WPCW p $jbJfXc-%0bRO7sOd `[en Pl@*RoT2^4Ȝ3TÛj9L_|_y3D%lT)r:y R`& A

̇C'p7j6NEr"/WA9Yk +$dh5RA40Rq$U݂Bm-T<'xK4NCLw'ֳFb(Dx7n _\nDs.PY/vDl{#t1;񄎽<8­:#@^*!_Vu24Bl\pQ<&P1 ׃g$[v;ڠ~30Qɓ91zvHjyzx\!xʢNzZ|eg#UNc % 0: 0 0 0 0 0 0 0| 0^ 0= 0 0 0 0 0 0e 08 0 0 0 0 0^ 09 0 0 0 0 0S 00! 0<L! 0! 0>F" 0v" 0`" 0`Z# 0`# 0`$ 0`z$ 08$ 0`% 02% 0& 0:' 0YL' 0_' 0 ( 0j) 0x* B*+ D/&, D+U, 0, D/. 03. 06/ 07/ 0:?0 0^y0 0<0 A1U61U>1(2 0B2 0(03 AMX3U*3f3a3 B-3@ 4o4@ 4o4@ 5o5@ 6o6f7a7@ 7?7@v9o :? A^ /w;4?Sb mdo{@ MoW@ )o3 D5 B:Lexmark Z51 Series Col (Copy 3)PX,,,,PX0(9 Z6Times New Roman RegularX($USUS.,2J+M 0_level1  X 2( ` hp x 223  ..  5+ ` hp x 5  2G+M 0_level2   /%` ` hp x /23  ..  5+ ` hp x 5  2D+M 0_level3   ," hp x ,23  ..  5+ ` hp x 5  2A+M 0_level4  ` ) hp x )23  ..  5+ ` hp x 5  2>+M 0_level5   &hhp x &23  ..  5+ ` hp x 5  2;+M 0_level6   #p x #23  ..  5+ ` hp x 5  28+M 0_level7  h  p x 23  ..  5+ ` hp x 5  25+M 0_level8   pp x 23  ..  5+ ` hp x 5  22+M 0_level9    x 23  ..  5+ ` hp x 5  2JM 0_levsl1  X 2( ` hp x 223  Ԁ  5+ ` hp x 5  2GM 0_levsl2   /%` ` hp x /23  Ԁ  5+ ` hp x 5  2DM 0_levsl3   ," hp x ,23  Ԁ  5+ ` hp x 5  2AM 0_levsl4  ` ) hp x )23  Ԁ  5+ ` hp x 5  2>M 0_levsl5   &hhp x &23  Ԁ  5+ ` hp x 5  2;M 0_levsl6   #p x #23  Ԁ  5+ ` hp x 5  28M 0_levsl7  h  p x 23  Ԁ  5+ ` hp x 5  25M 0_levsl8   pp x 23  Ԁ  5+ ` hp x 5  22M 0_levsl9    x 23  Ԁ  5+ ` hp x 5  2JM 0_levnl1  X 2( ` hp x 223   5+ ` hp x 5  2GM 0_levnl2   /%` ` hp x /23   5+ ` hp x 5  2DM 0_levnl3   ," hp x ,23   5+ ` hp x 5  2AM 0_levnl4  ` ) hp x )23   5+ ` hp x 5  2>M 0_levnl5   &hhp x &23   5+ ` hp x 5  2;M 0_levnl6   #p x #23   5+ ` hp x 5  28M 0_levnl7  h  p x 23   5+ ` hp x 5  25M 0_levnl8   pp x 23   5+ ` hp x 5  22M 0_levnl9    x 23   5+ ` hp x 5  0.Normal<:Definition T<AA:Definition L , 5+ ` hp x 5  5+ ` hp x 586Definition(''&H1      XXX(&H2  XXX(&H3  XXX(&H4 XXX XXX(&H5  XXX(&H6  XXX20Address8MM6Blockquote , , 5+ ` hp x 5   5+ ` hp x 5,*CITE,dl*CODEK@<6X9`(Courier NewKXXXSA\  `&Times New RomanS42Emphasis64Hyperlink    <:FollowedHype    4go2Keyboard K@<6X9`(Courier NewK XXXSA\  `&Times New RomanS<:Preformatted/%  ,Kk %#/K@<6X9`(Courier NewKXXXSA\  `&Times New RomanS/%  ,Kk %#/<:zBottom of 75(X7  ?F%2A`Arial?76(X7  XXXSA\  `&Times New RomanS&  d d4)1dxd'dxd<:zTop of For78(X7  ?F%2A`Arial?76(X7  XXXSA\  `&Times New RomanS4)2dxd0KS.SampleK@<6X9`(Courier NewKSA\  `&Times New RomanS0.Strong 8dl6TypewriterK@<6X9`(Courier NewKXXXSA\  `&Times New RomanS42Variable: 8HTML MarkupB      2 0CommentB  5&Draw Object <<=8C HKKKK<6X9`(Courier New\  `&Times New Roman Level 1 Level 2 Level 3 Level 4 Level 5("$ !  ($BCD6A<< c%2A`ArialTable_A)Hairline dK WPCb513 *%'513 h!h!*3%)+.- h1h1M WPCb513 *%'513 h!h!*3%)+.- h1h1O WPCb513 *%'513 h!h!*3%)+.- h1h1Q WPCb513 *%'513 h!h!*3%)+.- h1h1Table_A` S@D:\RICK'S~1\WEBPAG~1\INPROG~1\GUIDEL~1\ARTICLES\GOKAL\GIFS\CATHETER.GIFD:\Rick's Work\Web Pages\In Progres\guidelines\articles\gokal\gifs\catheter.gifDD5^ e F[6[6TDD5A5B55FD  @p` p WD:\RICK'S~1\WEBPAG~1\INPROG~1\GUIDEL~1\ARTICLES\GOKAL\GIFS\CATHETER.GIFWPCGG111GG   !!!"""###$$$%%%&&&'''((()))***+++,,,---...///000111222333444555666777888999:::;;;<<<===>>>???@@@AAABBBCCCDDDEEEFFFGGGHHHIIIJJJKKKLLLMMMNNNOOOPPPQQQRRRSSSTTTUUUVVVWWWXXXYYYZZZ[[[\\\]]]^^^___```aaabbbcccdddeeefffggghhhiiijjjkkklllmmmnnnooopppqqqrrrssstttuuuvvvwwwxxxyyyzzz{{{|||}}}~~~]1} ,   *** 5QY9 B1ye0 A1Rz(5XH$1{(*4y+{.CsfGtgkl yD8xSYwok/EbSAXzY:d/R1)gg}r WAnniT}|btliudoiHusnhD,e_q|P]X!|^yvek`]nvkfS6pu1, hF}kqojP;)ssjY$e]cc4o}aomg;}kuliY86!{(qI!:,Qi8fDWxVk4LHzW#m3#)=5(I-#NE| Qa@R 4*i$,^%5]32"D~2h#^Niy1StpCv9];h1n-d<~ytDc>van 03z3&l ^~>spC||>X8sZ2 <fւO,<q4Yf6S A&Gfk G]tp9FMS:]v]2jqR DTI P8 FSbBhjA@ \0tp$`MpI _rO +ei{/)| 6O7QH`L3<y(spC$ux-i|gP+@piF aWh!z2VGt&zcSY#cA <sqgGIUvmҶljObwjwgwxJmoLVLGT[btJeKO\SAOъ%]KVY[H>`Pe6aM`MSPt q{ xg{zd{cqŝ܀jzfna ~mayp jpSa~ۦ,p +nK?M](c^)QSl5V4a."\?@}-^/k2Y<)UX;$(:~B x3^Ӓ-} -b.|6I3s2veTf|:~u5O"&9Y<LO+b.va+)a2);~9x) lo\d X f$2R'X#?;w!#x8>O0NxaKv kvtlxm!2>T=!F @lk'U8y$SavD W6'Tq<,Yqf2pX>AnF::RijNė>b?D4g:})v,]5|A?m+ʯۧܶuzi2F;wsɮ&l象kiB+|B؈% x+;kL6# ^9Vط/IB>U' ];R%MǀKi^5>&mh-7{B~0fx #u$jsqn3k{{E8<}i|rf`lz^qR8%wszc{B~ 7n*f[5i ^sqzxx32ƛ0~<U^2(fjP&?x.  TOK%d,Z0T6H9;|c% lp.  \l1.`L,?Ied61݈/$0T( ~YPcu0&o)h>y "Ł.+)[V~    & $QAO mqcDa.A'zܦ+.*;W-MQOQQaIW\g[JNNQOOQOROLPNNQROONTPQRb+% Cy-~l.XsJ(nb# `oD.UM{K'^c" V^m*^'c?Xٚ 1^"$E$@)g>cq,#Z# f[!7Pik>B?gL+ ^k#% l4tfqc+k o/l"( 1l lW,z  Gvp7 8 B |;wqK,d  &ga=@vI.wS- <gS0 3,nde+ m]3c4|- J65L:t4J :SB#*2 +U TXҗvcbU= )}xGL'=^\jDG40)". _ '}4 2R>N:,wc )#:ħ _Gւ }\': ?ZYG_9ɡ Ur)`r+$4 NqpeJAo8(jK^@S _vCS:[*%,gZCv{HI5S(9*op?K0vD*&&*f|C@F+ 7(9 >9 1{y* '&(9=<p0 *wu9׋5"x6 [s}!y3  @ؖ?9( Z0 X-|aTkz1PR cFO-987+\N l ](8XRA.\M{/dZ&QOF+|w[1=V5P<^ j R) $H|-tX  Q5ǥ&Mx_R( `B+|!Y-1&&Zh;$Z|I%|! puUdso6rdsxFa!t"q%s=i}" @2F8~lQGr1a8Q~WRJY1Ft?XB]wKeX\4}" XC9EWH}#5L<EI}y N+I}a;}I}z  ]@G}   $Q'209P}[ ޖwo~U}+$J}z B?}3(.3t }U,Lm6t:7|t}<au}$<v4<4/<L//,1!%2בA0o=J X21R*h\0\J S }2t o8#V0[I޾`P|H#{="f0[VH t MmkH ƨ0rJ`H &~ҧ9LH kp` /I1G8PpSbHY] Gl,cG'{` j 3s|Ai{MJM0R#q Q]c| (GmLsVCbKG  Eueeh"'?|2h8t]7gvV?{rF"  Z6iw PV q Ҽ^ dz@O'9~Ea Q-"{}BDz:t 9.p<gu :E !1 2 %Y(5> /N1mGG} LLF;z4tFgu '|9;)3{+ Lf U4 Ci7mɐl;4eN wef! 4?jx Iv[g}Wy)0+G OeT-8Tz mbwSc~kbSa^{eeT  fjugud -3biH+U yybJ) Nu<„;몙l A`C O!) Ͷnѩ 2ck bw$òwE9{Oc  9 ^oSdv68)#P(m)U#u)?A- ,~() T Y f~M[Oe#BIBEHPf^T?C=C8CCQ@#5GXU у12lp vN ,h0. \}ny}|~vfG%!([+w? T ~, ы -  N6CH-;I`d6T*x.yx#( F, \3 ? >J O`A+@xz& ,  ME<@;??Y{ADCh%  .,y5/ %.