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Peritoneal Dialysis
Peritoneal Dialysis LESTER PERSKY, M.D.* WILLIAM S. CUMMING, M.D.**
It is with a great deal of nostalgia that one looks back and attempts to recapture the impressions, attitudes, and enthusiasm of an earlier period. The surgical laboratories at the Beth Israel Hospital in Boston during the period of reawakened interest in peritoneal lavage were busy and ever-stimulating places. Government contracts, chemotherapeutic agents, progress in shock, histochemistry, and a host of other activities were a constant encouragement to work and study. The recollections of the early animal and chemical work with dialysis are clouded and suppressed by impressions of the enthusiasm engendered from the rapid emergence of the artificial kidney as a most valuable tool. More than 2 decades have elapsed since those experiences, and the true role of peritoneal dialysis is at times still debated, but it is fair to say that from Dr. Fine's laboratories sprang a reawakened interest in this mode of treatment for uremia and that certainly the demonstration of its widespread clinical application can be credited to this reawakening. Chemotherapy, better knowledge of fluid and electrolytes, and anticoagulants all contributed to make success finally a clinical fact. The history of peritoneal dialysis antedates the work of Fine, Frank, and Seligman by many years. Beginning in 1877, work was done by Wegner, Starling, Hanyburger, and others in body temperatures, absorption, and permeability of the peritoneum and alterations in the constituents of the body fluids. 1 Attempts to manage patients were made by a variety of workers over the years, and since 1945, publications concerning peritoneal dialysis have become an everyday occurrence. As a matter of fact, the first attempt to use it for the uremic state in man was reported in 1903. Since that time, due to the efforts of a great many workers. 2 • 3. 4 peritoneal dialysis has become an accepted method of treatment and can be performed in any hospital where there is sufficient interest to maintain *Professor of Urology, Department of Surgery, Case Western Reserve University School of Medicine, and University Hospitals, Cleveland, Ohio ,'* Assistant Clinical Professor of Medicine, Case Western Reserve University School of
Medicine, and University Hospitals, Cleveland, Ohio
Surgical Clinics of North America- VoL 49, No.3, June, 1969
665
666
LESTER PERSKY, WILLIAM
S.
CUMMING
an adequate routine. Because of readily available, commercially produced materials, including catheters, solutions, and various trocars, peritoneal dialysis can be established with a minimum of capital investment. The advantages of peritoneal dialysis are readily discernible. It can be started quickly, particularly under emergent circumstances: it takes only 10 to 15 minutes to insert the catheter under local anesthesia and instill the first cycle of solutions. Since cannulation of vessels is not necessary, the patient need not be transported to another area, which, in itself, can be lethal if hyperkalemia is a major problem. Because of its simplicity, a highly trained team of nurses and technicians is not necessary as it is with hemodialysis. Likewise, it is possible to maintain an adequate technique with five or six dialyses a year, whereas with the machine, some 20 or 30 dialyses are necessary. Since there is no direct cannulation of blood vessels, there is no need for blood priming. Peritoneal dialysis can be performed under almost any circumstance. Even when the patient is in shock, there is still adequate perfusion of the peritoneal membrane for an effective dialysis. Since very little heparin is used, active bleeding is not affected by the procedure. Recent abdominal surgery of any type or magnitude may decrease its efficiency but, of itself, is not a contraindication. Despite lack of integrity of the peritoneum, sufficiently effective peritoneal dialysis can be performed, providing hypertonic solutions are not used, for these cause sequestration of fluid in the subcutaneous tissues. Effective peritoneal dialyses have been performed in the face of fulminating peritonitis and, in fact, were an effective treatment for it, particularly when the appropriate antibiotics were added to the dialysate. Septicemia, which is a contraindication to cannulation of blood vessels, does not interfere with peritoneal dialysis. Because of the blood volume of the machine, the patient's size can be a critical factor, yet peritoneal dialysis has been performed on a 3 1/2-pound premature infant with little difficulty and a good result. Since it is a relatively slow process, it can be very effective in correcting massive edematous states. At least 6 kg. have been removed in 19 hours without shock. It can be regulated without