Peritoneal Dialysis Catheters: Placement, Function and Access Care

Peritoneal Dialysis Catheters:
Placement, Function and Access Care

Planning | Device | Mapping | Insertion | Healing | Function | Exit Site | Salvage

CHAPTER MISSION Build a bedside-to-procedure mental model that converts a decision for PD into a safe, durable and comfortable peritoneal access: map the patient before choosing the catheter, match insertion technique to anatomy and expertise, protect healing, prove function, maintain a healthy exit site, and localise mechanical failure before the access is unnecessarily replaced.

MASTER PRINCIPLE A PD catheter is successful only when it repeatedly fills and drains with acceptable comfort, has a visible low-trauma exit site, resists infection, and can be maintained or rescued without unnecessary interruption of PD. Catheter creation is an event; usable access is the outcome.

0. One-page chapter map

Table 5.1 - The eight decisions that govern PD catheter care.

Learning outcomes

• Use preoperative mapping to select an insertion point and exit site that jointly permit pelvic catheter-tip position, visibility, accessibility and low mechanical stress.

• Explain the functional anatomy of the intraperitoneal segment, deep cuff, intercuff tunnel, superficial cuff, exit site, external limb and transfer set.

• Choose among standard and extended catheter configurations without treating straight versus coiled tips or any proprietary design as universally superior.

• Compare open surgical, advanced laparoscopic, peritoneoscopic and image-guided percutaneous insertion approaches using patient anatomy, anaesthetic risk, urgency and operator expertise.

• Apply the peri-insertion safety bundle: multidisciplinary planning, bowel/bladder preparation, antimicrobial prophylaxis, sterile technique, watertight placement and immediate catheter immobilisation.

• Use the elective break-in period correctly and understand how urgent-start PD modifies fill volume and posture when PD must begin earlier.

• Recognise normal healing, mechanical irritation, definitive exit-site infection and tunnel-infection warning signs without overcalling erythema alone.

• Localise poor flow into outflow-predominant, two-way obstruction, positional pain or leakage phenotypes and troubleshoot in least-invasive order.

• Distinguish constipation, bladder distension, catheter migration, kink, intraluminal fibrin, omental wrapping and adhesions by mechanism and bedside clues.

• Choose nonoperative versus operative catheter salvage according to urgency, likely mechanism, local capability and the goal of preserving PD continuity.

• Protect long-term access by preventing traction, maintaining bowel function, monitoring the exit site, and acting on change from the patient’s baseline.

EVIDENCE POSTURE The 2019 ISPD adult peritoneal-access guideline remains the principal comprehensive adult access guideline, complemented by the 2023 ISPD catheter-related infection recommendations, the 2024 SAGES PD-access guideline update, the 2023 Cochrane review of insertion techniques, and newer comparative evidence through 2026. Where guidelines diverge, this chapter shows the certainty and clinical context rather than forcing a single universal technique. [1–8]

1. Core concept: the catheter is an access system, not a tube

The catheter is the only permanent interface between the peritoneal cavity and the outside world. Its intraperitoneal tip must sit where dialysate can move freely; its abdominal-wall passage must resist leakage and migration; its cuffs must support tissue ingrowth; and the external segment must exit through skin that the patient can see, clean and secure. A defect in any one of these domains can present later as slow drainage, pain, leak, cuff extrusion, infection or technique failure. [1]

This explains why a “successful operation” is not the same as successful access. A catheter can be patent on the operating table yet be poorly positioned for the patient’s body habitus, hidden under a pannus, repeatedly compressed by a belt, or so mobile that the exit sinus is continually traumatized. Conversely, a patient with prior abdominal surgery or obesity can have excellent long-term PD when the access is deliberately mapped and placed by an experienced team. [1,3]

BEDSIDE TRANSLATION When a catheter problem appears, identify which component failed: intraperitoneal tip, lumen, abdominal-wall tract, cuff/tunnel, exit site, external limb or connection system. “Catheter dysfunction” is a syndrome, not a diagnosis.

Table 5.2 - Catheter segment -> function -> failure clue.

