💧 Chapter 146: Peritoneal Dialysis Catheter Insertion

Indications (acute kidney injury, inborn errors of metabolism, dialysable toxins) · Contraindications (abdominal surgery, peritonitis, coagulopathy) · Bedside Seldinger technique · Priming with fluid · Complications (bleeding, bowel perforation, peritonitis, catheter obstruction)

🔍 Core Concepts: Peritoneal Dialysis Catheter Insertion

📌 Indications
Acute kidney injury (oliguria/anuria, fluid overload, severe electrolyte disturbances, metabolic acidosis), inborn errors of metabolism, dialysable toxins (salicylates, lithium, alcohols).
🚫 Contraindications
Absolute: recent abdominal surgery, ventriculoperitoneal shunt, omphalocele/gastroschisis, diaphragmatic hernia. Relative: abdominal wall cellulitis, ileus, adhesions, severe coagulopathy.
📍 Insertion Sites
Midline 1-2 cm below umbilicus (avascular linea alba). Left or right lower quadrant (5-7 o'clock position) to avoid adhesions from prior surgery.
🔧 Bedside Seldinger Technique
Infuse PD fluid (25-30 mL/kg) to distend abdomen (bowel away). Small incision. Introduce trocar/cannula with 'give'. Advance catheter toward paracolic gutter. Secure with purse-string suture.
✅ Advantages of PD
Bedside procedure, no vascular access, no anticoagulation needed, less expensive, avoids blood priming.
⚠️ Complications
Bleeding (coagulopathy), bowel perforation (needle/trocar), bladder perforation (empty bladder), catheter obstruction (omentum wrap), leak, peritonitis, respiratory compromise (abdominal distension).
🩺 Peritonitis Management
Cloudy effluent, abdominal pain. Culture (inoculate blood bottles). Empiric antibiotics (vancomycin + ceftazidime or aminoglycoside).

🩺 Stepwise Bedside Peritoneal Dialysis Catheter Insertion (Seldinger)

1
Indication & consent
Confirm need for RRT (AKI, fluid overload, metabolic disturbance). Obtain consent. Empty bladder (catheterise if needed).
2
Prime abdomen with PD fluid
Infuse 25-30 mL/kg of warmed PD fluid through an IV catheter (16-18G) to distend abdomen, moving bowel away from insertion site. This reduces bowel injury risk.
3
Select site & sterile prep
Midline (1-2 cm below umbilicus) or paramedian (avoiding scars). Chlorhexidine prep. Local anaesthesia.
4
Trocar/cannula insertion
Small skin incision. Insert trocar with stylet, advance perpendicular until 'give' (entering peritoneal cavity). Remove stylet – fluid returns confirming placement. Advance catheter toward paracolic gutter (aim toward groin).
5
Secure & start dialysis
Secure catheter with purse-string suture. Connect to dialysis system. Start with small fill volumes (10-20 mL/kg), dwell, drain. Monitor for leaks, respiratory compromise.