+ i>.S, Yy 6TtݣP# xO}G*  p ]*0zub{#j1" q)S*  % (3XFyy  pvp!0 JVze* 8&Z*ly$m7x!- .W{yb*  x@&V|xyw+ V / Ayd* LU#MqM c|6U#n$ / "ze)  4ˢW y YN  p*R*  0k63bF2h4fX!uhĜxh}Hk3aex)|<H1s4 > =*  .savtbCbNo/! *mpR){:186q!+ s( YY BaaBy5])N+KP! +  $bUyu3% VAW;m rA* @! ,  ~-IP^{bOTc4E@O* , 'A#e" ,  ,UֻI( iIRvD1"DHg;!* >5  .}e#- ~#sS71  D%,Q '^U=)AQKN'TLYF^*9=:"!eR^$ Cã.  " ELF1[idskmp C& 0 " +! ^ S")//-22  " GX> Ʋ ?T ՜nxtd  !tT;h> ]  |eliFƚϑZV =ihr02mf     ]R~%z6u@}h :DSuJO [5KL'8 aA_SYg   S ]gA-SNv[23qNUduoI(sLg  } ꜱ͜*@-ijrA J@dmdC/U_ h   >1r'AW+ vbewz4w A GVXƲzi d!olAE[`@jl  }aS8lCWEypD.Xuo   e   w|  n    ~    Q    |  ,;lX2 |C) CAUBUWLp4V  (us  y'   '2`  t&C^/-  %xYAVTAI  $[oQ7  $ -#e $Y p"Ÿ)X  $ *N" LrVW   # $ }@PjV  #QT 5-`*V  ~  / 3-ӛ QU  @  hh 2fW    y1z3Y  }6=+ / (;Z  W1 UY.[   N♈h, nQ,i]   SH; 1*P` e 1 %9L  1);b  se= 9m݄x|з/' n %c   z-b,vp G8v9*gI1 N4YL g/&d    (, 'F6>4j9R/ 8G @ Ah@0C2F5 ~e P q t؋[ xpb4-w<5Wqis0Q h  & dV-4= M/% Nj  z da/ Ml   m(\ gl ~C|M %nm   >izTP=C5I.27.}m  |f g%5w=t3ao8 I.m   du N=tU? )U8Eym  t $ X+mQ5@ W8ת Ѳ1^"m 7 2_ě6O8.*f !<=:;DQ   ;yscxBGaZcn+8] >8gl ;yr]wq  ;[2 ,ū姛8Rw < L -@Q4ry <Fvl8Q ̰5J4{  <6(bv$rcp   R.0|   ~<2Q(82#k -t[ rA&~  <#;W, _&-Z<zX%PGw',9"bA~( !$[9<.8sd h~  =a~,Y΀r*vʘc`H90ܤQ0 s"T$A7d!x #  Y,+}Or>oLu@Y ,J g:5) 7|_ uY&A][;a[ a`_p_H#2aafYHsAP[}   Y d2K49yT9K*'$=11\.%D6@f#T, "D` b P#"7  i Yc{'  _a,F  kFOՂ mg Fگ  yt 63{(v1< 1&$eUGxf  ,UqVkӤ * *)zv[   * l/ qě!.y kuh\rTT  (8rN-'ws~ :$rBZm\P ?'W [0+'ÿ̶вԯ ǰʠ  &K\  {&qMZl  %aS' ~H$f~F $bg /;  $ 7  $ ' [#   p x7$ 7   >3C {Z$  9U@ Mv  }10D{ @  t  UĹ lS s*"jŬ TU    W fK    K$i p  a4Ӏ  q T   #T4{xк  v iF[VgiZGDRpq|t@G1  nQV/ 9]]b|׵9 ATS   dH  +    n8p )#.    rI>mcwy×rXx$e\Az,mxősce_ldai]m  Dxv@4#^ֺs1fDA"8'\Q8_O,vgW@ j3-/_.W^;5f:;IUcF7֛D    ;0^;< Z@Ov b>\)\,J}V%Ţs_SbWLy/VhMWivpE  v lhl z`s2n#<e'&i eai!m 9wsh+U  4&C @pdf s  D) ]7 I  a8CƽĿ   ;'91D}MH)qIP   L<kp)&N  <nc=C9   <KF P b{unr |pJ  I<$ 7X*7 1q9  -<M&T ׈h9&pzG%-Ke lx   =}M2݄-V`rF_^V1M X9WMM-hx  [VQ Ӂ" H2ٺ5WZ  od<b  \3Ԩ촬ۤùⱬS  I\C <V `  )    \    F ^  L   .    G      "  (   @  /       D   l    4    K FhO c     b 8 "   5 L mU{  S.$ty  Q u3x NOv  Nl_u PMwdt tL V[TSs F? s F j ȁRFr %FP N~q  EQf  q XD  p &BxA~ Cp )Bs o$a C?Ѐ :o#^ _ 3DLo$ ̯O0$] Ecn)S;oHX] hD!$n-\ ? ^ D JYebn-b Kl_ -Cno n,lE_ B F`n61` OApJfr6` `A j58wa `@"Kj5dsb  @ {Azj5b0c ,?cpj3Uc H>&#/i3Kd =Gf0_i3lӯe  _=iL̗i2p9e V< $7i2e N;+ EDJ~jbi1f  :o C|Ukj1:g #:{ _XOY e1g  %9Z$4 ne0 3o>Rl9J1֍ J9!`ZLA߹پݼY.bn z|} 8JZ$8Gܟϧ޳Y.9cH(35hMr &7%;0&?`.>V6H b+ٞOj- 6%e.# 33 ~ v$SL,A) 16Yv&jco_oba@/?\^Gt 5cG':j,WN0 c.+@OLDk`wDu}NBsVm Y5[)r j58=B%!  4jY+%k   0P'! 3+ 0 J {1i 2?G+l <0  '=0j  1i?2޾ϭX8* VVS- ]!r hG"k \0AxAZ^}9I7@Ns[. A 1]=k b0IB =t^~/ "@1Skm. Rf s!N cMk  /At RVz, pqim. Ol\k /C_f2bz(dZ- v)&#l $." 6Gcdvbl - F$*]X[=,DG2 1 4'5974<$-9:-(1476/..0360!559AID?167<&-=4.c,KTHhGku|E+D(! <%ia$o   +qfg0rhJ+їx" pywc>%  q M 羿e*9"  G6;,p b< -ĝ h!~%3b#*W#{& bo:$[Rr=' jI5Ax(4Lo#F1-`)U#$[@pl[:k*Ln2&SLvkjZ+ GKmt"LALi}$eV-' ]ќu$]\M(x9#$I 7<g?YJB+(ͼAV ӵa` o%(樇Ta&_u|Y'%z$Ҧīۤ@㣬{ ,NdbW,'w&r .y8Q60R&2faZ^_Pr<oNC%֋7vRm x} ZK]%u;9 ʊ%x׌4aIO$? jD tF #_SB4 0.lC*"E *iٺUFHAA"5?1J /gîJTA!M8`N0 AR P `YA[ 4R XR~mAYB!BVIky/ X:|#&qwa5S/L/KM .u o#%tq>۩ 'Fh$L\838T ;T&y ZGV&SrQj4 'T3&]X@,)CB@'hک?KS7 v5-84_3)$3P3oP⥚0 @y % m0P s% _" -  K\n) H{ `&p V z%?y#+d% }TcBzpR.c% |ߛ`cH^0 f9?ZeXݚ^0h E ;L `E^0~@"^0&<yJ^0fxZUbs^0^=?+-_1YsguF  >1j@#p Iz`]]_y=1wn}˔n2 3qG ;:vk9m ̒p2Fl 2akA %33X jސ|L <,ZIpq ŋ;h =RG`a8%?*FN3TTЄS<v/6\;<{h03p:MS28oMDT &@T ]psMZuUbgSjpw;/9{;"<|'; 9M\m.H 1\_v7.'a aC3iM\B'  r\P#?8 $Pj):MT5Q~P`hwtM #xay3b1o-Y!= I $(+ T:M}6 9EE^8W|%uVV#} 9v~UKo2Y i@>a yC:P$( ilK}q#KPFh-P_j S8GwqApvz~-x>' q%[,g3`;`.B,a:f3W9R X/61 ,xL7,"C*s%el<'YY Ek' 'TvoLjhVNgK~vXyZfހwtXOMYbsu೟:RbNiFS&RpFR>g%  n46;Sm  y~S]:0mM <O}SXonJ; i}SPp   }Tr C} -L} D 8US>`2noflOEHD$%qYVgc k¦eB/,D޺ PC G4lgDHIOt@bJn1hrw+A K)BVշ o ]D JYSY3N98Ǻlk-?\؇ CL  _ c HvV ]Q,> [ ? x,eg|R PS 8/=7  @ IG f[dC}a/#pn,=,Ț]` h - .r+, ac/'8{h.-YL[BXWJXp[G-$+<m h)BUXSBqvO}; ~~;J*Xn46;: P: : ;: c1,7A! C(O;E>&Q ey D HC3224? iZ9& _nBtYg`Uf{c"# :xkI  K`O &> ^xr~ qT     .%M a$1 kQ  fhm˷~1&(m쵧u~ sc e-~T73'itWNOa,o.o<~0/ u46p(GMgF? wNu.&gy3ɯ!by42 dN z}ovV(My5${%|46(Y%':\iYZ THmV/*p/ty  >] S(0y])45eY y'+#) E>SG=r{ꕢՔ U(w gqAF|.5X((m46?^R'=N3&@?^/Wv  {  y0~hn9 77GnZ2>h Qu.(-YzGQ)a=G. fI4MI2!Z2pt˃ a2[ ouQ;A0Y6+HU08sp3JG@;9[3MMj M BEt{&EFv3 %/ #݂N#&nx/c$dN*\# fߘ>p5'cw2vN]䡅" sBia.}u7 /|}'VWivCqO_qOBToR4l= 8Ps;0E^!#c[n._&JrQlu8PEX=@?lA3el)3Mu8 !mSAY-JqR̨#D󫢷ݱ毡3٫ƐĴKS#BoSEɉS&r;'ZpplXFؑd]ڌSIT&. 'xQ~D9utSM&-"@)pk^ 5ph.{gBD_ix>pKXT'vxU$4skoe4.N,V(" #+ra@Qe0#",47B%X69?xOxj{cD>7b)(wI{|pX'<n't 0|}3-i)'nT\$j`+;,kjVRdU+K5HcI-%Iፅ&V@D:\RICK'S~1\WEBPAG~1\INPROG~1\GUIDEL~1\ARTICLES\GOKAL\GIFS\CATHETER.GIFD:\Rick's Work\Web Pages\In Progres\guidelines\articles\gokal\gifs\catheter.gifDD@5^ e FD5D5TDD@5B5GC55FD  @p` p BCD6 I&mage <=8C HKKKKڑ( ;ng(+003|x"UWPCb513 *%'513 h!h!*3%)+.- h1h1b WPCb513 *%'513 h!h!*3%)+.- h1h1d WPCb513 *%'513 h!h!*3%)+.