Pd intervention-1
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This document provides information about peritoneal dialysis (PD), including: - An overview of PD, how it works, and the components of PD fluid. - Details on different PD modalities, principles of exchanges, and factors in patient selection. - Complications of PD like peritonitis and their treatment, as well as non-infectious complications. - The PD program at Mansoura International Hospital, including patient education, catheter insertion, and home visits.
![Failure of PD program
Cost Problems
• Limited number of patients
– Local production of peritoneal bags is not feasible except on
a large scale >500 – 1000 pts [All bags are imported from
western countries therefore, they are relatively very
expensive ].!
– Manufacture of local bags will not be feasible due to limited
number of patients.
– Difficulty in increasing the number of patients due to the
high cost of CAPD
• Limited Resources
– Depending only on government subsidy
– Lack of a integrated insurance system](https://image.slidesharecdn.com/pd-intervention-1-180104122826/85/Pd-intervention-1-40-320.jpg)
Pd intervention-1
- 1. PD administration program Dr. Hamed Ezzat El-Eraky Nephrology Specialist Mansoura International Hospital
- 5. FORMATION & ACTIVATION OF CERTAIN HORMONES & VITAMINS
- 6. CHRONIC KIDNEY DISEASE IS A GENERAL TERM FOR HETEROGENEOUS DISORDERS AFFECTING THE STRUCTURE AND FUNCTION OF THE KIDNEY. KIDNEY FAILURE IS DEFINED AS A GFR OF LESS THAN 15 ML/MIN PER 1·73 M², OR THE NEED FOR TREATMENT WITH DIALYSIS OR TRANSPLANTATION.
- 9. Symptoms & Signs Of Renal Failure 1- Accumulation Of Waste Products (Urea, K, Po4,..) 2- Accumulation Of Salt & Water ( HTN, L.L. Edema, Dyspnea,…) 3- Acidosis 4- Hormones & Vitamins Defiancy( Anemia, Itching, Bonache, Deformity, HTN, Anasarca)
- 10. RRT
- 11. The right modality at the right time. Complementary Not Competitive
- 12. MULTIDISCPLINARY TEAM •Pharmacist•Social worker •PD nurse•Ward nurse Dietitian nephrologist Tx team Access team
- 14. 0 50 100 150 200 250 300 350 400 UAE KSA Morocco Oman Qater Egypt Algeria
- 15. INDICATION OF PD: - UNAVAILABLE HD - HYPOTENSION - ACCESS FAILURE - DIABETIC PATIENT - ISCHEMIC HEART DISEASE - HEART FAILURE - BLEEDING TENDENCY - FEAR OF BLOOD - ACTIVE PERSONS - INFANT BELOW 12 YEARS
- 16. - Peritoneal adhesion due to previous operation or inflammation - Hernia - Poor vision - Psychiatric disorders - COPD & asthma - Morbid obesity CONTRAINDICATION OF PD
- 17. Patient selection - AGE - GENERAL CONDITION - PERSONALITY - RENAL FUNCTION
- 18. • It’s an internal process inside the body in which Dialysis fluid is introduced to the peritoneal cavity through a catheter placed in the lower part of the abdomen. • peritoneum serves as the dialysis membrane. The peritoneal cavity can often hold more then 3 liters, but in clinical practice only 1.5 – 2.5L of fluid are used. • Solutes are transported across the membrane by diffusion. • Fluid is removed by ultrafiltration driven by an osmotic pressure gradient.
- 20. Peritoneal fluid Osmotic agent , Electrolytes , Acid – Base buffer
- 21. Osmotic agent Glucose : Glucose was the only osmotic agent available until 1990. It is not directly toxic, effective and inexpensive available in con. 1.36% 1.5% 2.5% and 4.25% with high glucose concentration is used for effective UF
- 23. Electrolytes Sodium (Na) Na conc. In P.D. Solution is bet 130 – 137 mEq/L. Potassium (K) K can in available solution from (0 to 2 mEq/L). In hyperkalemic patient K free solution used to maximize K removal . To avoid hypokalemia add 1 to 4 mEq/L. Calcium (Ca+) Ca level in the dialysate solution varies from 0 to 1.75 mmol/L. Ca level 1.0 to 1.25 mmol/L lead to adequate Ca balance & Ph control with oral Ca binder. Low Ca dialysate (0.6 – 1 mmol/L) is used in sever hyperparathyroidism . Magnesium Mg. in P.D. Solution at concentration varies from 0.25 to 0.75 mmol/l may be associated with hypermagnesiumia,
- 24. Acid – Base buffer The buffer composition of available P.D. solutions can be divided into three categories. • Non bicarbonate buffers • Bicarbonate / lactate combination buffers • Bicarbonate buffers
- 25. PRINCIPLES OF PD EXCHANGES Dialysis fluid is introduced to the peritoneal cavity through a catheter placed in the lower part of the abdomen. peritoneum serves as the dialysis membrane. The peritoneal cavity can often hold more then 3 litres, but in clinical practice only 1.5 – 2.5L of fluid are used. Solutes are transported across the membrane by diffusion. Fluid is removed by ultrafiltration driven by an osmotic pressure gradient.
