KEY ACTIVITIES

Conservative noninvasive steps:^{1, 2}

• Eliminate kinks or remove clamps on transfer set and catheter. Examine portions hidden by clothing and dressings
• Change body position
• Dislodge blockage by forceful catheter flush (by experienced PD personnel)
• • Infuse dialysate or normal saline with a 50 mL syringe using moderate pressure (“push and pull” maneuver). Discontinue procedure if patient notes pain or cramping
• Correct constipation
• Obtain flat plate of abdomen to visualize catheter position; a lateral view may be necessary to identify a subcutaneous and intraperitoneal catheter kink

Invasive steps:

• Laparoscopy
• Open surgical repositioning of catheter or replacement
• Partial omentectomy or omentopexy³
• Adhesiolysis if indicated
• Fluoroscopically guided stiff wires or stylet manipulation⁴
• Fogarty catheter manipulation⁵

THROMBOLYTIC THERAPY FOR OBSTRUCTED CATHETER

• Instill recombinant tissue plasminogen activator (tPA)⁶

Administration of tPA

Prepare a solution of sterile water that has tPA 1 mg/mL. Instill up to 8 mLs (1–8 mg) after the filling of the abdomen with dialysis solution and allow to dwell for 1–2 hours. If the dialysate does not drain adequately, ensure that there is enough dialysate in the abdomen and re-instill the tPA at the same dose and allow to remain for an additional 90 minutes. Upon clearance of catheter, allow effluent to drain by gravity. Prior to initiating dialysis, the catheter may be flushed with sterile heparinized solution. Consider antibiotics (first-generation cephalosporin preferred) to dialysate in following exchange.

SHORT-TERM PREVENTION FOR RECURRENCE OF CATHETER OBSTRUCTION

In case of fibrin-related obstruction:

• Add heparin 500 U/L to each dialysate exchange⁷