- h1h1ffff)!dxdx d !USUS.,  _SS S L8XXAL8L8 #AX4XAL8{##X4XXAX4#AX4XXX4SVS#X4XXAX4# L8XX4AL8L8#AX4XAL8l#ReviewsandOriginalArticles V  #X4XXAX4#AX4XXX4   Sq T   #X4XXAX4%#AX4XXX4PERITONEALCATHETERSANDEXITSITEPRACTICESTOWARDOPTIMUM  PERITONEALACCESS:1998UPDATE #X4XXAX4#AX4XXX4   (OfficialReportfromtheInternationalSocietyforPeritonealDialysis) T݌  Ќ     S. ~ + x  RamGokal,1,StevenAlexander,2,StephenAsh,3,TzenW.Chen,4, . ~ AndersDanielson,5,CliffHolmes,6,PrebenJoffe,7,JackMoncrief,8,  j KirtNichols,9,BethPiraino,10,BarbaraProwant,9,AlainSlingeneyer,11,  V BerndStegmayr,12,ZbylutTwardowski,9,StephenVas13 x݌  B Ќ     S 1    ManchesterRoyalInfirmary,1,Manchester,U.K.;   StanfordUniversityMedicalCentre,2, p  Stanford,HemoCleanse,3,WestLafayette,Indiana,U.S.A.; \  VeteransGeneralHospital,4,Taipei,Taiwan; H  KarolinskaInstitute,5,Huddinge,Sweden; 4  BaxterHealthcare,6,McGawPark,Illinois,U.S.A.;HolbkCountyHospital,7Holbk,Denmark;  p  MoncriefDialysisCenter,8Austin,Texas,UniversityofMissouri,9Columbia,Missouri;  \ UniversityofPittsburghMedicalCentre,10Pittsburgh,Pennsylvania,U.S.A.; H H==pitalLapeyronie,11Montpellier,France; 4 UniversityHospital,12Ume,Sweden;   TorontoWesternHospital,13Toronto,Ontario,Canada ݌   Ќ     SNK   ?Nxhd$~bp@+pddx bEb V9f ݌̌     S0    #X4XXAX4#AX4XXX4Thekeytosuccessfulchronicperitonealdialysis ݌ 0 Ќ  #X4XXAX4W#AX4XXX4   Sro 6  (PD)ispermanentandsafeaccesstotheperitonealcavity.Despiteimprovementsincatheter r survivaloverthelastfewyears,catheterrelatedcomplicationsstilloccur,causingsignificant ^ morbidityandoftenforcingtheremovalofthecatheter.Catheterrelatedproblemsareacauseof J permanenttransfertohemodialysis(HD)inupto20%ofallpatientswhoneedsuchtherapy 6 changes;manymorerequiretemporaryperiodsonHD.Sincetheincidenceofperitonitisis " r decliningfollowingtheintroductionofnewconnectology,catheterrelatedcomplicationsduring !^ PDhavebecomeamajorconcern. 6f݌ !J Ќ     S#9#   Apanelofexperts,whoarecoauthorsofthisreport,recentlymettodiscusscatheterrelated # problemswithaviewtoestablishingguidelinestowardoptimalperitonealaccess.Someofthe x$ membersofthisgroupalsoparticipatedinpreviousreports(Oreopoulosin1987;Gokaletal.in d%  1993).Whereverpossible,theguidelinesareevidencebased(e.g.,randomizedcontrolledtrials); P&! wherescientificevidenceisnotavailable,recommendationsarebasedonaconsensusopinion.It <'"  isourhopethattheseguidelinesforperitonealcathetermanagementwillhelptoimprove ((x#! cathetercareand,therefore,patientoutcomes.AnAppendixgivesguidelinesforpediatric )d$" catheterpracticeswheretheydifferfromtheadultpractices.  ݌ *P%# Ќ     S+&?+& :   #X4XXAX4#AX4XXX4PERITONEALCATHETERS :j݌ +&$ Ќ  #X4XXAX4#AX4XXX4   S$-t(,!(   Theidealcatheterprovidesreliable,rapiddialysateflowrateswithoutleaksorinfections. $-t(% Despitemanynewercatheterdesigns,theTenckhoffcatheterisstillmostoftenused(USRDS  1992;Lupoetal.,1994).Variationsoftheperitonealcatheterincludethenumberofcuffs(one  versustwo),thedesignofthesubcutaneouspathway(permanentlybentvsstraight),andthe  intraabdominalportion(straightvscoiled). ݌ t Ќ     S V R   #X4XXAX4Q#AX4XXX4TypesofCatheters(Figures1and2) R݌  V Ќ  #X4XXAX4#AX4XXX4mYV9)%`|0Y t `h %EY ttf zm p(#p(#(#(#   S f  2   Thechronicperitonealcatheter  f comprisesanintraӀandan R  extraperitonealportion;the >  latterconsistsofa *  subcutaneouspartthathasa   meanstoanchorthecatheter   (e.g.,cuffs),andtheexternal   portionbeyondtheexitsite  (thelatteristhesameforall v catheters).Thestandard,two b cuff,straightTenckhoff N catheterisstillthemostwidely : usedaccessdevice,becauseit &v satisfiestheneedsofmost b patientsandthereisno N conclusiveevidencethatany : othercatheterissuperior & (USRDS1992;Piraino,1995;  Lupoetal.,1994).Thereare,  however,manycatheter  variationsdesignedto  minimizecomplicationsof r  pain,inadequateflow,and ^! infections(Figures1and2). J" Cathetersthatarecommonly 6# usedtogainperitonealaccess "$r  areshowninFigure1.These %^ ! arethestandardoneӀortwo %J!" cuff,straightorcoiled &6"# Tenckhoffcatheters,theSwan '"#$ neckcatheters,andthe ($%  (#(#p(#p(#Toronto!!WesternHospital(TWH)catheter.Figure2showsthecurrentlyavailablechronic )$& catheters,illustratingtheintraperitoneal(IP)andextraperitoneal(EP)designs.Itispossibleto *%' combineEPandIPdesignsasshown. 2 b ݌ +&( Ќ     S-d(,( +(   IntraperitonealSegment""forImprovingOutflow: Thecathetershouldalwaysalloweasy -d() inflowandoutflowoffluid;thelattercanbemorevariableanddifficult,especiallyduringthe  lastpartofdrainage. +([(݌  Ќ     S.~+ )   Straight: Thestraightcatheter,whichcanbeutilizedincombinationwithalmostall .~ extraperitonealdesigns(Figure2),isthemostcommondesignandtheonethatwasoriginally n usedwhenthecatheterwasintroducedinthe1960sbyTenckhoff.Itcomprisessideholesto  Z enhanceflowinandoutoftheperitonealcavity. )&*݌  F Ќ     S 5  1,   Coiled: Thecoiledcatheterdesign,whichcanbeutilizedincombinationwithmost   extraperitonealdesigns(Figure2),providesanincreasedbulkoftubingtoseparatetheparietal x  andviscerallayersoftheperitoneum.Flowinandoutofthetipofthecatheterismoreprotected d  andtherearemoresideholesforoutflow.Itisbelievedthatthisdesignallowsforbetterflow, P  lessinflowpain,lesspropensityforcathetermigrationandomentalwrapping,andisless <  traumatictoviscerathanthetipofastraightcatheter;however,conclusiveevidenceforthisis (x  lacking. 1,a,݌ d  Ќ     S S  /   SiliconeDiscs: Siliconediscsperpendiculartothecatheter(asintheTWHcatheter,Figures1   and2)holdtheomentumandbowelawayfromtheexitholes.Thesearealsodesignedto  maintaintheirpositioninthepelvisandthusminimizecathetertipmigration.Disadvantages  includemoredifficultsurgicalimplantationandremovalthanstandardTenckhoffcatheters. //݌ n Ќ     SP 2   TFluted: Thisdesignisshapedlikea  T.Theintraperitonealportionliesagainsttheparietal P peritoneum.Insteadofsideholes,theintraperitonealportionhaseight,1mmwidelongitudinal @   flutesorgrooves.Thisdesignallowsbetterflowandpreventsmigration(AshandJanle, , 1993). 