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Peritoneal dialysis in the first 60 days of life
Peritoneal Dialysis in the First 60 Days of Life By David E. Matthews, Karen W. West, Frederick J. Rescorla, Dennis W. Vane, Jay L. Grosfeld, Rebecca S. Wappner, Jerry Bergstein, and Sharon Andreoli Indianapolis, Indiana 9 This report describes a 7-year experience with acute peritoneal dialysis in 31 neonates and infants less than 60 days of age, There were 20 boys and 11 girls, ages 3 to 60 days. Tenckhoff catheters of modified length w e r e placed in the newborn intensive care unit (ICU), pediatric ICU, or surgery suites, and hourly exchanges (20 cc/kg) w e r e started immediately postoperatively, Diagnoses included congenital metabolic disorders (11 ), acute tubular necrosis (6), postcardiopulmonary bypass with renal failure (5), renal cortical necrosis (5}, obstructive uropathy (2), renal agenesis (1), and bilateral renal dysplasia (1). Complications included: peritonitis (4), bowel perforation (1), exit site infection (3), leaking dialysate (4), catheter obstruction (2), inguinal hernias (3), umbilical hernia (1), and retroperitoneal hemorrhage (1). There w e r e 19 deaths (61.3%) from 1 to 90 days postinsertion in this high risk group. The (1), and post liver transplant (1). Effective dialysis (lowering of blood urea nitrogen (BUN) or ammonia, correction of acidosis, decrease in fluid overload) w a s possible in all cases. Five of the 12 survivors remain on chronic dialysis awaiting renal transplantation. Peritoneal dialysis is effective in the newborn period in the management of metabolic disturbances as well as renal failure. Morbidity and mortality (61.3%) is related to the near-morbid condition of the baby at the time of insertion and the severity of the complex underlying diagnosis often associated with multiorgan failure. 9 1990 by W.B. Saunders Company. INDEX WORDS: Renal failure; peritoneal dialysis.
HE ABILITY of the peritoneum to act as a dialyzing membrane was established by Putnam in 1922, and further developed by Ganter later that decade. 1 Due to the high incidence of complications (mainly infectious), clinical applicability of peritoneal dialysis was limited until resurgence in the use of this technique following the innovations described by Popovich, Tenckhoff, and others in the 1960s and 1970s.2'3 Since that time, peritoneal dialysis has become an effective and increasingly popular alternative to hemodialysis in the management of patients with end-stage renal disease. Although the greatest benefit of this
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modality of treatment was initially observed in adult patients, peritoneal dialysis gradually became more practical for use in the pediatric setting as equipment and techniques were adapted for smaller patients. These refinements in peritoneal dialysis have resulted in a more effective treatment of renal failure and certain metabolic conditions for neonates and young infants--a group in whom the technical difficulties related to hemodialysis had greatly limited previous therapy. The incidence of acute renal failure in patients admitted to newborn intensive care units (ICU) is approximately 6% to 8%. The mortality rate in this population may approach 4 5 % . 4,5 Recent reports indicate that peritoneal dialysis is technically possible in very small infants, and may decrease the morbidity and mortality associated with renal failure in the newborn period. 4'6s These reports, however, mainly concern isolated cases or small series of patients. A large series detailing the experience with peritoneal dialysis in neonates is lacking. The purpose of this report is to describe a 7-year experience with acute peritoneal dialysis in 31 critically ill infants less than 60 days of age at a single, high-risk tertiary pediatric facility. MATERIALS AND METHODS
From the Sections of Pediatric Surgery and Nephrology, Department of Surgery, Indiana University Medical Center, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN. Presented at the 20th Annual Meeting of the American Pediatric Surgical Association, Baltimore, Maryland, May 28-31, 1989. Address reprint requests to Jay L. Grosfeld, MD, Surgeonin-Chief, J.W. Riley Hospital for Children, 702 Barnhill Dr, Indianapolis, IN 46223. 9 1990 by W.B. Saunders Company. 0022-3468/90/2501-0020503.00/0
From March 1982 to March 1989, 31 infants less than 60 days of age were managed with peritoneal dialysis at the James Whitcomb Riley Hospital for Children, Indiana University Medical Center. Twenty patients were boys and 11 were girls. Eight of 31 infants were premature (<38 weeks gestation). The average weight of the infants at the time of catheter insertion was 3.67 kg (range, 1.90 to 6.24 kg). The average age at catheter insertion was 23 days (range, 3 to 60 days). Indications for dialysis included congenital metabolic disorders (urea cycle defects with hyperammonemia or lactic acidosis) in 1t babies, acute tubular necrosis in 6, postcardiopulmonary bypass with renal failure in 5, renal cortical necrosis in 5, obstructive uropathy in 2, renal agenesis in 1, and renal dysplasia in 1 (Fig 1). Patients were evaluated for comprehensive history, age, sex, weight, technique of catheter placement, technique of dialysis, duration of dialysis, clinical course, complications, pertinent laboratory data, mortality, and autopsy findings. An estimate of the overall severity of illness was obtained by calculating the physiological stability index (PSI) score (modified by Georgieff et al) for each infant at the time of catheter placement. 9 This scoring system modified specifically for newborn infants takes into account 23 laboratory and vital sign variables in seven categories (cardiovascular, respiratory, neurological, hematologic, renal, gastroenterology, and metabolic). The PSI has a potential scoring range between zero (a physiologically stable child) and 84 (significant severe physiological instability associated with multiple organ failure and sepsis).
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Journal of Pediatric Surgery, Vo125,No 1 (January),1990: pp 110-116
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ME' TN
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RENAL DYSPLA{ 1
RENAL AGENESIS 1 )BSTRUCTION
2 POST
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CORTICAL NECROSIS
5 Fig 1. Diagnoses. The majority of patients referred for peritoneal dialysis had metabolic disorders or renal insufficiency.