undue discomfort, so that the patient can be maintained in a more constant internal environment for prolonged periods of time, particularly under circumstances in which both liver and kidney failure are present, and so that blood ammonia levels do not become excessive. There is only one absolute contraindication-a defect in the diaphragm which allows fluids to flow freely into the thorax. The indications for peritoneal dialysis are the same as those for hemodialysis, namely, any acute oliguric state that is not secondary to dehydration or obstructive uropathy. Overhydration, hyperkalemia, uremia, and acute intoxication, particularly due to phenobarbital, can all be effectively treated. Chronic renal failure has been treated effectively with both peritoneal dialysis and hemodialysis. However, because of the decreased efficiency of peritoneal dialysis, few patients are maintained on that system. Roughly 32 hours of peritoneal dialysis per week are the equivalent of 20 hours of hemodialysis with a Kill dialysis. One of the methods for peritoneal dialysis which has been found to be effective and efficient is the following: A small incision, with a No. 11
PERITONEAL DIALYSIS
667
Bard-Parker blade, is made along the lines of Zahn generally in the midline of the abdominal wall just below the umbilicus. A mixture of 5 mI. of 1 per cent lidocaine (Xylocaine) and 0.5 ml. of 1 : 1000 adrenaline is used for local anesthesia. The trocar (Fig. 1) is then placed in the incision and pushed abruptly through the abdominal wall into the peritoneal cavity. The inside diameter of the trocar is just sufficient to allow a No. 17 French catheter (commercially available) to slide through. The catheter is then directed toward the base of the true pelvis, and the trocar is removed. A gentle curve of the catheter is indicated by a small identifying mark on one wall (Fig. 2). The flow of solutions is started as soon as practical so that fibrin formation does not block the small holes of the catheter. The catheter is then fixed to the abdomen by adhesive type. No sutures are used. Two bottles of commercially available dialysate solution are allowed to flow in as rapidly as possible. This is followed by 250 ml. of either 10 or 5 per cent dextrose in water or distilled water to which has been aded Xylocaine and heparin and, if necessary, potassium. This last portion of fluids has many advantages. First of all, the integrity of only one bottle in four cycles is violated so that the chances of introducing bacteria are greatly lessened. Secondly, it increases the total volume of dialysate to about 2350 ml. Thus, when the solutions are cycled every 45 minutes, this gives a dialysate volume of 3.1 liters per hour in and out of the abdomen. In general, the commercially available solutions have too high a sodium concentration, particularly for the postoperative cardiac patients, and have too high a calcium concentration for prolonged periods of di-
Figure 1. Trocar used for insertion of cannula.
668
LESTER PERSKY, WILLIAM
S.
CUMMING
Figure 2. Cannula with gentle curve and identifying mark.
alysis. The modification outlined above decreases the sodium from 140 to 126 mEq. per liter, and the calcium from 7 to 6.3 mEq. per liter. When the narrow portions of the commercially available tubing are removed, this volume will flow into the peritoneal cavity in 7 to 8 minutes when the catheter is properly placed, and the IV poles are 7 to 8 feet high. Likewise, if the bed is placed on four shock blocks so that the patient is 45 inches off the floor, this volume will flow out in 8 to 9 minutes. In general, the drain period is started every 45 minutes so that if two patients are being dialyzed at the same time one nurse may attend both. For the acute oliguric patient, cultures are taken routinely every third cycle from the rubber sleeve that connects the tubing to the catheter. Likewise, the patient is weighed every eighth cycle, while the fluids are in, so that the efficiency of the dialysis is not interrupted. In order to maintain the acute oliguric patient, 40 to 50 liters of dialysate are cycled twice weekly depending upon the body mass of the patient and the speed of catabolism. The catheter is removed after each dialysis, and the skin incision will usually close itself. A series of appropriate forms and graphs permit ready monitoring of the patient's status. As work continues in this field, unquestionably the technique of peritoneal dialysis will be improved. Perhaps some surface-active agent will be found which is nontoxic and can be used to accelerate the dialysis of metabolites. At this point in history, there is not question that the work of Dr. Fine and all of the others has added a very effective clinical tool to our armamentarium which has saved countless lives that otherwise would have been lost.