2C2݌  Ќ     SZW 4   SubcutaneousTract:Straight: ThisoriginaldesignhasbeenusedwithsingleӀordoublecuff Z cathetersorthebeadedTWHcatheter.Thesubcutaneoussegmentmaybeimplantedinan J arcuatetunnel,toenablethecatheterexittobecaudallyorlaterallydirected.Implantationofthe 6 straightcatheterinanarcuatetunnelmayincreasecathetertipmigrationorexternalcuff "r extrusionasthecathetertendsto  straightenbecauseofitsresilienceor  shapememory; ^ however,goodresultswithstraightcatheterscanbeachieved(Favazzaetal.,1995). 44݌ J Ќ     S!9! b8   PermanentBend: Thisdesignhasapreformedbend,eliminatingtheresilienceforceor  shape ! memoryofstraightcatheters.Itmustbeimplantedinatunnelthatexactlyreflectsthisshape. |" Thereareseveralvarietiesavailable: b88݌ h# Ќ  + , ,?+ ` hp x X?  S$J $+[:  1.TheSwanneckcatheter.InvestigatorsattheUniversityofMissouri(Twardowskietal, $J  1992)haveadvocatedcatheterswithaninvertedUshapedarc(170!!180degrees) %6! betweenthedeepandsuperficialcuffs.TheUshaped,(arcuate)bendallowsthecatheter &""  toexittheskinpointingdownwardandyetentertheperitoneumpointingtowardthe '#! pelvis,inanunstressedconditionasTenckhofforiginallysuggested.Thebeadanddisc (#" cuffisincorporatedintothedesign.TheSwanneckTenckhoffdiffersfromthedouble )$# cuffTenckhoffonlybythe170!!180degreebendbetweenthecuffs. *%$ 2.TheMoncrief!!Popovichcatheter(Moncriefetal.,1996).Thiscatheterisverysimilar n+&% tothestandardSwanneckTenckhoffcatheterexceptthattheexternalskincuffis Z,'& elongatedto2.5cmandistaperedattheendsofthecuff. F-(' 3.TheSwanneckMissouri(seebelow).  4.Pailhandle(Cruz)catheter(Cruz,1992).Thiscatheterhastworightanglebends:one  todirecttheintraperitonealportionparalleltotheparietalperitoneum,andonetodirect  thesubcutaneousportiondownwardtowardtheskinexitsite.Thecuffsaresmall, t permittingperitoneoscopicinsertion.Thecatheterisavailableonlyinpolyurethane.The ` clinicalbenefitsofthiscatheterincludemorerapidinflowandoutflowthanstandard L  siliconecathetersbecauseofthelargerinnerdiameter. 8  5.Swanneckpresternalcatheter.ThiscatheterisamodifiedSwanneckMissouricoil $ t catheter.ThemajordifferencefromthestandardSwanneckMissouricatheterisinthe  ` lengthofthesubcutaneoustunnel.Thecatheteriscomposedoftwosiliconerubbertubes  L  thataretobeconnectedendtoendatthetimeofimplantation(Twardowskietal.,1996).  8  Theimplantedlower(abdominal)tubeconstitutestheintraperitonealcathetersegment $  andapartoftheintramuralsegment.Theupper,orchest,tubeconstitutestheremaining   partoftheintramuralsegmentandtheexternalcathetersegment.Thisupperparthastwo   cuffs,oneoneithersideofthebentsegment.Thiscatheterisusefulinextremelyobese   patientsandthosewithostomies(Twardowskietal.1996).+[::݌   Ќ , ,! XX!  ?+ ` hp x X?   Sf 3G   OutcomeinRelationtoExitDirection: Adownwarddirectedexitsitewasassociatedwith f lowerperitonitisratesinareportfrompediatriccentersinNorthAmerica(Waradyetal.,1996). V Inaddition,theNetwork9studyfoundthatdirectingthesubcutaneousportionofthecatheter B downwarddecreasedtheriskofperitonitisassociatedwithexitsiteand/ortunnelinfectionby . 38%,whileanupwarddirectedcatheterhada50%increasedriskofcatheterrelatedperitonitis,  comparedtohorizontallydirectedtunnels(Golperetal.,1996).TheUnitedStatesRenalData  System(USRDS)reportedthattherelativeriskofperitonitiswasessentiallyidenticalforstraight  andbentcatheters;however,whentheanalysiswasrepeatedwithadjustmentforpossiblecenter  effect,theperitonitisratewassignificantlylowerwithpermanentbentcatheters. 3GcG݌ z Ќ     S \  3L  Swanneckcathetersweredesignedtodiminishcuffextrusionsandcathetertipmigration  \ associatedwithstraightcathetersimplantedinarcuatetunnels.Althoughseveralstudieshave H shownnoadvantageofbentcathetersoverstraightcatheters(Nebeletal.,1991;Bonzeletal., 4 1993),otherstudieshaveshownsignificantlybetterresults(HwangandHuang,1994;Tielenset   al.,1993).RandomizedstudiescomparingaSwanneckcathetertothestraightTenckhoff   catheterwithoutapreformedbendshowedalowerprobabilityforafirstexitinfectionwiththe ! Swanneckcatheter,butthesurvivalwasnotdifferent(Eklundetal.,1994;Eklundetal.,1995). " CuffextrusionsandcathetermigrationwereseenonlyintheTenckhoffcatheters.Inanother #  randomizedstudy,therewasasignificantlylowerrateofexitsiteinfectionswithSwanneck l$! catheters(Lyeetal.,1996). 3LcL݌ X% " Ќ     S&:"&! Q   Anchorage:DacronCuffs: Theseareeitheroneortwoinnumberandaremadeofpolyester &:"# fiber.Theusualdistancebetweenthetwocuffsis5cms.Forobesepatientsthismaybe '*#$ inappropriatelyshort.Asinglecuffcanfunction(flowandstability)aswellasadoublecuff ($% whenthesinglecuffisinthedeepposition. QLQ݌ )%& Ќ     SD+&*A& US   TheBeadandFlangeattheDeepCuff: Thisfeatureisutilizedtostrengthentheanchorageof D+&' thecatheterintotheabdominalwall.Duringimplantation,theballislocatedintraperitoneallyand 4,'( theflangeispositionedflatabovetheperitoneumontheposteriorrectussheath.Apursestring  -p() suturebetweenthebeadandtheflangedecreasestheriskofearlyleakage.Theflangeincreases  themassoftissueingrowthintothecuff/flangestructure,whichdecreasestheriskofleakage. USS݌  Ќ  + , ,?+ ` hp x X?  S.~++yV  1.TheTWHcatheterhastheflangeandbeadaffixedperpendiculartothetubing. .~ 2.TheSwanneckMissouricatheterhasthebeadandflangeaffixedtothetubingata45 j degreeangle,sothat,withplacement,theintraperitonealpartnaturallytendstoangle  V downwardswithlesstendencytomigrateintotheupperabdomen.Theslantedflange  B andbead,andbenttunnelsegmentrequirethattheSwanneckMissouricathetersforright  . andlefttunnelsbemirrorimagesofeachother.Aradiopaquestripeonthefrontofthe   catheterfacilitatesrecognitionoftherightandleftMissouricathetersandproper   implantation.