Peritoneal dialysis catheters were placed under sterile conditions, either in the operating room (under general anesthesia) or in a pediatric ICU (using intravenous sedation, muscle relaxants, and local anesthetics as needed). The catheter type used was either a neonatal straight or pigtail single cuff catheter. In larger infants the pediatric size was placed. The catheters are customized (in length and cuff position) by the dialysis nurses before surgery. A useful guide for determining intraabdominal catheter length is the distance between the umbilicus and the symphysis pubis plus one centimeter. The cuff is fixed to the catheter at a distance of 3 to 5 cm from the most proximal sidehole. Formerly, straight catheters were routinely used; more recently, pigtail (coiled) catheters have become available, and may be preferable due to a reduced risk of catheter erosion into abdominal viscera. A minilaparotomy technique is used for insertion. The site of incision should be chosen distant from previous incisions and insertion sites. A 2 to 3 cm incision is made over the midportion of the rectus muscle and carried down to the anterior rectus sheath. A muscle splitting technique is used to gain access to the peritoneum and as the posterior sheath and peritoneum are tented up, a stab wound celiotomy is created. A 3-0 polypropylene pursestring suture is then placed around the small peritoneal opening. If the omentum presents through the small wound, a partial omentectomy may be performed. The catheter is threaded through the opening in the peritoneum and directed into the pelvis (Fig 2). Intraoperatively, catheter malposition and kinking can be detected using fluoroscopy. The position of catheters placed at bedside is checked with a portable abdominal x-ray. The dacron cuff on the catheter is positioned at the level of the peritoneum, and the pursestring is tied, securing the catheter. At this point, catheter function is checked by infusing approximately 10 cc/kg of dialysate to ensure free inflow and outflow of fluid, as well as to detect a possible leak at the insertion site. If leakage occurs, a second pursestring is placed in the posterior rectus sheath and tied around the catheter. Emphasis is placed on a watertight seal, so that dialysis may be started immediately after the procedure. A superolateral subcutaneous tunnel is created so the exit site is located outside of the diaper area. The aperture at the skin site fits the catheter snugly. The wound is closed with a running subcuticular suture (4-0 vicryl) or skin closure (4-0 prolene). A temporary fixation suture (3-0 silk) anchors the catheter at the exit site, and may be removed in 1 week. The catheters are available for dialysis use immediately after insertion. The standard dialysate solution is Dianeal PD-2 (BaxterTravenol Lab, Deerfield, IL), with dextrose concentrations of 1.5%, 2.5%, and 4.25%. A special bicarbonate containing (instead of lactate) dialysate solution is used in cases of lactic acidosis. Exchange volumes used in the immediate postoperative period are only 20 cc/kg to decrease the risk of peritoneal leak. Volume can be increased to 25 to 40 cc/kg as respiratory status permits. Peritoneal exchanges are performed hourly, with a 10-minute infusion time,
A
Fig 2. (A) The catheter cuff is secured at the peritoneal level and the tunnel directed away from the diaper area. (B) The catheter tip is placed into the pelvis and effective, immediate dialysis can be achieved even in infants with ascites.
35-minute dwell time, and a 15-minute drainage time. The fluid is prewarmed to body temperature. The dialysate is infused from a single large volume bag, and the effluent drains to a separate drainage bag with the aid of a Y-connector in the tubing. RESULTS
E f f e c t i v e d i a l y s i s ( d e f i n e d as r e s o l u t i o n o f h y p e r k a l e m i a , u r e m i a , h y p e r a m m o n e m i a , acidosis, a n d / o r fluid o v e r l o a d in t h e p r e s e n c e o f o l i g u r i a or a n u r i a ) was possible in all p a t i e n t s . Five patients retained their peritoneal catheters b e y o n d t h e a c u t e d i a l y s i s period, a n d e v e n t u a l l y c o n v e r t e d to o u t p a t i e n t c h r o n i c a m b u l a t o r y p e r i t o n e a l dialysis ( C A P D ) w h i l e a w a i t i n g r e n a l t r a n s p l a n t a t i o n . In t h e r e m a i n i n g p a t i e n t s , t h e m e a n d u r a t i o n o f c a t h e ter use was 16 d a y s ( r a n g e , 1 to 73 d a y s ) . I n d i c a t i o n s for c e s s a t i o n o f c a t h e t e r use i n c l u d e d d e a t h in 19 p a t i e n t s , r e s o l v e d a c u t e r e n a l f a i l u r e in 3, c o n t r o l l a b l e h y p e r a m m o n e m i a in 4, a n d f u n g a l p e r i t o n i t i s in 2. N i n e t e e n o f t h e 31 p a t i e n t s ( 6 1 . 3 % ) d i e d at i n t e r v a l s r a n g i n g f r o m 1 to 90 d a y s p o s t i n s e r t i o n . D e a t h s w e r e
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related to cardiac failure in five babies, multisystem organ failure in five, brain death in four, sepsis in three, pulmonary hypoplasia in one, and post liver transplant in one. There was no mortality directly related to catheter insertion or use. The 31 patients had a mean PSI score of 18.4 _+ 8.3. The PSI score for the 12 infants that survived was 14.0 _+6.0 and was 21.9 ___ 7.7 for the 18 early deaths (P < .05 compared.with survivors using a Student's t test). Peritonitis, defined as development of cloudy peritoneal fluid with more than 100 white blood cells per milliliter in the dialysate, occurred in four patients. Standard therapy for catheter-associated peritonitis included three quick dialysate exchanges without dwell time, with resumption of dialysis using bags containing cephalexin (250 mg/L), gentamicin (8 mg/L), and heparin (500 U/L). Culture and sensitivity data on the dialysate were used to modify antibiotic therapy. Two patients had bacterial peritonitis (one with a pure Klebsiella pneumoniae culture, the second with Escherichia coli, Staphylococcus epiderrnidis, and Bacteroidesfragilis) that resolved with intraperitoneal antibiotics, and the catheter remained functional. Two patients with fungal peritonitis (one with Candida albicans the other with Candida parapsilosis) responded to removal of the peritoneal catheter and a 3-week course of intravenous amphotericin B. Exit site infections occurred in three patients. The exit site and proximal tunnel were opened, dressing changes initiated, and broad spectrum antibiotics administered. Cultures in two patients grew Staphylococcus aureus and E coli; the other was sterile. Two catheters required removal to clear the exit site of infection, while one remained in place and the infection cleared. Each patient was later able to resume peritoneal dialysis. Four patients developed a leak from the exit site (3) or incision (1), and the exchange volume was therefore decreased. Two catheters subsequently required revision for continued dialysate leakage. Two children required revisions for catheter obstruction. One catheter became obstructed 3 days after placement, was replaced, and functioned well for 2 weeks until it was no longer needed. The cause of the obstruction was not apparent at the time of revision. The second child developed difficulties in draining effluent shortly after placement due to a constricting suture at the fascial level. Four patients developed abdominal wall hernias after initiation of peritoneal dialysis. All presented clinically with swelling at the inguinal canal site (3) or umbilicus (1). The inguinal hernias were simply observed during the acute illness, with plans for elective future repair. The large umbilical hernia (>3.0
MATTHEWS ET AL
cm) was repaired at age 6 months, recurred, and was again repaired at age 8 months. Dialysis was discontinued for approximately 2 days after the hernia repair (to decrease the chance of leak and hernia recurrence) and then reinstituted. There were no complications referable to hernias that developed while on peritoneal dialysis. Two patients ultimately developed bowel perforations. One was a rectal perforation from erosion of the tip of a straight peritoneal dialysis catheter, occurring 10 days postinsertion. This complication was detected when the anuric infant suddenly was found to have a wet diaper. Radiographs showed the catheter tip in the rectum (Fig 3). The child was afebrile and clinically asymptomatic. The perforation, which was located at or just below the peritoneal reflection, was managed by catheter removal, broad-spectrum antibiotics, and bowel rest. A new pigtail peritoneal catheter was placed 12 days later (Fig 4). The second bowel perforation (ileum) was noted at autopsy in a patient with a severe metabolic encephalopathy associated with a urea cycle defect. This was
Fig 3. Injection of contrast material through the Tenckhoff catheter shows a rectal perforation below the peritoneal reflection in a premature infant.