- 26. CAPD (Continuous Ambulatory Peritoneal Dialysis) APD (Automated Peritoneal Dialysis) CCPD (Continuous Cycling Peritoneal Dialysis) IPD (Intermittent Peritoneal Dialysis) NIPD (Nocturnal Intermittent Peritoneal Dialysis) TPD (Tidal Peritoneal Dialysis) Types of Chronic Peritoneal Dialysis
- 27. 1. Fill Phase (<15 minutes) * Disconnect 2. Dwell phase (4-8 hours) 3.Drain phase (<20 minutes) CAPD
- 28. Preservation of RRF Higher Hb concentration Less risk of acquiring blood borne infections e.g. HCV Better quality of life It allows expansion with limited resources Lower staff / patient ratio saves vascular access preferred for children ADVANTAGES OF PD
- 29. Complications of PD therapy infectious Non infectious Peritonitis TunnelExit site Acute Chronic
- 30. peritonitis • It is the major complication of PD and remains the main reason for switching patient to HD . • The rate should not be > 1 episode/18 patient-month or 0.67 episode / year at risk (ISPD guidelines)
- 31. clinical presentation of peritonitis abdominal pain ( 80% ) fever ( 50%) nausea ( 30% ) diarrhea ( 7-10% ) poor drainage cloudy fluid or drainage loss of UF function
- 32. Diagnosis of peritonitis Based on the number of WBCs :100 wbc / mm3. A gram stain should be done. Bacteria are present in low concentrations in PD fluid. positive culture, in the absence of WBCs usually represent contamination Culture negative ~ 20% of cases. sterile culture: antibiotic, poor culture technique, early sampling.
- 33. Initiate empiric therapy with Cefazolin or Cephalothin and OR Glycopeptide ( Vancomycin or Teicoplanin) and Ceftazidime Initial therapy Continuous dosing Intermitt. dosing Cefazolin or cephalothin 250 mg/L load,then 125 mg/L in each exchange 15 mg/kg in a single exchange/day Ceftazidime 250 mg/L load,then 125 mg/L /change 15 mg/kg in a single exchange /day Vancomycin 500 mg/L load,then 30mg/L /change 30 mg/kg in a single exchange q 5-7 days Teicoplanin 200 mg/L load,then 20mg/L /change 15 mg/kg in a single exchange q 5-7 d.
- 34. Maintenance therapy Staph. aureus Enterococcus strepto. Other gram +ve Methicilin sensitive: continue cephalosporin Discontiue ceftazidime and glycopeptide. Add rifampicin 20mg/kg/day, orally. Mehticillin resistant: Discontinue ceftazidime Continue glycopeptide Discontiue cephalosporin or glycopeptide and ceftazidime,start ampicillin 125 mg/L. Aminoglycoside may be added based on sensitivity result and patient response. Vancomycin for ampicillin resitancs cases Methicillin sensitive: Discontinue ceftazidime and glycopeptide, continue cephalosporin Duration: 21 days 14 days 14 days
- 35. Single gram –ve /non Pseudomonas pseudomonas Multiple organisms and /or anaerobe Adjust antibiotics to sensitivity pattern. May continue ceftazidime Discontinue cephalosporin or glycopeptide. Continue ceftazidime, add agent with activity against pseudomonas ( piperacillin,ciprofloxacin,a minoglycoside or aztreonam Consider surgical intervention and add : Metronidazole 15 mg/kg/day in divided doses (max. 1.5gm/day). Duration: 14 days 21 days 21 days Maintainance therapy
- 36. Non-infectious Complications of Peritoneal Dialysis Mechanical complications Metabolic Disturbances Early Pain Bleeding Perforation of a viscera Exit site leak Late Catheter – related complications Pain Bleeding Catheter obstruction Catheter cuff extrusion Increased intra – peritoneal pressure Fluid leak Hernias Low back pain GERD Alteration of diaphragmatic mechanics Alteration of peritoneal transport Peritoneal – membrane related complications Ultrafiltration Failure (UFF) Encapsulating peritoneal Sclerosis Hyperglycaemia Hyperlipidemia Malnutrition Hypokalemia Hypermagnesaemia
- 37. • Closed system • Semi closed • Open system
- 40. Failure of PD program Cost Problems • Limited number of patients – Local production of peritoneal bags is not feasible except on a large scale >500 – 1000 pts [All bags are imported from western countries therefore, they are relatively very expensive ].! – Manufacture of local bags will not be feasible due to limited number of patients. – Difficulty in increasing the number of patients due to the high cost of CAPD • Limited Resources – Depending only on government subsidy – Lack of a integrated insurance system
- 41. PD program in Mansoura PD program in Nephrology Department Of New Mansoura General Hospital ( international ) is established about 6 years ago. The service in our department introduced to the patient for free. At 1st Its mainly depend on donation supported by البريتونى الغسيل لدعم المصرية االهلية الجمعية
- 42. البري الغسيل لدعم المصرية االهلية الجمعيةتونى
- 50. 240 * 5.5 = 1320 120 * 28 = 3360 monthly cost = 4680 240 * 12 = 2880 120 * 50 = 6000 monthly cost = 8880
- 51. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 52. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 53. Patient selection • From the start for cases of CKD either young age , cardiac or difficult access. • Transformed from HD: mainly due to access failure or life style.
- 54. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 58. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 59. Insertion Of PD Catheter
- 60. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 62. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 63. Home visit
- 64. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 65. Dialysis
- 66. 1. Fill Phase (<15 minutes) * Disconnect 2. Dwell phase (4-8 hours) 3.Drain phase (<20 minutes) CAPD
- 67. • Home visit • Dialysis • Monthly visit • complication • Patient selection • Education • Catheter insertion • Wash PREPARATION FOR PD
- 68. Monthly visit