+yVW݌    Ќ , ,! XX!  ?+ ` hp x X?   S4 1  ![   OutcomeinRelationtoNumberofCuffs: Thesinglecuffcatheterisassociatedwithashorter 4  timetothefirstperitonitisepisode(USRDS1992;Waradyetal.,1996;Hondaetal.,1996).In $t  addition,thesinglecuffcatheter(Lindbladetal.,1988;Favazzaetal.,1995)hasmoreexitsite `  complicationsandshortersurvivaltimesthanthedoublecuffcatheter.Therefore,convincing L  dataexisttoindicatethatdoublecuffratherthansinglecuffcathetersshouldbeusedforchronic 8 PD. ![Q[݌ $ Ќ     Sfc ^   #X4XXAX4z#AX4XXX4CatheterMaterials ^^݌ f Ќ  #X4XXAX4_#AX4XXX4   SH _   Silicone: Themostfrequentlyusedmaterialforpermanentcathetersoverthelast30yearshas H beensmoothsiliconerubber(Silastic).ThestandardPDcatheterisstillmadeofsiliconerubber 8 andprovidedwithuptotwopolyestercuffs.Thesiliconerubberisapolymerofmethylsilicate, $ thehighermolecularweightsbeinggumsfromwhichsiliconerubberismade.The  biocompatibilityofsiliconerubberissatisfactorybecauseitisinert,atraumatictothe  surroundingtissues,soft,flexiblethroughawiderangeoftemperatures,andcontainsno  clinicallyharmful,leachableplasticizers. __݌  Ќ     Sf hc   Polyurethane: Toovercometheproblemofcatheterwallstrength,polyurethanehasbeenused. f Thishasallowedthinnerwalledcatheterswithlargerlumens,thusallowingforquickerflows.It V isalsomorepliablewithincreasingtemperature.Theredoesappeartobehydrolysisofthe B polyurethanesurfaceandtherehavebeenreportsofcrackingofthematerialwithconstantuse,  . especiallywhenpolyethyleneglycoloralcoholisapplied.Theexperiencesofonlyonecenterare ! available(Cruz,1992). hcc݌ " Ќ  S% 4% #X4XXAX4_# AX4XXX4CATHETERCHOICEANDCATHETEROUTCOMES %   #X4XXAX4f#AX4XXX4   S&E"&! xg  ANetwork9study(Golperetal.,1996)reportedtheoutcomeof1930cathetersusedbetween &E"  1991and1993.Overall,1Ӏand2yearcathetersurvivalswere82%and70%,respectively. '1#! Peritonealdialysisrelatedinfections,includingperitonitis,catheterrelatedperitonitis,and ($" catheterinfection,accountfor75%ormoreofthecatheterslost(Golperetal.,1996;Eklund, ) %# 1995;Weberetal.,1993).IntheNetwork9study,mechanicalproblemssuchasdialysateleaks *%$ (3%)anddrainagefailure(4%)werelesscommoncausesofcatheterlossthanreasonsinvolving +&%  infections. xgg݌ },'& Ќ     SS !k   #X4XXAX4Ig#AX4XXX4OutcomeStudies !kQk݌ S   #X4XXAX4k#AX4XXX4   SB ll   Thesearesummarizedasfollows: lll݌  Ќ     S'w$ :m   RandomizedStudies: Table1summarizesoutcomesinrandomizedtrialswithvariouscatheter 'w designsandplacementtechniques. :mjm݌  g Ќ     S V  n   OtherOutcomeAnalyses: Anextensiveoverviewofoutcomesintermsofcomplicationrates   (infection,obstruction,andleaks)bytypeofcatheterandplacementtechniquehasbeen   publishedandshowsvariableresults(AshandNichols,1994). nn݌   Ќ     Sg   ]p   RECOMMENDATIONS ]pp݌ g  Ќ  + , ,?+ ` hp x X?  S V +q  1.Cathetersurvivalof>80%at1yearisareasonablegoal.   2.Convincingdataexisttoindicatethatthedoublecuffcatheterispreferabletothe   singlecuffcatheter,thereforeadoublecuffconfigurationisadvocated.   3.Adownwarddirectedexitmaydecreasetheriskofcatheterrelatedperitonitis. m  Properlyimplanted,preformedarcuateorpailhandlecatheters,willalwayshavea Y  downwarddirectedexitandare,therefore,advantageousinthisrespect. E  4.Overall,nocatheterappearstobesuperiortotheoriginal2cuff,standardTenckhoff 1 catheter,althoughexperiencewithSwanneckcathetersispromising;thereisaneedfor m large,randomizedprospectivestudiesandlongtermexperience.+qq݌  Y Ќ , ,! XX!  S*GH ddd Xdd Xdd X(#(#,,} ,,,+  5+HH 5?+ ` hp x X?   SH S x   #X4XXAX4=l#AX4XXX4Table1 #X4XXAX4x#AX4XXX4 xax݌ F<    FЌ     S* y  RandomizedControlledStudiesonCatheterOutcome yy݌ F< *   FЌ     Si z  ?Jxhd$~bp@+pddx bEb V9jf zz݌ B8 i   BЌ     SXU &|   Study  &|V|݌ 'X 'Ќ     SXU |   Catheter  |}݌ +!X +Ќ     SXU }   Outcome  }}݌ * X *Ќ     SXU ~   Significance  ~~݌ C9X  CЌ     SD i  ?Lxhd$~bp@+pddx bE3b V9f i݌ B8    BЌ     S&   #X4XXAX4y#AX4XXX4Akyol, & 1990#X4XXAX4l#AX4XXX4 ݌ ' 'Ќ     S& G  #X4XXAX4́#AX4XXX4Tenkhoffstraightvscoiled,20 & pts#X4XXAX4ɂ#AX4XXX4 Gw݌ ' 'Ќ     S&   #X4XXAX4B#AX4XXX41yrSurvival:#X4XXAX4>#AX4XXX4 ݌ '& 'Ќ     S&   #X4XXAX4#AX4XXX490%Straight & 70%Coiled#X4XXAX4#AX4XXX4 H݌ '  'Ќ     S&   #X4XXAX4#AX4XXX4NS#X4XXAX4#AX4XXX4 †݌ ?5&!  ?Ќ     S!Q    #X4XXAX4X#AX4XXX4Nielson, !Q" 1995#X4XXAX4l#AX4XXX4 ݌ '!=# 'Ќ     S!Q  I  #X4XXAX4ψ#AX4XXX4Tenckhoffstraightvscoiled,72 !Q$ pts#X4XXAX4ˉ#AX4XXX4 Iy݌ '!=% 'Ќ     S!Q    #X4XXAX4E#AX4XXX43yrSurvival:#X4XXAX4A#AX4XXX4 ݌ '!Q& 'Ќ     S!Q    #X4XXAX4#AX4XXX478%Straight !Q' 40%Coiled#X4XXAX4#AX4XXX4 K݌ '!=( 'Ќ     S!Q    #X4XXAX4#AX4XXX4p<0.01#X4XXAX4#AX4XXX4 ō݌ ?5!Q)  ?Ќ     S,#|")   #X4XXAX4a#AX4XXX4Scott,1994#X4XXAX4u#AX4XXX4 #݌ ',#|* 'Ќ     S,#|") <  #X4XXAX4#AX4XXX4Straightvscoiledvs ,#|+ TorontoWestern,90pts#X4XXAX4#AX4XXX4 <l݌ +!$h, +Ќ     S,#|")   #X4XXAX4b#AX4XXX4Nodifferencesincomplications#X4XXAX4b#AX4XXX4 ݌ * ,#|- *Ќ     S,#|") @  #X4XXAX4Ò#AX4XXX4NS#X4XXAX4“#AX4XXX4 @p݌ ?5,#|.  ?Ќ     SW% %T    #X4XXAX4#AX4XXX4Eklund, W% / 1994#X4XXAX4#AX4XXX4 Ȕ݌ 'C&!0 'Ќ     SW% %T    #X4XXAX4|#AX4XXX4StraightvsSwanneck,40pts#X4XXAX4x#AX4XXX4 &݌ 'W% 1 'Ќ     SW% %T  Q  #X4XXAX4ז#AX4XXX42yrSurvival:#X4XXAX4ӗ#AX4XXX4 Q݌ 'W% 2 'Ќ     SW% %T    #X4XXAX43#AX4XXX478%#X4XXAX4/#AX4XXX4 ݘ݌ 'W% 3 'Ќ     SW% %T    #X4XXAX4t#AX4XXX4NS#X4XXAX4p#AX4XXX4 ݌ ?5W% 4  ?