2. Catheter design: keep the device simple and make the geometry right

ISPD recommends silicone-rubber catheters for chronic PD, generally with double polyester cuffs. Standard adult catheters may have straight or coiled intraperitoneal tips and straight or preformed-arc intercuff segments. The guideline does not support a universal functional superiority of one standard geometry over all others. The practical priority is choosing a device whose length and shape fit the patient’s anatomy. [1]

Randomized trials have sometimes favoured straight intraperitoneal tips over coiled designs for migration or dysfunction, including a 2020 multicentre trial, but results across eras, insertion methods and catheter families are not sufficiently uniform to turn tip shape into the dominant access decision. Proper insertion site, catheter length, tunnel geometry and operator technique matter at least as much. [1,9,10]

Table 5.3 - Catheter design: what matters clinically.

DEVICE RULE Do not let a familiar catheter force an unfamiliar body into bad geometry. Keep a small inventory that allows the access team to choose length and exit-site reach deliberately. [1]

3. Preoperative mapping: the tip and exit site are one decision

Preoperative mapping is one of the highest-yield opportunities to prevent later problems because catheter design, insertion site and exit-site location are mechanically linked. ISPD recommends a protocol that maps the patient before the procedure, using fixed anatomical landmarks rather than the umbilicus alone. [1]

The sequence is important. First determine an insertion site and catheter length that place the intraperitoneal tip in the true pelvis without excessive depth. Then, with the patient sitting, verify that the reachable exit site is visible and accessible and does not fall under the belt line, within a skin crease, on the blind side or apex of a pannus, near a stoma, or in an area of chronic moisture or friction. If both goals cannot be achieved with a standard catheter, an extended catheter may solve the problem. [1]

Table 5.4 - Mapping findings that change the plan.

MAPPING RULE The best exit site is not the cosmetically easiest place for the operator; it is the place the patient can maintain for years with minimal friction, traction and contamination.

4. Pre-procedure assessment: identify the anatomy that changes technique

The access history should actively search for previous abdominal or pelvic surgery, peritonitis, hernia repair, ostomy, mesh, chronic constipation, urinary retention, organomegaly, severe obesity, inflammatory bowel or abdominal-wall disease, and prior PD access. These findings rarely function as simple yes/no contraindications; they determine whether direct visualization, adhesiolysis, hernia planning, remote exit sites or a different anaesthetic strategy is needed. [1,3]

Physical examination should be done in more than one posture. Look for hernias, scars, folds, ostomies, skin disease, belt position and locations the patient can see. If a hernia is clinically important, coordinate repair strategy with the access surgeon; the 2024 SAGES update conditionally favours staged hernia repair before catheter insertion in adults when both are required, but certainty is very low and local expertise/patient timing matter. [3]

Table 5.5 - Pre-procedure anatomy -> access consequence.

5. Peri-insertion preparation: prevent avoidable failure before the first incision

The 2019 ISPD access guideline frames catheter placement as a multidisciplinary process rather than a stand-alone procedure. Its best-practice checklist includes bowel management to prevent perioperative constipation, emptying the bladder, surgical-site antisepsis, and a single preoperative antibiotic dose. The 2023 ISPD catheter-infection update more strongly states that prophylactic antibiotics should be administered immediately before catheter insertion to prevent peritonitis (1A); known nasal Staphylococcus aureus carriers should receive nasal antibiotic prophylaxis according to local protocol (1C). [1,2]

The exact antibiotic and surgical antisepsis protocol should follow local microbiology, allergies, resistance patterns and institutional policy. This chapter deliberately avoids inventing a universal drug or dose. The principle is temporal and mechanistic: antimicrobial protection must be active at the time the peritoneal cavity and new catheter tract are created. [2,8]

Table 5.6 - Pre-insertion safety bundle.

SAFETY BOUNDARY Exact antibiotic selection, anaesthesia, skin-preparation agent, bowel regimen and operative details remain governed by local protocol and the procedural team. This chapter teaches the access logic, not an unsupervised procedure recipe.