669
PERITONEAL DIALYSIS
REFERENCES 1. Boen, J. J.: Peritoneal Dialysis in Clinical Medicine. Springfield, Illinois, Charles C
Thomas, 1964. 2. McDonald, H., Jr.: An automatic peritoneal dialysis machine: Preliminary report. Trans. Amer. Soc. Artif. Int. Organs, 11 :83, 1965. 3. Neinhois, L. J.: Clinical peritoneal dialysis. Arch. Surg., 93:643,1966. 4. Palmer, R. A., Newell, J. E., Gray, E. J., and Quinton, W. E.: Treatment of chronic renal failure by prolonged peritoneal dialysis. New Eng. J. Med., 274:248, 1966. University Hospitals 2065 Adelbert Road Cleveland, Ohio 44106
It is with a great deal of nostalgia that one looks back and attempts to recapture the impressions, attitudes, and enthusiasm of an earlier period. The surgical laboratories at the Beth Israel Hospital in Boston during the period of reawakened interest in peritoneal lavage were busy and ever-stimulating places. Government contracts, chemotherapeutic agents, progress in shock, histochemistry, and a host of other activities were a constant encouragement to work and study. The recollections of the early animal and chemical work with dialysis are clouded and suppressed by impressions of the enthusiasm engendered from the rapid emergence of the artificial kidney as a most valuable tool. More than 2 decades have elapsed since those experiences, and the true role of peritoneal dialysis is at times still debated, but it is fair to say that from Dr. Fine's laboratories sprang a reawakened interest in this mode of treatment for uremia and that certainly the demonstration of its widespread clinical application can be credited to this reawakening. Chemotherapy, better knowledge of fluid and electrolytes, and anticoagulants all contributed to make success finally a clinical fact. The history of peritoneal dialysis antedates the work of Fine, Frank, and Seligman by many years. Beginning in 1877, work was done by Wegner, Starling, Hanyburger, and others in body temperatures, absorption, and permeability of the peritoneum and alterations in the constituents of the body fluids. 1 Attempts to manage patients were made by a variety of workers over the years, and since 1945, publications concerning peritoneal dialysis have become an everyday occurrence. As a matter of fact, the first attempt to use it for the uremic state in man was reported in 1903. Since that time, due to the efforts of a great many workers. 2 • 3. 4 peritoneal dialysis has become an accepted method of treatment and can be performed in any hospital where there is sufficient interest to maintain *Professor of Urology, Department of Surgery, Case Western Reserve University School of Medicine, and University Hospitals, Cleveland, Ohio ,'* Assistant Clinical Professor of Medicine, Case Western Reserve University School of
Medicine, and University Hospitals, Cleveland, Ohio
Surgical Clinics of North America- VoL 49, No.3, June, 1969
665
666
LESTER PERSKY, WILLIAM
S.
CUMMING
an adequate routine. Because of readily available, commercially produced materials, including catheters, solutions, and various trocars, peritoneal dialysis can be established with a minimum of capital investment. The advantages of peritoneal dialysis are readily discernible. It can be started quickly, particularly under emergent circumstances: it takes only 10 to 15 minutes to insert the catheter under local anesthesia and instill the first cycle of solutions. Since cannulation of vessels is not necessary, the patient need not be transported to another area, which, in itself, can be lethal if hyperkalemia is a major problem. Because of its simplicity, a highly trained team of nurses and technicians is not necessary as it is with hemodialysis. Likewise, it is possible to maintain an adequate technique with five or six dialyses a year, whereas with the machine, some 20 or 30 dialyses are necessary. Since there is no direct cannulation of blood vessels, there is no need for blood priming. Peritoneal dialysis can be performed under almost any circumstance. Even when the patient is in shock, there is still adequate perfusion of the peritoneal membrane for an effective dialysis. Since very little heparin is used, active bleeding is not affected by the procedure. Recent abdominal surgery of any type or magnitude may decrease its efficiency but, of itself, is not a contraindication. Despite lack of integrity of the peritoneum, sufficiently effective peritoneal dialysis can be performed, providing hypertonic solutions are not used, for these cause sequestration of fluid in the subcutaneous tissues. Effective peritoneal dialyses have been performed in the face of fulminating peritonitis and, in fact, were an effective treatment for it, particularly when the appropriate antibiotics were added to the dialysate. Septicemia, which is a contraindication to cannulation of blood vessels, does not interfere with peritoneal dialysis. Because of the blood volume of the machine, the patient's size can be a critical factor, yet peritoneal dialysis has been performed on a 3 1/2-pound premature infant with little difficulty and a good result. Since it is a relatively slow process, it can be very effective in correcting massive edematous states. At least 6 kg. have been removed in 19 hours without shock. It can be regulated without undue discomfort, so that the patient can be maintained in a more