Ќ     S'"/'" F  #X4XXAX4#AX4XXX4Eklund, '"5 1995#X4XXAX4ț#AX4XXX4 Fv݌ 'n(#6 'Ќ     S'"/'"   #X4XXAX4*#AX4XXX4StraightvsSwanneck,40pts#X4XXAX4&#AX4XXX4 Ԝ݌ ''"7 'Ќ     S'"/'"   #X4XXAX4#AX4XXX43yrSurvival:#X4XXAX4#AX4XXX4 /݌ ''"8 'Ќ     S'"/'" [  #X4XXAX4#AX4XXX490%Swanneck '"9 80%Tenckhoff#X4XXAX4ݟ#AX4XXX4 [݌ 'n(#: 'Ќ     S'"/'" ٠  #X4XXAX4_#AX4XXX4NS#X4XXAX4[#AX4XXX4 ٠ ݌ ?5'";  ?Ќ     S)$Z)$ 1  #X4XXAX4#AX4XXX4Lye,1996#X4XXAX4#AX4XXX4 1a݌ ')$< 'Ќ     S)$Z)$ x  #X4XXAX4#AX4XXX4StraightvsSwanneckcoiled,40 )$= pts#X4XXAX4#AX4XXX4 x݌ '*%> 'Ќ     S)$Z)$   #X4XXAX4t#AX4XXX41yrSurvival:#X4XXAX4p#AX4XXX4 ݌ ')$? 'Ќ     S)$Z)$ J  #X4XXAX4Х#AX4XXX495%Swanneck )$@ 90%Straight#X4XXAX4̦#AX4XXX4 Jz݌ '*%A 'Ќ     S)$Z)$ ǧ  #X4XXAX4M#AX4XXX4NS#X4XXAX4I#AX4XXX4 ǧ݌ C9)$B  CЌ     S+('+& #   #c݌ * +('C *Ќ     S+('+&   #X4XXAX4#AX4XXX4Swanneck:#X4XXAX4b#AX4XXX4 ݌ '+('D 'Ќ     S+('+& (  #X4XXAX4#AX4XXX4lessexitsiteinfection#X4XXAX4#AX4XXX4 (X݌ '+('E 'Ќ     S+('+&    ά݌ C9+('F  CЌ     S-g(,( d  ?Pxhd$~bp@+pddx bE-b V9h-f d݌0&$-g(G   0Ќ     SS Ӯ   #X4XXAX4#AX4XXX4CATHETERINSERTION Ӯ݌ S Ќ  #X4XXAX4X#AX4XXX4   SB    Ideally,catheterinsertionshouldbeundertakenunderoperatingroom,sterileconditions.  Thiscanbedoneoneitheraninpatientoranoutpatientbasis.Severalplacement  techniquesaredescribedandpracticed: G݌ m Ќ  + , ,?+ ` hp x X?  S O +  1.Surgicalplacementbydissection.  O 2.BlindplacementusingTenckhofftrocar.  ; 3.Blindplacementusingguidewire(Seldingertechnique).  ' 4.Minitrocarplacementusingperitoneoscopy.   5.Othermodifications(MoncriefandPopovich,presternal).+L݌   Ќ , ,! XX!  ?+ ` hp x X?   SA >  Ǵ   #X4XXAX4#AX4XXX4PreimplantationPreparation Ǵ݌ A  Ќ  #X4XXAX4L#AX4XXX4   S#     Theprocedure,includingtheincidenceandnatureofcomplications,shouldbedescribedtothe #  patientandallquestionsansweredinareassuringway,allowingachangetoHDifnot   satisfactory. D݌   Ќ     S=:    PresurgicalAssessment: Presurgicalassessmentofthepatientisessential,searchingfor =  herniation,eventration,andweaknessoftheabdominalwall.Ifpresent,itmaybepossibleto -} correcttheseatthetimeofcatheterinsertion.Peritonealdialysisshouldthennotstartduringthe i first4weeks,duetoincreasedriskofleakage. ׷݌ U Ќ     SD    DeterminationoftheExitSite: Priortoinsertion,theexitsiteshouldbeidentifiedandmarked  ontheskin.Thiscanbedonebytheoperatingsurgeon,thenephrologist,oranexperiencedPD  nurse.Itisadvisabletoavoidlocationswheretheremaybepressureduringdailyactivities.  ݌ s Ќ     SU    Theexitsiteshouldbe: %݌ U Ќ  + , ,?+ ` hp x X?  SD+  1.eitheraboveorbelowthebeltline,shouldnotlieonascar,andshouldnotbein  abdominalfolds.Theumbilicusshouldnotbeusedasareferencemark;  2.determinedwiththepatientinanupright(seatedorstanding)position; o 3.placedlaterally.Astencilcanbeappliedtodemarcatethetunnelandexitsiteclearly [  (asisthecasefortheSwanneckcatheterinsertion).+F݌ G! Ќ , ,! XX!  ?+ ` hp x X?   S")" (   SkinPreparation: Onthemorningoftheoperation,thepatientshouldbatheorhaveashower ") withchlorhexidinesoap.Ifnecessary,abdominalhairshouldbeclipped.Patientsnaresmaybe # swabbedtodeterminenasalcarriageofStaphylococcusaureus.Eradicationofnasalcarriagehas $  shownsignificantimprovementinexitsiteinfectionsbuthasacostimplications(Drydenetal., %  1991;MupirocinStudyGroup,1996). (X݌ &! Ќ     S(o#'#    BowelPreparation: Bowelpreparationandtheavoidanceofconstipationareofparamount (o# importance.Similarly,emptyingthebladderbeforetheprocedureismandatory. /݌ )_$  Ќ     S*%N*% w   ProphylacticAntibioticsBeforeImplantation: Thereissomerecentevidencethatprophylactic *%! antibioticspreventsubsequentcatheterinfections,peritonitis,andwoundsepsis(Golperand +&" Tranus,1996).Inarecentcontrolledstudyusingcefuroxime(1.5g,IV1!!2hours },'# preoperatively,and250mgintraperitoneallyperioperatively),theprophylacticgrouphadfewer i-($ peritonitisepisodesthancontrols(Wikdahletal.,1997).However,otherreportsdiffer(Lyeetal.,  1992).USRDS1992datain3366patientsshowednodifferencebetweenpatientshavinghad  antibioticprophylaxiscomparedtothosewhodidnot(usingtheCoxproportionalhazards  method). w݌ t Ќ     S V z  Nevertheless,theuseofantibioticprophylaxisduringsurgicalinterventionshasalargeand  V convincingliterature.Itusuallyconsistsofusinganantistaphylococcalantibiotic,given1hour  B preӀand6!!12hourspostoperation. z݌  . Ќ     Sp  m V   RECOMMENDATIONS V݌ p  Ќ  + , ,?+ ` hp x X?  SR +  1.Theexperienceingeneralsurgicalpracticeindicatesthatperioperativeantibiotics, R  especiallyinthepresenceofaforeignbody,diminishtheincidenceofwoundinfection.A >  firstgenerationcephalosporinhasbeenmostfrequentlyusedinthiscontextandis *  advocatedespeciallyincenterswithhighpostoperativewoundorexitinfections.   2.Vancomycinshouldnotberoutinelyusedforperioperativeprophylaxistoavoidthe   developmentofresistantmicroorganismssuchasvancomycinresistantenterococci   (VRE)andvancomycinresistantStaph.aureus.+݌  Ќ , ,! XX!  ?+ ` hp x X?   Sl    #X4XXAX4#AX4XXX4CatheterImplantationTechniques ݌ l Ќ  #X4XXAX4#AX4XXX4   S[   Theimplantationtechniquehasasignificantinfluenceonthecomplicationsandoutcomeofthe  chronicperitonealcatheter.Toachievegoodlongtermresults,implantationmustbeperformed  byacompetentandexperiencedcatheterinsertionteam.Inexperiencedpersonnelshouldnotbe  permittedtoperformtheimplantationexceptunderthedirectsupervisionofanexperienced r physicianorsurgeon.Thereareseveralareasofgeneralagreementregardingtheplacementof ^ peritonealcatheterdevices.  ݌ J Ќ     S,    RECOMMENDATIONS ݌ , Ќ  + , ,?