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Fig 4. A barium enema obtained 10 days following r e m o v a l of t h e T e n c k h o f f c a t h e t e r documents a healed rectal perforation (A), a curled pigtail catheter w a s then successfully placed (B).
probably caused by necrotizing enterocolitis and not catheter placement. DISCUSSION
There is a 6% to 8% incidence of renal failure in admissions to neonatal ICUs with a mortality rate of 45%. Renal failure accounts for 7% of all deaths in newborn 1CUs. 4'5 Neonates usually develop acute renal failure following perinatal hypoxia and shock. Congenital malformations, obstructive uropathy, and renal vein thrombosis are other causes of acute renal failure in neonates which rarely occur in other age groups, l~ Evidence suggests that aggressive treatment of acute renal failure in neonates may decrease morbidity and mortality) 2"~6 In the last two decades, peritoneal dialysis has come to the forefront in the management of end-stage renal disease in children, and more recently, has been successfully adapted for neonates with renal failure. In addition, peritoneal dialysis can be effective in treating certain neonatal metabolic disturbances, including urea cycle defects with hyperammonemia ~7"~8and congenital lactic acidosis) Peritoneal dialysis is preferred over hemodialysis in the newborn infant because of the technical difficulties experienced with vascular access
in small children. This study documents the effectiveness of acute peritoneal dialysis in neonates and infants less than 60 days of age. The most common indication for peritoneal dialysis in this series was oliguric acute renal failure (19 out of 31 patients, 61.3%). Eleven of 31 babies (35.5%) required dialysis for treatment of a metabolic disorder; however, 7 of these 11 were also oliguric or anuric. Effective dialysis (as measured by improvement of hyperkalemia, uremia, hyperammonemia, acidosis, or fluid overload in the face of oliguria) was achieved in all patients. In previously published series concerning chronic peritoneal dialysis, the most common complication was related to infection (catheter induced peritonitis and exit site infection)? 3 In pediatric patients treated with chronic ambulatory peritoneal dialysis, the incidence of catheter related peritonitis is one episode per 10 patient-months. ~ It is not surprising therefore, that the most frequent complication in this series involved infection, with 4 cases of catheter related peritonitis in 23 total patient-months or 1 episode of peritonitis for every 6 patient-months in neonates. The infectious complications of peritoneal dialysis in neonates are managed no differently than in adults. In
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suspected catheter peritonitis, the peritoneal dialysate is cultured, and empiric antibiotics active against gram-positive and gram-negative organisms are administered (intraperitoneal cephalexin and gentamicin in this series). Any potentially infected catheter exit site or tunnel is opened ("unroofed") for drainage. Several exchanges are performed without dwell time to simply irrigate the peritoneal cavity. Heparin is added to the dialysate to prevent fibrin clotting in the peritoneal catheter. Indications for catheter removal include: failure to respond to appropriate antibiotic therapy within 3 to 5 days, and Pseudomonas or fungal peritonitis. Catheter removal is required in instances of fungal peritonitis due to a poor response to antifungal medication alone, and the fact that prolonged inflammation may render the peritoneal membrane ineffective for future dialysis. Iz19 Following catheter removal, systemic antifungal therapy (amphotericin B) was continued for 3 weeks in this series. Despite immediate postoperative institution of peritoneal dialysis, dialysate leakage developed in only four babies. In two, the leak resolved after decreasing the exchange volume, while two catheters required revision. Technical considerations that may be of importance in decreasing the incidence of dialysate leakage include (1) intraoperative demonstration of a watertight peritoneal seal around catheter, (2) close approximation of fascial and subcutaneous layers above the peritoneum, and (3) initiating peritoneal dialysis with small volume (approximately 20 cc/kg) exchanges before initiating to larger volumes (up to 40 cc/kg) as wound healing progresses and no leak is evident. Several investigators have observed that peritoneal catheter obstruction due to omental adherence occurs frequently enough to recommend routine omentectomy at the time of the initial catheter placement. 2w2z Reoperation for obstruction 3 days after placement was required in two of our cases. The cause of the catheter obstruction, however, was unrelated to omental plugging. The low incidence of omental plugging may simply be a result of a relatively short duration of dialysis (mean of 16 days in those not going on to CAPD) and/or to the relatively small, undeveloped omentum noted in most newborn infants. Routine omentectomy is therefore not indicated when inserting acute peritoneal dialysis catheters in the newborn population. However, partial omentectomy is reasonable when the omentum presents itself through the small peritoneal opening at laparotomy. In the present study, mortality was related to the near-morbid condition of the infants at the time of catheter insertion, and to the severity of the complex underlying illness as reflected by the newborn PSI. The modified PSI for survivors was 14.0 _+ 6.0 versus
MATTHEWS ET AL
nonsurvivors 21.9 _+ 7.80. The difference was statistically significant (P < .05). The mean PSI for the entire group was 18.4 _+ 8.3. Mortality may also be related to the indication for the dialysis. The mortality was highest (100%) in infants with congenital heart disease that developed renal failure after cardiopulmonary bypass procedures. Other investigators have noted a similar high mortality in the approximately 5% of children who develop acute renal failure after open heart procedures. 6"t4'23An aggressive approach, instituting peritoneal dialysis shortly after the onset of anuria, has been advocated in an effort to decrease mortality in this subset of patients. Interestingly, the other group with 100% mortality was those patients with congenital metabolic disorders who were not oliguric. Although mortality was high in all subgroups, the mortality rate in babies without congenital heart disease was in the 40% to 60% range. Infants that survive the acute illness requiring peritoneal dialysis can generally progress to outpatient CAPD and possible renal transplantation. Of the 12 patients who survived their acute illness in this study, 7 patients did not require further dialysis therapy, while 5 continue on outpatient CAPD. The development of abdominal wall (inguinal, umbilical, incisional) hernias is not uncommon in patients with increased intraabdominal pressure or fluid due to ascites, ventriculoperitoneal shunts, and peritoneal dialysate.24'2sThe reported incidence of hernias in CAPD patients ranges from 2.5% to 67%, with an average between 10% and 25%.26.33The incidence of hernias in newborns is 0.8% to 4.4% and that of a patent processus vaginalis is 30%.34 Four of 31 patients (12.9%) developed clinical hernias. This relatively low incidence may be related to the short duration of dialysis in those not requiring CAPD and the high early mortality rate during this period. Indeed, all 4 patients who developed hernias were in the group of 12 survivors, making the true incidence of hernias among survivors 33%. There were no complications attributable to the hernias. All hernias were repaired electively, after the patient had survived the acute illness. As a rule, hernias noted preoperatively in stable patients can be repaired at the time of catheter placement. In the critically ill infant, or in those in whom a hernia develops after initiation of peritoneal dialysis, early herniorrhaphy is recommended after the patient's lifethreatening condition has improved and before hospital discharge. In the premature infant the length of the straight dialysis catheters may increase the risk of bowel perforation, particularly the rectum. The pigtail dialysis catheter is less likely to erode into bowel and is now being used more frequently in small babies. The usual
PERITONEAL DIALYSIS IN INFANCY
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m a n a g e m e n t of an i n t e s t i n a l p e r f o r a t i o n r e q u i r e s l a p a r o t o m y a n d r e p a i r of t h e b o w e l injury. H o w e v e r , d a t a f r o m i n s t a n c e s of i n t e s t i n a l p e r f o r a t i o n a s s o c i a t e d w i t h ventriculoperitoneal shunt catheters suggest that the c a t h e t e r c a n be r e m o v e d a n d t h e i n f a n t s a f e l y t r e a t e d w i t h antibiotics, g a s t r i c suction, a n d b o w e l r e s t ) 5 T h i s t h e r a p y was successful for the single p a t i e n t w i t h a r e c t a l p e r f o r a t i o n in this series and c o u l d be u s e d s a f e l y in s e l e c t e d cases.
