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🔥PART 2/2 on #PD catheter complications
#NephTwitter #NSMC #medtweetorials #medtwitter #Nephmadness
You see a patient w/ a past history of C-section for poor inflow/outflow 1️⃣ week post laparoscopic PD catheter insertion
📊What are the possible causes of flow problems?
🔥PART 2/2 on #PD catheter complications
#NephTwitter #NSMC #medtweetorials #medtwitter #Nephmadness
You see a patient w/ a past history of C-section for poor inflow/outflow 1️⃣ week post laparoscopic PD catheter insertion
📊What are the possible causes of flow problems?
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What’s your approach to flow?
1️⃣ Catheter irrigation → 1L of solution (dialysate/saline)
2️⃣ If slow fill → Flush/aspirate with syringe (aseptic technique! 🧤 😷)
3️⃣ If resistance both ways → Likely two-way obstruction
👇 Use an approach to catheter flow problems:
What’s your approach to flow?
1️⃣ Catheter irrigation → 1L of solution (dialysate/saline)
2️⃣ If slow fill → Flush/aspirate with syringe (aseptic technique! 🧤 😷)
3️⃣ If resistance both ways → Likely two-way obstruction
👇 Use an approach to catheter flow problems:
3/
➡️⬅️obstructions due to intraluminal/extraluminal process
👉Fibrin → most common cause of intraluminal obstruction
👉Fibrin → arises with inflammation (e.g. peritonitis)/embedded catheters too!
👉 Diagnose by clinical suspicion (🔎 for fibrin traces in drain bag)
➡️⬅️obstructions due to intraluminal/extraluminal process
👉Fibrin → most common cause of intraluminal obstruction
👉Fibrin → arises with inflammation (e.g. peritonitis)/embedded catheters too!
👉 Diagnose by clinical suspicion (🔎 for fibrin traces in drain bag)
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👉Fibrin can also be extraluminal
👉Fibrin in dialysate drain bag may be an early sign of a profibrotic state → fibrin sheath development, see paper by @PD_Perls ncbi.nlm.nih.gov/pmc/articles/P…
👇Fibrin sheath with retrograde contrast spillage (white arrow)
👉Fibrin can also be extraluminal
👉Fibrin in dialysate drain bag may be an early sign of a profibrotic state → fibrin sheath development, see paper by @PD_Perls ncbi.nlm.nih.gov/pmc/articles/P…
👇Fibrin sheath with retrograde contrast spillage (white arrow)
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How do you manage fibrin plug?
1️⃣ R/O kinks w/ X-ray
2️⃣ Aspirate & flush catheter w/ heparinized solution
3️⃣Instill fibrinolytic agent in catheter
4️⃣ If unsuccessful, flexible wire under fluoroscopic guidance
5️⃣Surgical exploration as last step
pubmed.ncbi.nlm.nih.gov/20948542/
How do you manage fibrin plug?
1️⃣ R/O kinks w/ X-ray
2️⃣ Aspirate & flush catheter w/ heparinized solution
3️⃣Instill fibrinolytic agent in catheter
4️⃣ If unsuccessful, flexible wire under fluoroscopic guidance
5️⃣Surgical exploration as last step
pubmed.ncbi.nlm.nih.gov/20948542/
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🗣”The PD catheter is still not working. The patient is clinically stable without concerning labs & will likely get a catheter manipulation done in 1-2 weeks.”
📊Would you switch this patient to hemodialysis?
🗣”The PD catheter is still not working. The patient is clinically stable without concerning labs & will likely get a catheter manipulation done in 1-2 weeks.”
📊Would you switch this patient to hemodialysis?
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⚠️Do not reflexively switch to hemodialysis in patients with non-functioning PD catheters. If there is a long wait-time before manipulation, urgent need for clearance &/or minimal residual renal function then consider transition to HD
👇
⚠️Do not reflexively switch to hemodialysis in patients with non-functioning PD catheters. If there is a long wait-time before manipulation, urgent need for clearance &/or minimal residual renal function then consider transition to HD
👇
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What about kinks?
