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IMMEDIATE POSTOPERATIVE CARE

The goals of postoperative catheter care are to:

1. minimize bacterial colonization of the exit and tunnel during the early healing period;
2. prevent trauma to the exit site and traction on the cuffs by immobilization of the catheter;
3. minimize intra-abdominal pressure to prevent leakage.

There are several approaches to postoperative catheter care. However, there is little evidence to support the superiority of one approach over the others. In general terms, it is advisable to minimize catheter movement and handling of the catheter or exit site until healing of the wound and the catheter tract is complete; this is thought to take at least 3 – 4 weeks. There is also risk of fluid leakage if large volumes of dialysate are utilized prematurely, especially if the patient is active when fluid is in the peritoneal cavity; dialysis, if undertaken immediately, needs to utilize small exchange volumes and the patient should be in a supine position.

Postimplantation Dialysis

Although immediate dialysis without leakage of fluid is possible, it is preferable to postpone dialysis for 1 – 3 days to permit good tissue healing. It is common to flush the peritoneal cavity hourly with 200 – 1500 mL (most commonly 500 mL) PD solution. Heparin (500 – 1000 U/L) can be added in cases of fibrin or blood clot formation. Once the effluent is clear, the catheter can be safely capped.

If dialysis is required immediately, it should be initiated in the supine or semirecumbent position with reduced exchange volumes (500 – 1500 mL). For patients who will require further dialysis, the volumes should be increased gradually from 500 mL to the maximal desired volume in order to minimize the risk of dialysate leaks.

Depending on the implantation technique, ambulatory PD is usually not initiated for 10 days after catheter insertion; the longer the period of nonuse the better is the healing, with a resultant reduction in complications. During this period, the patient can be maintained with intermittent PD as described above, nighttime cycling, or placed on HD through temporary venous access via central veins. In the case of elective implantation, the patient remains off dialysis until the time for continuous ambulatory peritoneal dialysis (CAPD) training. If the peritoneal catheter is not used, there appears to be no need to check catheter patency and function.

RECOMMENDATIONS

1. Flush the catheter with small volumes until the effluent is clear.
2. Commencement of CAPD is dependent upon the implantation technique, but generally the catheter should be capped for at least 2 weeks before initiating CAPD.
3. Peritoneal dialysis in this interim period should be intermittent, using small volumes and with the patient in a supine position. The exchange volumes can be gradually increased.

Early Exit-Site Care

The optimal care of the PD catheter exit site after catheter implantation is not known. There is no consensus regarding specific procedures, cleansing agents, dressings, or methods of immobilization, and since there are no controlled studies on which to rely, the recommendations below are based on broad, general principles.

Dressings:

1. After implantation, the exit site should be covered with several layers of sterile gauze. Transparent, occlusive dressings should not be used alone because drainage tends to pool at the exit site and in the sinus. Gauze dressings are more appropriate because they wick the drainage away from the exit. The surgical dressing should not be changed for several days unless there is obvious bleeding or signs of infection.
2. Frequent dressing changes in the immediate postimplantation period are not necessary. The rationale for less frequent dressing changes is based on the risk of contaminating the exit at each dressing change, despite aseptic precautions, and the risk of local trauma from manipulations of the catheter. The dressings should be changed no more than once per week. Once the exit is colonized with bacteria, by week 2 or 3 (Twardowski et al., 1996b), more frequent dressing changes are indicated.
3. It is generally accepted that dressing changes following catheter implantation should be restricted to specially trained staff (Prowant et al., 1993; Lewis et al., 1997). Aseptic technique, using face masks and sterile gloves, is recommended for postimplantation exit-site care (Prowant and Twardowski, 1996).
4. Patients should avoid submerging the exit site during healing to avoid colonization with water-borne organisms.
5. Although sterile dressings are recommended until the exit is well-healed, there is no clear consensus as to when patients may begin to shower or change to chronic exit-site care. The exit-site evaluation and classification developed by Twardowski (see below) may be used for this purpose. When the exit site can be classified as good or equivocal, then showering and chronic care are appropriate.
6. In tropical or subtropical areas, sweating may affect the frequency of early dressing changes, which should be done when the exit site is wet, when the patient feels itchy under the taped skin, or when the stickiness of the tape is lost.

Cleansing Agents or Disinfectants: Povidone iodine and hydrogen peroxide were recommended by Tenckhoff for cleaning the exit postoperatively and have been used ever since. There is, however, evidence in the surgical literature that wound disinfectants, including hydrogen peroxide and povidone iodine, are cytotoxic, causing tissue damage and delaying clean wound healing (Lineaweaver et al., 1985). If a strong oxidant is used, care should be taken to keep it out of the exit sinus. Alternate cleansing agents such as normal saline, a nonionic surfactant agent (20% polaxamer 188), and pure soap are currently used for postimplantation care (Lewis et al., 1997; Prowant et al., 1993; Prowant and Twardowski, 1996); however, there are no prospective, controlled studies to assess outcomes.

Immobilization: The catheter should be immobilized using a dressing or tape. It is advisable to prevent torquing movement and to minimize handling of the catheter until the exit site and tunnel are completely healed; usually this period lasts at least 4 – 6 weeks (Twardowski et al., 1996c). This will reduce the incidence of trauma and promote tissue growth. Although a number of devices for catheter immobilization are available, the only controlled study did not show the immobilizer to be more effective than tape or dressings in preventing exit infection (Turner et al., 1992).

RECOMMENDATIONS

1. Restrict care to experienced PD staff or trained patients.
2. Use aseptic technique.
3. Avoid irritating or toxic solutions for cleansing; if povidone iodine or hydrogen peroxide are used, keep them out of the sinus or wound.
4. Use absorbent dressings and keep the exit as dry as possible.
5. Continue sterile dressings until the exit is healed.
6. Immobilize the catheter.
7. Infrequent dressings changes (once per week) suffice for the first 2 – 3 weeks.