In s u m m a r y , p e r i t o n e a l dialysis is an e f f e c t i v e t h e r a p y for seriously ill n e w b o r n i n f a n t s w i t h l i f e - t h r e a t e n ing d i s e a s e s t a t e s a s s o c i a t e d w i t h a c u t e r e n a l f a i l u r e or certain inborn errors of metabolism. Mortality remains h i g h d u e to t h e s e v e r i t y o f t h e u n d e r l y i n g d i s e a s e a n d c o - m o r b i d c o n d i t i o n s (as d o c u m e n t e d b y t h e i r P S I ) . H o w e v e r , g r a t i f y i n g s u r v i v a l c a n be a c h i e v e d in 38.7% o f cases t h a t s u r e l y o t h e r w i s e w o u l d h a v e s u c c u m b e d .
REFERENCES
1. Salusky IB, Lucull0 L, Nelson P, et al: Continuous ambulatory peritoneal dialysis in children. Pediatr Clin North Am 29:10051012, 1982 2. Fine RN: Peritoneal dialysis update. J Pediatr 100:1-7, 1982 3. Balfe JW, Stefanidis C J, Steele BT, et al: Continuous ambulatory peritoneal dialysis: Clinical aspects, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 135-148 4. Kanarek KS, Root E, Sidebottom R, et al: Successful peritoneal dialysis in an infant weighing less than 800 grams. Clin Pediatr 21:166-169, 1982 5. Jones AS, James E, Bland H, et al: Renal failure in the newborn. Clin Pediatr 18:286-291, 1979 6. Baxter R, Rigby ML, Jones ODH, et al: Acute renal failure following cardiopulmonary bypass in children: Results of treatment. Int J Cardiol 7:235-246, 1985 7. Steele BT, Vigneux A, Blatz S, et al: Acute peritoneal dialysis in infants weighing < 1500 g. J Pediatr 110:126-129, 1987 8. Nash MA, Rusco JC: Neonatal lactic acidosis and renal failure: The role of peritoneal dialysis. J Pediatr 91:101-105, 1977 9. Georgieff MK, Mills MM, Paurvi B: Validation of two scoring systems which assess the degree of physiologic instability in critically ill newborn infants. Crit Care Med 17:17-21, 1989 10. Cruder SF, Jones DP, Green RS: Acute renal failure in neonates: Incidence, etiology and outcome. Pediatr Nephrol 1:314320, 1987 11. Broyer M: Incidence and etiology of ESRD in children, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 9-16 12. Lattouf OM, Ricketts RR: Peritoneal dialysis in infants and children. Am Surg 52:66-69, 1986 13. Offner G, Brodehl J, Galaske R, et al: Acute renal failure in children: Prognostic features after treatment with acute dialysis. Eur J Pediatr 144:482-486, 1986 14. Abbad FC, VanAmstel SL: Continuous ambulatory peritoneal dialysis in small children with acute renal failure. Proc Eur Dial Transplant Assoc 19:607-613, 1983 15. Book K, Ohqvist G, Bjork VO, et al: Peritoneal dialysis in infants and children after open heart surgery. Scand J Thorac Cardiovasc Surg 16:229-233, 1982 16. Alexander SR: Treatment of infants with ESRD, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 17-29 17. Girgis N, McGravey V, Shah BL, et al: Lethal ornithine transcarbamylase deficiency in a female neonate. J Inherited Metab Dis 10:274-275, 1987 18. Donn SM, Swartz RD, Thoene JG: Comparison of exchange transfusion, peritoneal dialysis, and hemodialysis for the treatment of hyperammonemia in an anuric newborn infant. J Pediatr 95:6770, 1979 19. Oh SH, Conley SB, Rose GM, et al: Fungal peritonitis in
children undergoing peritoneal dialysis. Pediatr Infect Dis 4:62-66, 1985 20. Orkin BA, Fonkalsrud EW, Salusky IB, et al: Continuous ambulatory peritoneal dialysis catheters in children. Arch Surg 118:1398-1402, 1983 21. Finan P J, Guillou P J: Experience with surgical implantation of catheters for continuous ambulatory peritoneal dialysis. Ann R Coil Surg Engl 67:190-192, 1985 22. Sherman N J, Atkinson JB: Vascular and peritoneal access: Technical considerations, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 85-94 23. Rigden SP, Barratt TM, Dillon M J, et al: Acute renal failure complicating cardiopulmonary bypass surgery. Arch Dis Child 57:425-430, 1982 24. Grosfeld JL, Cooney DR: Inguinal hernia after ventriculoperitoneal shunt in infants and children. J Pediatr Surg 9:311-315, 1974 25. Engeset J, Younson GG: Ambulatory peritoneal dialysis and hernia complications. Surg Clin North Am 64:385-392, 1984 26. Nelson H, Lindner M, Schuman ES, et al: Abdominal wall hernias as a complication of peritoneal dialysis. Surg Gynecol Obstet 157:541-544, 1983 27. Von Lilien T, Salusky IB, Yap HK, et al: Hernias: A frequent complication in children treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 5:256-260, 1987 28. Stone MM, Fonkalsrud EW, Salusky IB, et al: Surgical management of peritoneal dialysis catheters in children: Five-year experience with 1,800 patient-month follow-up. J Pediatr Surg 21:1177-1181, 1986 29. Schleifer CR, Morfesis FA, Cupit M: Management of hernias and Tenckhoff catheter complications in CAPD. Perit Dial Bull 4:146-150, 1984 30. Zaontz MR, Cohn RA, Moel DI: Continuous ambulatory peritoneal dialysis: The pediatric experience. J Urol 138:353-356, 1987 31. Francis DMA, Donnelly PK, Veitch PS, et al: Surgical aspects of continuous ambulatory peritoneal dialysis--3 years experience. Br J Surg 71:225-229, 1984 32. Tank ES, Hatch DA: Hernias complicating chronic ambulatory peritoneal dialysis in children. J Pediatr Surg 21:41-42, 1986 33. Alexander SR, Tank ES: Surgical aspects of continuous ambulatory peritoneal dialysis in infants, children and adolescents. J Urol 127:501-504, 1982 34. Rowe MI, Lloyd DA: Inguinal hernia, in Welch K J, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book Medical, 1986, pp 779-791 35. Grosfeld JL, Cooney DR, Smith J, et al: Intra-abdominal complications following ventriculoperitoneal shunts. Pediatrics 54:791-796, 1974
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Discussion D. Tapper (Seattle, W,4): I believe that this is the first report that really describes the indications, techniques, and complications of peritoneal dialysis in the newborn; and it is particularly significant for those of us in pediatric surgery as we are being asked to more frequently see these children who are increasingly ill and who survive their illnesses and end up with renal failure. We need to develop a management scheme for these infants, and we need to understand the consequences of placing these catheters. When read this report you have a better understanding of the risks involved as documented by the Indiana group. The
presentation and the report, which I had the opportunity to read, raised several questions which I would like to pose to you. With regard to technique, you seem to place the dacron cuff within the peritoneal cavity. Having been instructed by Hickman and Tenckhoff, I generally place it under the rectus muscle in the smaller children, having been told that it serves both to anchor the catheter and is a barrier for infection. In addition, the pigtail catheter which is a Quinton advancement also makes a showerhead which is large but stays up against the abdominal wall and decreases the chance of nonfunction.