constant internal environment for prolonged periods of time, particularly under circumstances in which both liver and kidney failure are present, and so that blood ammonia levels do not become excessive. There is only one absolute contraindication-a defect in the diaphragm which allows fluids to flow freely into the thorax. The indications for peritoneal dialysis are the same as those for hemodialysis, namely, any acute oliguric state that is not secondary to dehydration or obstructive uropathy. Overhydration, hyperkalemia, uremia, and acute intoxication, particularly due to phenobarbital, can all be effectively treated. Chronic renal failure has been treated effectively with both peritoneal dialysis and hemodialysis. However, because of the decreased efficiency of peritoneal dialysis, few patients are maintained on that system. Roughly 32 hours of peritoneal dialysis per week are the equivalent of 20 hours of hemodialysis with a Kill dialysis. One of the methods for peritoneal dialysis which has been found to be effective and efficient is the following: A small incision, with a No. 11
PERITONEAL DIALYSIS
667
Bard-Parker blade, is made along the lines of Zahn generally in the midline of the abdominal wall just below the umbilicus. A mixture of 5 mI. of 1 per cent lidocaine (Xylocaine) and 0.5 ml. of 1 : 1000 adrenaline is used for local anesthesia. The trocar (Fig. 1) is then placed in the incision and pushed abruptly through the abdominal wall into the peritoneal cavity. The inside diameter of the trocar is just sufficient to allow a No. 17 French catheter (commercially available) to slide through. The catheter is then directed toward the base of the true pelvis, and the trocar is removed. A gentle curve of the catheter is indicated by a small identifying mark on one wall (Fig. 2). The flow of solutions is started as soon as practical so that fibrin formation does not block the small holes of the catheter. The catheter is then fixed to the abdomen by adhesive type. No sutures are used. Two bottles of commercially available dialysate solution are allowed to flow in as rapidly as possible. This is followed by 250 ml. of either 10 or 5 per cent dextrose in water or distilled water to which has been aded Xylocaine and heparin and, if necessary, potassium. This last portion of fluids has many advantages. First of all, the integrity of only one bottle in four cycles is violated so that the chances of introducing bacteria are greatly lessened. Secondly, it increases the total volume of dialysate to about 2350 ml. Thus, when the solutions are cycled every 45 minutes, this gives a dialysate volume of 3.1 liters per hour in and out of the abdomen. In general, the commercially available solutions have too high a sodium concentration, particularly for the postoperative cardiac patients, and have too high a calcium concentration for prolonged periods of di-
Figure 1. Trocar used for insertion of cannula.
668
LESTER PERSKY, WILLIAM
S.
CUMMING
Figure 2. Cannula with gentle curve and identifying mark.
alysis. The modification outlined above decreases the sodium from 140 to 126 mEq. per liter, and the calcium from 7 to 6.3 mEq. per liter. When the narrow portions of the commercially available tubing are removed, this volume will flow into the peritoneal cavity in 7 to 8 minutes when the catheter is properly placed, and the IV poles are 7 to 8 feet high. Likewise, if the bed is placed on four shock blocks so that the patient is 45 inches off the floor, this volume will flow out in 8 to 9 minutes. In general, the drain period is started every 45 minutes so that if two patients are being dialyzed at the same time one nurse may attend both. For the acute oliguric patient, cultures are taken routinely every third cycle from the rubber sleeve that connects the tubing to the catheter. Likewise, the patient is weighed every eighth cycle, while the fluids are in, so that the efficiency of the dialysis is not interrupted. In order to maintain the acute oliguric patient, 40 to 50 liters of dialysate are cycled twice weekly depending upon the body mass of the patient and the speed of catabolism. The catheter is removed after each dialysis, and the skin incision will usually close itself. A series of appropriate forms and graphs permit ready monitoring of the patient's status. As work continues in this field, unquestionably the technique of peritoneal dialysis will be improved. Perhaps some surface-active agent will be found which is nontoxic and can be used to accelerate the dialysis of metabolites. At this point in history, there is not question that the work of Dr. Fine and all of the others has added a very effective clinical tool to our armamentarium which has saved countless lives that otherwise would have been lost.
669
PERITONEAL DIALYSIS
REFERENCES 1. Boen, J. J.: Peritoneal Dialysis in Clinical Medicine. Springfield, Illinois, Charles C
Thomas, 1964. 2. McDonald, H., Jr.: An automatic peritoneal dialysis machine: Preliminary report. Trans. Amer. Soc. Artif. Int. Organs, 11 :83, 1965. 3. Neinhois, L. J.: Clinical peritoneal dialysis. Arch. Surg., 93:643,1966. 4. Palmer, R. A., Newell, J. E., Gray, E. J., and Quinton, W. E.: Treatment of chronic renal failure by prolonged peritoneal dialysis. New Eng. J. Med., 274:248, 1966. University Hospitals 2065 Adelbert Road Cleveland, Ohio 44106