KEY ACTIVITIES
- Set up appropriate communication plan with surgeon for catheter placement and patient follow-up (see Appendix)
- Confirm catheter placement date
- Determine exit-site location that optimizes longevity and patient satisfaction
-
- Patient preference should be considered in determining exit-site placement unless there is a strong clinical indication that precludes choice
- Locate exit-site to maximize self-care skills (vision, handedness, strength, and motor skills).2,5 Patient should be able to look down and easily visualize the proposed exit-site
- Evaluate patient while dressed and in the sitting position to determine belt-line location and other anatomical features that will influence selection of catheter type, insertion site, and exit-site location
- Avoid scars, belt line, skin creases, apices of floppy skin folds, moist areas due to perspiration, pressure points from clothing or areas that cannot be sufficiently visualized during exit-site care2
- Determine whether lower abdominal, midabdominal, high abdominal, or presternal location is most appropriate for individual patient
- Mark exit-site location with indelible ink using stencils or actual catheter or record measurements of exit-site position in relation to anatomical landmarks that will permit subsequent indication of exit-site location (see Appendix)
- Choose appropriate catheter configuration and operative methodology
-
- Despite innovative attempts to design peritoneal catheters to overcome problems with flow function, none of these devices have been shown to outperform the standard Tenckhoff-style catheters with or without a preformed intercuff bend or a straight- or coiled-tip configuration3,2
Figure 1. Shown are commonly used peritoneal catheters. (A) Tenckhoff catheters with preformed intercuff arc bend, 2 cuffs, and straight or coiled tips. (B) Tenckhoff catheters with straight intercuff segment, 2 cuffs, and straight or coiled tips. (C) Extended catheter with one-cuff, coiled-tip abdominal catheter, two-cuff extension catheter with preformed intercuff arc bend, and titanium doublebarbed connector.
Patients with belt lines
BELOW umbilicus
FIG. 2
Patients with belt lines below the umbilicus may require a Tenckhoffstyle catheter that produces a laterally directed exit-site above the belt.
Patients with belt lines below the umbilicus may require a Tenckhoffstyle catheter that produces a laterally directed exit-site above the belt.
Patients with belt lines
ABOVE umbilicus
FIG. 3
Patients with belt lines below the umbilicus may require a Tenckhoffstyle catheter that produces a laterally directed exit-site above the belt.
Patients with belt lines below the umbilicus may require a Tenckhoffstyle catheter that produces a laterally directed exit-site above the belt.
Illustrations courtesy of John Crabtree, MD
Indications for Presternal/Upper Abdominal Peritoneal Dialysis Catheter3
- Morbid obesity
- Multiple loose skin folds, scars, or other abdominal wall deformities
- Chronic abdominal wall intertrigo
- Abdominal stomas (colostomy, ileostomy, urostomy)
- Urinary or fecal incontinence
- Desire to be able to take deep tub bath2,6
- Patient preference
Contraindications for Presternal/Upper Abdominal Peritoneal Dialysis Catheter
- Body image issues
- Breast implants (presternal)
- Requires surgical expertise
FIG. 4
An extended catheter for upper abdominal exit-site may be useful for patients with obesity or floppy skin folds or per patient preference.3
An extended catheter for upper abdominal exit-site may be useful for patients with obesity or floppy skin folds or per patient preference.3
FIG. 5
An extended catheter with an upper chest exit-site can be utilized in patients with morbid obesity, abdominal stomas, or urinary-fecal incontinence or per patient preference.3
An extended catheter with an upper chest exit-site can be utilized in patients with morbid obesity, abdominal stomas, or urinary-fecal incontinence or per patient preference.3
Illustrations courtesy of John Crabtree, MD
- Choice of catheter type may be impacted by belt-line location and body habitus2
-
- Patients with belt lines below the umbilicus are often best suited for a catheter with a straight intercuff segment that is bent in a gentle arc to produce a laterally directed exit-site above the belt (Figure 2)2
- Patients with belt lines above the level of the umbilicus are often best suited for a catheter with a preformed intercuff bend, a so-called swan neck design, that results in a downwardly directed exit-site below the belt (Figure 3)2
- Patients with obesity, especially with large rotund abdominal contours, or urinary-fecal incontinence may be best suited for an extended catheter to provide an upper abdominal exit-site (Figure 4)2
- Patients with morbid obesity, floppy skin folds, abdominal stomas, urinary-fecal incontinence, or those desiring to be able to take a deep tub bath may be suitable candidates for an extended catheter to produce a presternal exit-site (Figure 5)3
- Patients for whom dialysis initiation is not anticipated until at least 3 to 5 weeks after catheter implantation may benefit from having the catheter embedded (Moncrief-Popovich technique) (Figures 6A, 6B)7
- Catheter embedding procedure can be performed with any catheter type, i.e., conventional Tenckhoff abdominal catheters or two-piece extended catheters for upper abdominal or presternal exit-sites2
Advantages of Embedded Peritoneal Dialysis Catheter2
- Catheter heals in environment without exposure to contamination from exit-site
- Greater patient acceptance for earlier catheter implantation:
-
- No catheter maintenance until dialysis starts
- Avoids urgent temporary hemodialysis
- Start full-dose peritoneal dialysis without break-in period after exteriorization
FIG. 6A
The external limb of catheter is buried under the skin, permitting healing and tissue ingrowth of the cuffs in a sterile environment.
The external limb of catheter is buried under the skin, permitting healing and tissue ingrowth of the cuffs in a sterile environment.
FIG. 6B
External limb of catheter is exteriorized when time to initiate dialysis.
External limb of catheter is exteriorized when time to initiate dialysis.
Illustrations courtesy of John Crabtree, MD