HE ABILITY of the peritoneum to act as a dialyzing membrane was established by Putnam in 1922, and further developed by Ganter later that decade. 1 Due to the high incidence of complications (mainly infectious), clinical applicability of peritoneal dialysis was limited until resurgence in the use of this technique following the innovations described by Popovich, Tenckhoff, and others in the 1960s and 1970s.2'3 Since that time, peritoneal dialysis has become an effective and increasingly popular alternative to hemodialysis in the management of patients with end-stage renal disease. Although the greatest benefit of this
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modality of treatment was initially observed in adult patients, peritoneal dialysis gradually became more practical for use in the pediatric setting as equipment and techniques were adapted for smaller patients. These refinements in peritoneal dialysis have resulted in a more effective treatment of renal failure and certain metabolic conditions for neonates and young infants--a group in whom the technical difficulties related to hemodialysis had greatly limited previous therapy. The incidence of acute renal failure in patients admitted to newborn intensive care units (ICU) is approximately 6% to 8%. The mortality rate in this population may approach 4 5 % . 4,5 Recent reports indicate that peritoneal dialysis is technically possible in very small infants, and may decrease the morbidity and mortality associated with renal failure in the newborn period. 4'6s These reports, however, mainly concern isolated cases or small series of patients. A large series detailing the experience with peritoneal dialysis in neonates is lacking. The purpose of this report is to describe a 7-year experience with acute peritoneal dialysis in 31 critically ill infants less than 60 days of age at a single, high-risk tertiary pediatric facility. MATERIALS AND METHODS
From the Sections of Pediatric Surgery and Nephrology, Department of Surgery, Indiana University Medical Center, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN. Presented at the 20th Annual Meeting of the American Pediatric Surgical Association, Baltimore, Maryland, May 28-31, 1989. Address reprint requests to Jay L. Grosfeld, MD, Surgeonin-Chief, J.W. Riley Hospital for Children, 702 Barnhill Dr, Indianapolis, IN 46223. 9 1990 by W.B. Saunders Company. 0022-3468/90/2501-0020503.00/0
From March 1982 to March 1989, 31 infants less than 60 days of age were managed with peritoneal dialysis at the James Whitcomb Riley Hospital for Children, Indiana University Medical Center. Twenty patients were boys and 11 were girls. Eight of 31 infants were premature (<38 weeks gestation). The average weight of the infants at the time of catheter insertion was 3.67 kg (range, 1.90 to 6.24 kg). The average age at catheter insertion was 23 days (range, 3 to 60 days). Indications for dialysis included congenital metabolic disorders (urea cycle defects with hyperammonemia or lactic acidosis) in 1t babies, acute tubular necrosis in 6, postcardiopulmonary bypass with renal failure in 5, renal cortical necrosis in 5, obstructive uropathy in 2, renal agenesis in 1, and renal dysplasia in 1 (Fig 1). Patients were evaluated for comprehensive history, age, sex, weight, technique of catheter placement, technique of dialysis, duration of dialysis, clinical course, complications, pertinent laboratory data, mortality, and autopsy findings. An estimate of the overall severity of illness was obtained by calculating the physiological stability index (PSI) score (modified by Georgieff et al) for each infant at the time of catheter placement. 9 This scoring system modified specifically for newborn infants takes into account 23 laboratory and vital sign variables in seven categories (cardiovascular, respiratory, neurological, hematologic, renal, gastroenterology, and metabolic). The PSI has a potential scoring range between zero (a physiologically stable child) and 84 (significant severe physiological instability associated with multiple organ failure and sepsis).
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Journal of Pediatric Surgery, Vo125,No 1 (January),1990: pp 110-116
PERITONEAL DIALYSIS IN INFANCY
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ME' TN
6
RENAL DYSPLA{ 1
RENAL AGENESIS 1 )BSTRUCTION
2 POST
5
CORTICAL NECROSIS
5 Fig 1. Diagnoses. The majority of patients referred for peritoneal dialysis had metabolic disorders or renal insufficiency.
Peritoneal dialysis catheters were placed under sterile conditions, either in the operating room (under general anesthesia) or in a pediatric ICU (using intravenous sedation, muscle relaxants, and local anesthetics as needed). The catheter type used was either a neonatal straight or pigtail single cuff catheter. In larger infants the pediatric size was placed. The catheters are customized (in length and cuff position) by the dialysis nurses before surgery. A useful guide for determining intraabdominal catheter length is the distance between the umbilicus and the symphysis pubis plus one centimeter. The cuff is fixed to the catheter at a distance of 3 to 5 cm from the most proximal sidehole. Formerly, straight catheters were routinely used; more recently, pigtail (coiled) catheters have become available, and may be preferable due to a reduced risk of catheter erosion into abdominal viscera. A minilaparotomy technique is used for insertion. The site of incision should be chosen distant from previous incisions and insertion sites. A 2 to 3 cm incision is made over the midportion of the rectus muscle and carried down to the anterior rectus sheath. A muscle splitting technique is used to gain access to the peritoneum and as the posterior sheath and peritoneum are tented up, a stab wound celiotomy is created. A 3-0 polypropylene pursestring suture is then placed around the small peritoneal opening. If the omentum presents through the small wound, a partial omentectomy may be performed. The catheter is threaded through the opening in the peritoneum and directed into the pelvis (Fig 2). Intraoperatively, catheter malposition and kinking can be detected using fluoroscopy. The position of catheters placed at bedside is checked with a portable abdominal x-ray. The dacron cuff on the catheter is positioned at the level of the peritoneum, and the pursestring is tied, securing the catheter. At this point, catheter function is checked by infusing approximately 10 cc/kg of dialysate to ensure free inflow and outflow of fluid, as well as to detect a possible leak at the insertion site. If leakage occurs, a second pursestring is placed in the posterior rectus sheath and tied around the catheter. Emphasis is placed on a watertight seal, so that dialysis may be started immediately after the procedure. A superolateral subcutaneous tunnel is created so the exit site is located outside of the diaper area. The aperture at the skin site fits the catheter snugly. The wound is closed with a running subcuticular suture (4-0 vicryl) or skin closure (4-0 prolene). A temporary fixation suture (3-0 silk) anchors the catheter at the exit site, and may be removed in 1 week. The catheters are available for dialysis use immediately after insertion. The standard dialysate solution is Dianeal PD-2 (BaxterTravenol Lab, Deerfield, IL), with dextrose concentrations of 1.5%, 2.5%, and 4.25%. A special bicarbonate containing (instead of lactate) dialysate solution is used in cases of lactic acidosis. Exchange volumes used in the immediate postoperative period are only 20 cc/kg to decrease the risk of peritoneal leak. Volume can be increased to 25 to 40 cc/kg as respiratory status permits. Peritoneal exchanges are performed hourly, with a 10-minute infusion time,
A
Fig 2. (A) The catheter cuff is secured at the peritoneal level and the tunnel directed away from the diaper area. (B) The catheter tip is placed into the pelvis and effective, immediate dialysis can be achieved even in infants with ascites.