+ ` hp x X?  Snk+  1.Theimplantationmustbeperformedbyacompetentandexperiencedoperator,ina n plannedmanner.Theproceduremustberegardedasanimportantsurgicalintervention Z demandingcareandattentiontodetailequaltoanyothersurgicalprocedure. F  2.Peritonealentryshouldbelateral(deepcuffinorbelowtherectusmusculature),or 2! paramedian(deepcuffatthemedialedgeoftherectusmuscle),togivegooddeepcuff "n fixationandminimizeherniationandfluidleaks.Otherentrysites(midlinethroughthe  #Z lineaalba)areusedwithtrocarinsertions. #F 3.Thedeepcuffshouldbeplacedinthemusculatureoftheanteriorabdominalwallorin $2  thepreperitonealspace.Goodresultshavealsobeenobtainedwiththecuffplacedwithin %! theposteriorrectusfascia.Thedeepcuffshouldneverbeplacedwithintheperitoneal & "  cavity.Afterproperpositioningofthecathetertip,theperitoneumisclosedtightlyaround '"! thecatheterbelowthelevelofthedeepcuffusingapursestringsuture. (#" 4.Thesubcutaneouscuffshouldbelocatedneartheskinsurfaceandatadistanceofat ~)$# least2cmfromtheexitsite.Careshouldalsobetakentoavoidmechanicallystressing j*%$ thecuffmaterial. V+&% 5.Checkforcatheterpatency.Thecathetershouldbetestedtoensurethatthereis B,'& adequateinflowandoutflowwithoutleakage.Techniquestoaccomplishthisinclude .-~(' infusing1Lofperitonealfluidover5minutesandallowinganequaltimefordrainage,or  injecting60mLof0.9%salineandobservingif30!!40mLiseasilyaspirated.  6.Theexitsiteshouldbefacingdownwardsorbedirectedlaterally.Upwarddirectedexit  sitesshould,ingeneral,beavoided. t 7.Theintraabdominalportionofthecathetershouldbeplacedbetweenthevisceraland ` parietalperitoneumtowardthepouchofDouglasandshouldnotbeplacedwithinloops L  ofbowelordirectlyinomentaltissue.Thismaneuverhasbeenshowntobefacilitatedby 8  theuseofabentstylet(Stegmayretal.,1993)oranydevicethatwilladdrigiditytothe $ t catheter.+3݌  ` Ќ , ,! XX!  ?+ ` hp x X?   S O    SurgicalInsertionofPDCatheters(PlacementbyDissection):Surgicalimplantationisthemost    commonmethodforplacementofchronicperitonealcatheters.Surgicalplacementbeginswith   eitherextensivelocalanesthesiaorlightgeneralanesthesia.Therearetwogeneralapproaches: z  thelateralapproachandtheparamedianapproach.Eithercanbeusedwithanyofthecatheters, f  althoughTWHandMissouricathetersareusuallyplacedusingtheparamediantechnique. R  Detaileddescriptionsofthevarioustechniquescanbefoundelsewhereandarenotreproduced >  here(AshandNichols,1994;AshandDaugirdas,1994). ݌ *z Ќ     S i K   BlindInsertionTechnique(TenckhoffTrocar): Thisprocedureshouldnotbedoneinpatients   whoareextremelyobeseorwhereintraabdominaladhesionsmaybeexpected,sincetheriskof  bowelperforationswillbeincreasedinsuchpatients.Italsoisnotoptimalinpatientsforwhom  PDistostartacutely,sincethereisanincreasedincidenceforearlyleakage(2%!!43%),  outflowfailures(5%!!50%),andinfectiouscomplications.Normally,thecatheterforchronic p useisinsertedononeoccasionandthennotuseduntil2!!4weekslater,enablingingrowthof \ thecuffandtherebyreducingtheriskofleakage.Ifanimmediatestartisnecessary,andsupine H dialysisisnotpossible,thenthistechniqueisinappropriate.Surgicalbackupshouldbeavailable 4 forcomplicationssuchasbowelperforationorexcessivehemorrhage.Thedetaileddescriptionof  p theinsertiontechniquehasbeenpreviouslydescribed(Gokaletal.,1993;AshandDaugirdas,  \ 1994).Ifthecatheterisnotused,thereisnoneedforregularflushingtomaintainpatencyor H checkingforit. K{݌ 4 Ќ     Sv # s x   BlindPlacementUsingtheSeldingerTechnique: Thistechniqueissomewhatsimilartothe v  splitsheathtechniqueusedforsubclavianorinternaljugularcatheters,andisdescribedindetail f! elsewhere(AshandDaugirdas,1994;AshandNichols,1994). x݌ R" Ќ     S#4# g  Thistechniqueinvolvespassingaguideneedle,attachedtoasyringewith2!!3mLofsaline, #4 throughthelineaalbaorthedissectedrectusmusclesheathintotheperitonealcavity,withthe $  syringecontentsbeinginjectedafterappreciatingthe  give,indicatingentryintothe % !! peritonealcavity.ASeldingerguidewireispassedthroughtheneedle,whichisthenremoved. g݌ &!" Ќ     S:(#'7#   Atapereddilatorwithsurroundingscoredsheathispassedcaudallyoverthewire,whichisin :(## turnremoved.TheTenckhoffcatheteristheninsertedthroughtheguideandthesheathissplitto &)v$$ allowthecufftoreachtheoutersurfaceofthefascia.Withthecatheterheldinplace,thecatheter *b%% guideisstrippedaway. 8݌ *N&& Ќ     S,'=,' ,   UseoftheMinitrocarandPeritoneoscopy: Theuseoftheperitoneoscopyforperitoneal ,'' catheterplacementisnowwellacceptedanddetailsoftheinsertiontechniquearedescribed -(( elsewhere(AshandNichols,1994;AshandDaugirdas,1994). ,\݌  Ќ     SB?    Moncrief!!PopovichTechnique: Thistechniqueincorporatestwomodificationsofthe B conventionalimplantationprocedure.Thesegmentthatwouldordinarilybebroughtoutthrough 2 theskininthestandardimplantationtechnique,iscompletelyburiedundertheskinina n subcutaneoustunnel.Theentirewoundisthenclosedwithnoexitsite.Healingandtissue  Z ingrowthoccursintothecuffsinasterileenvironment.Atasubsequentdateofconvenience,4  F !!6weeksafterinsertion,asmallincisionismade2cmdistaltothesubcutaneouscuffandthe  2 distalsegmentofthecatheterisbroughtoutthroughtheskin.Thecathetermaybeleftinplace   undertheskinformanymonths.Peritonealdialysismaybeinitiatedimmediatelyfollowing   exteriorization,withoutbreakinorwaitingtime.Thistechniquetheoreticallypreventsearly    bacterialinvasionofthetunnelandthecuffmaterialimmediatelypostoperatively,whenthe   woundisfreshandmostvulnerabletobacterialinvasionintothedeeptissues. 