⚡️Catheter kinks commonly occur in the pre-peritoneal space in subcutaneous tissue.
⚡️Kinks can be seen on X-ray
🔥Try inverting the image such that 🦴 appears black 👇, most modern catheters have a radio-opaque line that you can see
What about kinks?
⚡️Catheter kinks commonly occur in the pre-peritoneal space in subcutaneous tissue.
⚡️Kinks can be seen on X-ray
🔥Try inverting the image such that 🦴 appears black 👇, most modern catheters have a radio-opaque line that you can see
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⚡Follow the shape of the catheter closely as kinks or twists are NOT always very obvious
⚡Significant wrapping of the catheter can also present with a ➡️⬅️way obstructive pattern, especially if the catheter is folded on itself or completely encased 👇
⚡Follow the shape of the catheter closely as kinks or twists are NOT always very obvious
⚡Significant wrapping of the catheter can also present with a ➡️⬅️way obstructive pattern, especially if the catheter is folded on itself or completely encased 👇
10/
How do you manage Fallopian tube wrap?
⚡️Laparoscopic manipulation recommended
⛔️Never remove catheter suspected of Fallopian tube wrapping without direct visualization; may lead to Fallopian tube avulsion⛔️
@prakashneph has a great summary here:
ncbi.nlm.nih.gov/pmc/articles/P…
How do you manage Fallopian tube wrap?
⚡️Laparoscopic manipulation recommended
⛔️Never remove catheter suspected of Fallopian tube wrapping without direct visualization; may lead to Fallopian tube avulsion⛔️
@prakashneph has a great summary here:
ncbi.nlm.nih.gov/pmc/articles/P…
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What about omental wraps?
🔥Predominantly outflow failure related but can be two-way if severe
🔥Occurs in about 5-15% of PD catheters
🔥Risk reduced when omentopexy done at time of insertion (⚠️See operative video if interested from 0:04-01:00)
What about omental wraps?
🔥Predominantly outflow failure related but can be two-way if severe
🔥Occurs in about 5-15% of PD catheters
🔥Risk reduced when omentopexy done at time of insertion (⚠️See operative video if interested from 0:04-01:00)
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How do you diagnose & treat omental wraps?
1️⃣ Clinical history
2️⃣ Get X-ray with catheterograph
3️⃣ If unclear then get CT peritoneogram
4️⃣ If confirmed, get surgical manipulation of catheter
#ICYMI @NephroShah has 👍overview on approach to flow: renalfellow.org/2018/11/20/let…
How do you diagnose & treat omental wraps?
1️⃣ Clinical history
2️⃣ Get X-ray with catheterograph
3️⃣ If unclear then get CT peritoneogram
4️⃣ If confirmed, get surgical manipulation of catheter
#ICYMI @NephroShah has 👍overview on approach to flow: renalfellow.org/2018/11/20/let…
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Conclusion :
📌Two-way obstruction is due to intraluminal or extraluminal causes
📌Fibrin plug is the most common cause of intraluminal obstruction
📌Invert images (black bones) on X-ray to check for catheter kinks
📌Fallopian tube wraps need surgical manipulation
Conclusion :
📌Two-way obstruction is due to intraluminal or extraluminal causes
📌Fibrin plug is the most common cause of intraluminal obstruction
📌Invert images (black bones) on X-ray to check for catheter kinks
📌Fallopian tube wraps need surgical manipulation
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🏁This concludes Part II of catheter complications in PD
Many thanks to @NSMCInternship @captainchloride @amyaimei @drM_sudha & @Nephro_Sparks for the continued support on this #tweetorial!
Stay tuned for regular #PD pearls #Nephtwitter #medtwitter moving forward!
🏁This concludes Part II of catheter complications in PD
Many thanks to @NSMCInternship @captainchloride @amyaimei @drM_sudha & @Nephro_Sparks for the continued support on this #tweetorial!
Stay tuned for regular #PD pearls #Nephtwitter #medtwitter moving forward!
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