35-minute dwell time, and a 15-minute drainage time. The fluid is prewarmed to body temperature. The dialysate is infused from a single large volume bag, and the effluent drains to a separate drainage bag with the aid of a Y-connector in the tubing. RESULTS
E f f e c t i v e d i a l y s i s ( d e f i n e d as r e s o l u t i o n o f h y p e r k a l e m i a , u r e m i a , h y p e r a m m o n e m i a , acidosis, a n d / o r fluid o v e r l o a d in t h e p r e s e n c e o f o l i g u r i a or a n u r i a ) was possible in all p a t i e n t s . Five patients retained their peritoneal catheters b e y o n d t h e a c u t e d i a l y s i s period, a n d e v e n t u a l l y c o n v e r t e d to o u t p a t i e n t c h r o n i c a m b u l a t o r y p e r i t o n e a l dialysis ( C A P D ) w h i l e a w a i t i n g r e n a l t r a n s p l a n t a t i o n . In t h e r e m a i n i n g p a t i e n t s , t h e m e a n d u r a t i o n o f c a t h e ter use was 16 d a y s ( r a n g e , 1 to 73 d a y s ) . I n d i c a t i o n s for c e s s a t i o n o f c a t h e t e r use i n c l u d e d d e a t h in 19 p a t i e n t s , r e s o l v e d a c u t e r e n a l f a i l u r e in 3, c o n t r o l l a b l e h y p e r a m m o n e m i a in 4, a n d f u n g a l p e r i t o n i t i s in 2. N i n e t e e n o f t h e 31 p a t i e n t s ( 6 1 . 3 % ) d i e d at i n t e r v a l s r a n g i n g f r o m 1 to 90 d a y s p o s t i n s e r t i o n . D e a t h s w e r e
1 12
related to cardiac failure in five babies, multisystem organ failure in five, brain death in four, sepsis in three, pulmonary hypoplasia in one, and post liver transplant in one. There was no mortality directly related to catheter insertion or use. The 31 patients had a mean PSI score of 18.4 _+ 8.3. The PSI score for the 12 infants that survived was 14.0 _+6.0 and was 21.9 ___ 7.7 for the 18 early deaths (P < .05 compared.with survivors using a Student's t test). Peritonitis, defined as development of cloudy peritoneal fluid with more than 100 white blood cells per milliliter in the dialysate, occurred in four patients. Standard therapy for catheter-associated peritonitis included three quick dialysate exchanges without dwell time, with resumption of dialysis using bags containing cephalexin (250 mg/L), gentamicin (8 mg/L), and heparin (500 U/L). Culture and sensitivity data on the dialysate were used to modify antibiotic therapy. Two patients had bacterial peritonitis (one with a pure Klebsiella pneumoniae culture, the second with Escherichia coli, Staphylococcus epiderrnidis, and Bacteroidesfragilis) that resolved with intraperitoneal antibiotics, and the catheter remained functional. Two patients with fungal peritonitis (one with Candida albicans the other with Candida parapsilosis) responded to removal of the peritoneal catheter and a 3-week course of intravenous amphotericin B. Exit site infections occurred in three patients. The exit site and proximal tunnel were opened, dressing changes initiated, and broad spectrum antibiotics administered. Cultures in two patients grew Staphylococcus aureus and E coli; the other was sterile. Two catheters required removal to clear the exit site of infection, while one remained in place and the infection cleared. Each patient was later able to resume peritoneal dialysis. Four patients developed a leak from the exit site (3) or incision (1), and the exchange volume was therefore decreased. Two catheters subsequently required revision for continued dialysate leakage. Two children required revisions for catheter obstruction. One catheter became obstructed 3 days after placement, was replaced, and functioned well for 2 weeks until it was no longer needed. The cause of the obstruction was not apparent at the time of revision. The second child developed difficulties in draining effluent shortly after placement due to a constricting suture at the fascial level. Four patients developed abdominal wall hernias after initiation of peritoneal dialysis. All presented clinically with swelling at the inguinal canal site (3) or umbilicus (1). The inguinal hernias were simply observed during the acute illness, with plans for elective future repair. The large umbilical hernia (>3.0
MATTHEWS ET AL
cm) was repaired at age 6 months, recurred, and was again repaired at age 8 months. Dialysis was discontinued for approximately 2 days after the hernia repair (to decrease the chance of leak and hernia recurrence) and then reinstituted. There were no complications referable to hernias that developed while on peritoneal dialysis. Two patients ultimately developed bowel perforations. One was a rectal perforation from erosion of the tip of a straight peritoneal dialysis catheter, occurring 10 days postinsertion. This complication was detected when the anuric infant suddenly was found to have a wet diaper. Radiographs showed the catheter tip in the rectum (Fig 3). The child was afebrile and clinically asymptomatic. The perforation, which was located at or just below the peritoneal reflection, was managed by catheter removal, broad-spectrum antibiotics, and bowel rest. A new pigtail peritoneal catheter was placed 12 days later (Fig 4). The second bowel perforation (ileum) was noted at autopsy in a patient with a severe metabolic encephalopathy associated with a urea cycle defect. This was
Fig 3. Injection of contrast material through the Tenckhoff catheter shows a rectal perforation below the peritoneal reflection in a premature infant.
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Fig 4. A barium enema obtained 10 days following r e m o v a l of t h e T e n c k h o f f c a t h e t e r documents a healed rectal perforation (A), a curled pigtail catheter w a s then successfully placed (B).