1݌ ~  Ќ     S`      PresternalCatheterInsertionTechnique: ThiscatheterisamodifiedSwanneck,Missouricoil `  catheter.ThemajordifferencefromtheSwanneckMissouricatheterisinthelengthofthe P  subcutaneoustunnel.Thecatheteriscomposedoftwosiliconrubbertubeswhicharetobe < connectedendtoendatthetimeofimplantation.Insertiondetailsaredescribedelsewhere ( (Twardowskietal.,1996). ݌  Ќ  S#X4XXAX4#AX4XXX4SB? S#X4XXAX4# AX4XXX4IMMEDIATEPOSTOPERATIVECARE B  #X4XXAX4%#AX4XXX4   S]    Thegoalsofpostoperativecathetercareareto: ݌  Ќ  + , ,?+ ` hp x X?  SB?+  1.minimizebacterialcolonizationoftheexitandtunnelduringtheearlyhealingperiod; B 2.preventtraumatotheexitsiteandtractiononthecuffsbyimmobilizationofthecatheter; .~ 3.minimizeintraabdominalpressuretopreventleakage.+3݌ j Ќ , ,! XX!  ?+ ` hp x X?   SY t  Thereareseveralapproachestopostoperativecathetercare.However,thereislittleevidenceto  supportthesuperiorityofoneapproachovertheothers.Ingeneralterms,itisadvisableto  minimizecathetermovementandhandlingofthecatheterorexitsiteuntilhealingofthewound  andthecathetertractiscomplete;thisisthoughttotakeatleast3!!4weeks.Thereisalsorisk p  offluidleakageiflargevolumesofdialysateareutilizedprematurely,especiallyifthepatientis \! activewhenfluidisintheperitonealcavity;dialysis,ifundertakenimmediately,needstoutilize H" smallexchangevolumesandthepatientshouldbeinasupineposition. t݌ 4# Ќ     S$ s$ A   #X4XXAX4#AX4XXX4PostimplantationDialysis Aq݌ $  Ќ  #X4XXAX4#AX4XXX4   SX&!&U!   Althoughimmediatedialysiswithoutleakageoffluidispossible,itispreferabletopostpone X&! dialysisfor1!!3daystopermitgoodtissuehealing.Itiscommontoflushtheperitonealcavity D'"  hourlywith200!!1500mL(mostcommonly500mL)PDsolution.Heparin(500!!1000U/L) 0(#! canbeaddedincasesoffibrinorbloodclotformation.Oncetheeffluentisclear,thecathetercan )l$" besafelycapped. ݌ *X%# Ќ     S+&G+& Y  Ifdialysisisrequiredimmediately,itshouldbeinitiatedinthesupineorsemirecumbentposition +&$ withreducedexchangevolumes(500!!1500mL).Forpatientswhowillrequirefurtherdialysis, ,'% thevolumesshouldbeincreasedgraduallyfrom500mLtothemaximaldesiredvolumeinorder r-(& tominimizetheriskofdialysateleaks. Y݌  Ќ     SB?    Dependingontheimplantationtechnique,ambulatoryPDisusuallynotinitiatedfor10daysafter B catheterinsertion;thelongertheperiodofnonusethebetteristhehealing,witharesultant .~ reductionincomplications.Duringthisperiod,thepatientcanbemaintainedwithintermittent j PDasdescribedabove,nighttimecycling,orplacedonHDthroughtemporaryvenousaccessvia  V centralveins.Inthecaseofelectiveimplantation,thepatientremainsoffdialysisuntilthetime  B forcontinuousambulatoryperitonealdialysis(CAPD)training.Iftheperitonealcatheterisnot  . used,thereappearstobenoneedtocheckcatheterpatencyandfunction.   ݌   Ќ     S\  Y K   RECOMMENDATIONS K{݌ \  Ќ  + , ,?+ ` hp x X?  S>  +  1.Flushthecatheterwithsmallvolumesuntiltheeffluentisclear. >  2.CommencementofCAPDisdependentupontheimplantationtechnique,butgenerally *  thecathetershouldbecappedforatleast2weeksbeforeinitiatingCAPD.   3.Peritonealdialysisinthisinterimperiodshouldbeintermittent,usingsmallvolumes   andwiththepatientinasupineposition.Theexchangevolumescanbegradually   increased.+݌  Ќ , ,! XX!  ?+ ` hp x X?   Sl    #X4XXAX4]#AX4XXX4EarlyExitSiteCare ݌ l Ќ  #X4XXAX4,#AX4XXX4   S[   TheoptimalcareofthePDcatheterexitsiteaftercatheterimplantationisnotknown.Thereisno  consensusregardingspecificprocedures,cleansingagents,dressings,ormethodsof  immobilization,andsincetherearenocontrolledstudiesonwhichtorely,therecommendations  belowarebasedonbroad,generalprinciples. -݌ r Ќ     ST &   Dressings: &V݌ T Ќ  + , ,?+ ` hp x X?  SC+  1.Afterimplantation,theexitsiteshouldbecoveredwithseverallayersofsterilegauze.  Transparent,occlusivedressingsshouldnotbeusedalonebecausedrainagetendstopool  attheexitsiteandinthesinus.Gauzedressingsaremoreappropriatebecausetheywick n thedrainageawayfromtheexit.Thesurgicaldressingshouldnotbechangedforseveral Z daysunlessthereisobviousbleedingorsignsofinfection. F  2.Frequentdressingchangesintheimmediatepostimplantationperiodarenotnecessary. 2! Therationaleforlessfrequentdressingchangesisbasedontheriskofcontaminatingthe "n exitateachdressingchange,despiteasepticprecautions,andtheriskoflocaltrauma  #Z frommanipulationsofthecatheter.Thedressingsshouldbechangednomorethanonce #F perweek.Oncetheexitiscolonizedwithbacteria,byweek2or3(Twardowskietal., $2  1996b),morefrequentdressingchangesareindicated. %! 3.Itisgenerallyacceptedthatdressingchangesfollowingcatheterimplantationshouldbe & "  restrictedtospeciallytrainedstaff(Prowantetal.,1993;Lewisetal.,1997).Aseptic '"! technique,usingfacemasksandsterilegloves,isrecommendedforpostimplantationexit (#" sitecare(ProwantandTwardowski,1996). ~)$# 4.Patientsshouldavoidsubmergingtheexitsiteduringhealingtoavoidcolonization j*%$ withwaterborneorganisms. V+&% 5.Althoughsteriledressingsarerecommendeduntiltheexitiswellhealed,thereisno B,'& clearconsensusastowhenpatientsmaybegintoshowerorchangetochronicexitsite .-~(' care.TheexitsiteevaluationandclassificationdevelopedbyTwardowski(seebelow)  maybeusedforthispurpose.Whentheexitsitecanbeclassifiedasgoodorequivocal,  thenshoweringandchroniccareareappropriate.  6.Intropicalorsubtropicalareas,sweatingmayaffectthefrequencyofearlydressing t changes,whichshouldbedonewhentheexitsiteiswet,whenthepatientfeelsitchy ` underthetapedskin,orwhenthestickinessofthetapeislost.+i݌ L  Ќ , ,! X