGS TO STOP

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Material

Essentials

Sterile Draping
Chlorhexidine 20 mg/ml
Catheter set
4F Multipurpose Catheter
Surgical Suture Set
Scalpel
40 ml Lidocaine
18G Needle
180 cm Hydrophilic Terumo Wire
180 cm Amplatz Wire
12F Dilator
16F Dilator with Peel-Away Sheath
Three 60 ml Syringes for NaCl
10 ml Luer Lock Syringe for Contrast
Sterile Ultrasound Gel
Sterile Ultrasound Cover
500 ml NaCl
50 ml Contrast Medium
1 Liter NaCl or PD Fluid for Testing

Non Essentials

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Positioning

Supine

Steps

Insert the needle 2 cm lateral to the umbilicus.
Administer 20-40 ml of 1% Lidocaine for anesthesia.
Make a horizontal incision.
Insert the needle through the rectus abdominis.
Verify intraperitoneal position with contrast under fluoroscopy.
Direct the guide wire towards the small pelvis.
Remove the needle and place a 5F sheath.
Remove the guide wire.
Under fluoroscopic guidance:
Prepare 2-3 syringes with 60 ml NaCl and 2-3 syringes with 10 ml of contrast.
Use a 4F catheter with Terumo wire to reach Douglas.
Check the catheter's position in the horizontal direction.
Bluntly dissect to place the catheter cuff in the rectus abdominis.
Exchange the Terumo wire for the Amplatz wire.
Remove the sheath and catheter.
Use a 12F dilator followed by a 16F dilator with peel-away sheath.
Remove the dilator from the sheath.
Place the PD catheter.
Use a buddy wire if necessary.
Remove the peel-away sheath while positioning the deep cuff in the muscle.
Check for kinking.
Verify functionality with contrast (use the 12F dilator).
Administer local anesthetic at the exit site.
Make an incision and dissect along the tunnel trajectory.
Insert the tunneler.
Place the catheter in the tunnel.
Verify again for kinking and function with contrast.
Use a soluble suture for insertion.
Attach the transfer set to the catheter.
Perform a final check with 1 liter NaCl or PD fluid.

Tips & Tricks

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Complications

Early
* Bowel perforation
* Bladder perforation
* Hemorrhage (usually puncture of the inferior epigastric vessels)

Late
Flow dysfunction
* Extrinsic compression of the catheter tip
* Internal luminal obstruction
* Poor positioning and/or migration
* Tissue attachment and entrapment

Peritoneal leakage
* Pericatheter leaks
* Abdominal wall hernias
* Pleuroperitoneal connection or fistula development