probably caused by necrotizing enterocolitis and not catheter placement. DISCUSSION
There is a 6% to 8% incidence of renal failure in admissions to neonatal ICUs with a mortality rate of 45%. Renal failure accounts for 7% of all deaths in newborn 1CUs. 4'5 Neonates usually develop acute renal failure following perinatal hypoxia and shock. Congenital malformations, obstructive uropathy, and renal vein thrombosis are other causes of acute renal failure in neonates which rarely occur in other age groups, l~ Evidence suggests that aggressive treatment of acute renal failure in neonates may decrease morbidity and mortality) 2"~6 In the last two decades, peritoneal dialysis has come to the forefront in the management of end-stage renal disease in children, and more recently, has been successfully adapted for neonates with renal failure. In addition, peritoneal dialysis can be effective in treating certain neonatal metabolic disturbances, including urea cycle defects with hyperammonemia ~7"~8and congenital lactic acidosis) Peritoneal dialysis is preferred over hemodialysis in the newborn infant because of the technical difficulties experienced with vascular access
in small children. This study documents the effectiveness of acute peritoneal dialysis in neonates and infants less than 60 days of age. The most common indication for peritoneal dialysis in this series was oliguric acute renal failure (19 out of 31 patients, 61.3%). Eleven of 31 babies (35.5%) required dialysis for treatment of a metabolic disorder; however, 7 of these 11 were also oliguric or anuric. Effective dialysis (as measured by improvement of hyperkalemia, uremia, hyperammonemia, acidosis, or fluid overload in the face of oliguria) was achieved in all patients. In previously published series concerning chronic peritoneal dialysis, the most common complication was related to infection (catheter induced peritonitis and exit site infection)? 3 In pediatric patients treated with chronic ambulatory peritoneal dialysis, the incidence of catheter related peritonitis is one episode per 10 patient-months. ~ It is not surprising therefore, that the most frequent complication in this series involved infection, with 4 cases of catheter related peritonitis in 23 total patient-months or 1 episode of peritonitis for every 6 patient-months in neonates. The infectious complications of peritoneal dialysis in neonates are managed no differently than in adults. In
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suspected catheter peritonitis, the peritoneal dialysate is cultured, and empiric antibiotics active against gram-positive and gram-negative organisms are administered (intraperitoneal cephalexin and gentamicin in this series). Any potentially infected catheter exit site or tunnel is opened ("unroofed") for drainage. Several exchanges are performed without dwell time to simply irrigate the peritoneal cavity. Heparin is added to the dialysate to prevent fibrin clotting in the peritoneal catheter. Indications for catheter removal include: failure to respond to appropriate antibiotic therapy within 3 to 5 days, and Pseudomonas or fungal peritonitis. Catheter removal is required in instances of fungal peritonitis due to a poor response to antifungal medication alone, and the fact that prolonged inflammation may render the peritoneal membrane ineffective for future dialysis. Iz19 Following catheter removal, systemic antifungal therapy (amphotericin B) was continued for 3 weeks in this series. Despite immediate postoperative institution of peritoneal dialysis, dialysate leakage developed in only four babies. In two, the leak resolved after decreasing the exchange volume, while two catheters required revision. Technical considerations that may be of importance in decreasing the incidence of dialysate leakage include (1) intraoperative demonstration of a watertight peritoneal seal around catheter, (2) close approximation of fascial and subcutaneous layers above the peritoneum, and (3) initiating peritoneal dialysis with small volume (approximately 20 cc/kg) exchanges before initiating to larger volumes (up to 40 cc/kg) as wound healing progresses and no leak is evident. Several investigators have observed that peritoneal catheter obstruction due to omental adherence occurs frequently enough to recommend routine omentectomy at the time of the initial catheter placement. 2w2z Reoperation for obstruction 3 days after placement was required in two of our cases. The cause of the catheter obstruction, however, was unrelated to omental plugging. The low incidence of omental plugging may simply be a result of a relatively short duration of dialysis (mean of 16 days in those not going on to CAPD) and/or to the relatively small, undeveloped omentum noted in most newborn infants. Routine omentectomy is therefore not indicated when inserting acute peritoneal dialysis catheters in the newborn population. However, partial omentectomy is reasonable when the omentum presents itself through the small peritoneal opening at laparotomy. In the present study, mortality was related to the near-morbid condition of the infants at the time of catheter insertion, and to the severity of the complex underlying illness as reflected by the newborn PSI. The modified PSI for survivors was 14.0 _+ 6.0 versus
MATTHEWS ET AL
nonsurvivors 21.9 _+ 7.80. The difference was statistically significant (P < .05). The mean PSI for the entire group was 18.4 _+ 8.3. Mortality may also be related to the indication for the dialysis. The mortality was highest (100%) in infants with congenital heart disease that developed renal failure after cardiopulmonary bypass procedures. Other investigators have noted a similar high mortality in the approximately 5% of children who develop acute renal failure after open heart procedures. 6"t4'23An aggressive approach, instituting peritoneal dialysis shortly after the onset of anuria, has been advocated in an effort to decrease mortality in this subset of patients. Interestingly, the other group with 100% mortality was those patients with congenital metabolic disorders who were not oliguric. Although mortality was high in all subgroups, the mortality rate in babies without congenital heart disease was in the 40% to 60% range. Infants that survive the acute illness requiring peritoneal dialysis can generally progress to outpatient CAPD and possible renal transplantation. Of the 12 patients who survived their acute illness in this study, 7 patients did not require further dialysis therapy, while 5 continue on outpatient CAPD. The development of abdominal wall (inguinal, umbilical, incisional) hernias is not uncommon in patients with increased intraabdominal pressure or fluid due to ascites, ventriculoperitoneal shunts, and peritoneal dialysate.24'2sThe reported incidence of hernias in CAPD patients ranges from 2.5% to 67%, with an average between 10% and 25%.26.33The incidence of hernias in newborns is 0.8% to 4.4% and that of a patent processus vaginalis is 30%.34 Four of 31 patients (12.9%) developed clinical hernias. This relatively low incidence may be related to the short duration of dialysis in those not requiring CAPD and the high early mortality rate during this period. Indeed, all 4 patients who developed hernias were in the group of 12 survivors, making the true incidence of hernias among survivors 33%. There were no complications attributable to the hernias. All hernias were repaired electively, after the patient had survived the acute illness. As a rule, hernias noted preoperatively in stable patients can be repaired at the time of catheter placement. In the critically ill infant, or in those in whom a hernia develops after initiation of peritoneal dialysis, early herniorrhaphy is recommended after the patient's lifethreatening condition has improved and before hospital discharge. In the premature infant the length of the straight dialysis catheters may increase the risk of bowel perforation, particularly the rectum. The pigtail dialysis catheter is less likely to erode into bowel and is now being used more frequently in small babies. The usual
PERITONEAL DIALYSIS IN INFANCY
1 15
m a n a g e m e n t of an i n t e s t i n a l p e r f o r a t i o n r e q u i r e s l a p a r o t o m y a n d r e p a i r of t h e b o w e l injury. H o w e v e r , d a t a f r o m i n s t a n c e s of i n t e s t i n a l p e r f o r a t i o n a s s o c i a t e d w i t h ventriculoperitoneal shunt catheters suggest that the c a t h e t e r c a n be r e m o v e d a n d t h e i n f a n t s a f e l y t r e a t e d w i t h antibiotics, g a s t r i c suction, a n d b o w e l r e s t ) 5 T h i s t h e r a p y was successful for the single p a t i e n t w i t h a r e c t a l p e r f o r a t i o n in this series and c o u l d be u s e d s a f e l y in s e l e c t e d cases.
In s u m m a r y , p e r i t o n e a l dialysis is an e f f e c t i v e t h e r a p y for seriously ill n e w b o r n i n f a n t s w i t h l i f e - t h r e a t e n ing d i s e a s e s t a t e s a s s o c i a t e d w i t h a c u t e r e n a l f a i l u r e or certain inborn errors of metabolism. Mortality remains h i g h d u e to t h e s e v e r i t y o f t h e u n d e r l y i n g d i s e a s e a n d c o - m o r b i d c o n d i t i o n s (as d o c u m e n t e d b y t h e i r P S I ) . H o w e v e r , g r a t i f y i n g s u r v i v a l c a n be a c h i e v e d in 38.7% o f cases t h a t s u r e l y o t h e r w i s e w o u l d h a v e s u c c u m b e d .
REFERENCES
1. Salusky IB, Lucull0 L, Nelson P, et al: Continuous ambulatory peritoneal dialysis in children. Pediatr Clin North Am 29:10051012, 1982 2. Fine RN: Peritoneal dialysis update. J Pediatr 100:1-7, 1982 3. Balfe JW, Stefanidis C J, Steele BT, et al: Continuous ambulatory peritoneal dialysis: Clinical aspects, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 135-148 4. Kanarek KS, Root E, Sidebottom R, et al: Successful peritoneal dialysis in an infant weighing less than 800 grams. Clin Pediatr 21:166-169, 1982 5. Jones AS, James E, Bland H, et al: Renal failure in the newborn. Clin Pediatr 18:286-291, 1979 6. Baxter R, Rigby ML, Jones ODH, et al: Acute renal failure following cardiopulmonary bypass in children: Results of treatment. Int J Cardiol 7:235-246, 1985 7. Steele BT, Vigneux A, Blatz S, et al: Acute peritoneal dialysis in infants weighing < 1500 g. J Pediatr 110:126-129, 1987 8. Nash MA, Rusco JC: Neonatal lactic acidosis and renal failure: The role of peritoneal dialysis. J Pediatr 91:101-105, 1977 9. Georgieff MK, Mills MM, Paurvi B: Validation of two scoring systems which assess the degree of physiologic instability in critically ill newborn infants. Crit Care Med 17:17-21, 1989 10. Cruder SF, Jones DP, Green RS: Acute renal failure in neonates: Incidence, etiology and outcome. Pediatr Nephrol 1:314320, 1987 11. Broyer M: Incidence and etiology of ESRD in children, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 9-16 12. Lattouf OM, Ricketts RR: Peritoneal dialysis in infants and children. Am Surg 52:66-69, 1986 13. Offner G, Brodehl J, Galaske R, et al: Acute renal failure in children: Prognostic features after treatment with acute dialysis. Eur J Pediatr 144:482-486, 1986 14. Abbad FC, VanAmstel SL: Continuous ambulatory peritoneal dialysis in small children with acute renal failure. Proc Eur Dial Transplant Assoc 19:607-613, 1983 15. Book K, Ohqvist G, Bjork VO, et al: Peritoneal dialysis in infants and children after open heart surgery. Scand J Thorac Cardiovasc Surg 16:229-233, 1982 16. Alexander SR: Treatment of infants with ESRD, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 17-29 17. Girgis N, McGravey V, Shah BL, et al: Lethal ornithine transcarbamylase deficiency in a female neonate. J Inherited Metab Dis 10:274-275, 1987 18. Donn SM, Swartz RD, Thoene JG: Comparison of exchange transfusion, peritoneal dialysis, and hemodialysis for the treatment of hyperammonemia in an anuric newborn infant. J Pediatr 95:6770, 1979 19. Oh SH, Conley SB, Rose GM, et al: Fungal peritonitis in
children undergoing peritoneal dialysis. Pediatr Infect Dis 4:62-66, 1985 20. Orkin BA, Fonkalsrud EW, Salusky IB, et al: Continuous ambulatory peritoneal dialysis catheters in children. Arch Surg 118:1398-1402, 1983 21. Finan P J, Guillou P J: Experience with surgical implantation of catheters for continuous ambulatory peritoneal dialysis. Ann R Coil Surg Engl 67:190-192, 1985 22. Sherman N J, Atkinson JB: Vascular and peritoneal access: Technical considerations, in Fine RN, Gruskin AB (eds): End Stage Renal Disease in Children. Philadelphia, PA, Saunders, 1984, pp 85-94 23. Rigden SP, Barratt TM, Dillon M J, et al: Acute renal failure complicating cardiopulmonary bypass surgery. Arch Dis Child 57:425-430, 1982 24. Grosfeld JL, Cooney DR: Inguinal hernia after ventriculoperitoneal shunt in infants and children. J Pediatr Surg 9:311-315, 1974 25. Engeset J, Younson GG: Ambulatory peritoneal dialysis and hernia complications. Surg Clin North Am 64:385-392, 1984 26. Nelson H, Lindner M, Schuman ES, et al: Abdominal wall hernias as a complication of peritoneal dialysis. Surg Gynecol Obstet 157:541-544, 1983 27. Von Lilien T, Salusky IB, Yap HK, et al: Hernias: A frequent complication in children treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 5:256-260, 1987 28. Stone MM, Fonkalsrud EW, Salusky IB, et al: Surgical management of peritoneal dialysis catheters in children: Five-year experience with 1,800 patient-month follow-up. J Pediatr Surg 21:1177-1181, 1986 29. Schleifer CR, Morfesis FA, Cupit M: Management of hernias and Tenckhoff catheter complications in CAPD. Perit Dial Bull 4:146-150, 1984 30. Zaontz MR, Cohn RA, Moel DI: Continuous ambulatory peritoneal dialysis: The pediatric experience. J Urol 138:353-356, 1987 31. Francis DMA, Donnelly PK, Veitch PS, et al: Surgical aspects of continuous ambulatory peritoneal dialysis--3 years experience. Br J Surg 71:225-229, 1984 32. Tank ES, Hatch DA: Hernias complicating chronic ambulatory peritoneal dialysis in children. J Pediatr Surg 21:41-42, 1986 33. Alexander SR, Tank ES: Surgical aspects of continuous ambulatory peritoneal dialysis in infants, children and adolescents. J Urol 127:501-504, 1982 34. Rowe MI, Lloyd DA: Inguinal hernia, in Welch K J, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book Medical, 1986, pp 779-791 35. Grosfeld JL, Cooney DR, Smith J, et al: Intra-abdominal complications following ventriculoperitoneal shunts. Pediatrics 54:791-796, 1974
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Discussion D. Tapper (Seattle, W,4): I believe that this is the first report that really describes the indications, techniques, and complications of peritoneal dialysis in the newborn; and it is particularly significant for those of us in pediatric surgery as we are being asked to more frequently see these children who are increasingly ill and who survive their illnesses and end up with renal failure. We need to develop a management scheme for these infants, and we need to understand the consequences of placing these catheters. When read this report you have a better understanding of the risks involved as documented by the Indiana group. The
presentation and the report, which I had the opportunity to read, raised several questions which I would like to pose to you. With regard to technique, you seem to place the dacron cuff within the peritoneal cavity. Having been instructed by Hickman and Tenckhoff, I generally place it under the rectus muscle in the smaller children, having been told that it serves both to anchor the catheter and is a barrier for infection. In addition, the pigtail catheter which is a Quinton advancement also makes a showerhead which is large but stays up against the abdominal wall and decreases the chance of nonfunction.