6. Insertion approaches: four routes to the same physiological goal

Chronic PD catheters can be placed by open surgical dissection, image-guided percutaneous techniques, peritoneoscopy or laparoscopy. The appropriate question is not which specialty “owns” PD access; it is which approach can safely deliver the required catheter geometry for this patient, at the needed time, with a team able to rescue complications. [1,3,4]

Evidence does not support a single universal winner. The 2023 Cochrane review found low-certainty evidence and insufficient high-quality data to show one insertion method consistently reduces catheter dysfunction. SAGES 2024 conditionally favours advanced laparoscopy over basic laparoscopy or open insertion and considers either advanced laparoscopy or image-guided percutaneous insertion reasonable in adults, but the certainty is very low. More recent meta-analyses continue to show broadly comparable outcomes between contemporary percutaneous and laparoscopic strategies. [3–6]

Table 5.7 - Insertion approaches: operational trade-offs.

EVIDENCE CALIBRATION Do not misread a conditional guideline recommendation as proof of superiority. Advanced laparoscopy has mechanistic advantages and favourable observational data, but RCT evidence comparing modern techniques remains limited. [3–6]

7. Advanced laparoscopy: use adjuncts only when they solve a failure mechanism

The value of “advanced” laparoscopy is not the camera itself. It is the opportunity to prevent or correct specific mechanical causes of failure. Rectus-sheath tunnelling fixes the craniocaudal direction of the catheter through the abdominal wall; omentopexy can move redundant omentum away from the side holes when it lies near the tip; adhesiolysis can open a compartmentalized peritoneal cavity; and hernias can be identified and managed in a planned fashion. [1,3]

These adjuncts should be selective rather than ritual. An omentopexy is useful when redundant omentum threatens the catheter, not because every patient has an omentum. Adhesiolysis is useful when adhesions would compromise placement or drainage, not as a search for “perfect” anatomy. The operative goal is reliable flow with the least additional intervention. [1]

Table 5.8 - Advanced laparoscopic adjunct -> mechanism -> endpoint.

8. Choosing the insertion technique: a patient-specific access conference

The access team should make an explicit technique decision before the day of insertion. For a patient with no prior surgery, favourable anatomy and high anaesthetic risk, an image-guided percutaneous approach may be ideal. A patient with multiple prior laparotomies, suspected adhesions and a hernia may gain more from advanced laparoscopy. An urgent inpatient with limited theatre access may require a different pathway again. [1,3]

Table 5.9 - Patient feature -> technique discussion.

PROGRAMME RULE A PD programme without timely catheter insertion and rescue capacity does not truly offer PD. Access expertise is part of modality availability.

9. Placement endpoints: what must be true before the procedure is considered finished

Regardless of insertion method, several end-state principles are shared: the catheter should not be twisted or kinked; the deep cuff should sit in an appropriate muscular/fascial position; the intraperitoneal tip should be directed to the pelvis; the abdominal-wall passage should be watertight; the exit site should be small, appropriately directed and separated from the superficial cuff; and flow should be tested before completion. [1]

The exit site should not be secured by sutures through or immediately beside the skin-catheter interface because local trauma can impair healing. The catheter and extension should instead be immobilized in a way that prevents torque on the new tract. [1,2]

Table 5.10 - Insertion completion checklist.

10. Immediate postoperative care: protect the tract while tissue ingrowth develops

The newly created exit site and tunnel are mechanically vulnerable. Early handling should be minimized, the catheter should be immobilized, and the dressing should remain clean and dry according to the procedural and PD-unit protocol. The operative team should document catheter type, insertion technique, exit-site location, any adhesiolysis/omentopexy/hernia repair, intraoperative flow findings, complications and the intended earliest-use plan. [1,2]

The catheter should not simply disappear under a dressing until the first dialysis. The PD team needs a defined postoperative pathway: who reviews the wound, when the catheter is flushed if local practice requires it, how constipation is prevented, what symptoms trigger urgent contact, and whether the patient will start electively or urgently. [1]

Table 5.11 - First postoperative days: what to protect.

HANDOFF RULE Every catheter insertion should end with a written handoff to the PD team: device, technique, flow test, wound/exit plan, break-in plan, complications and who owns the first problem.

11. Break-in and early use: healing is part of access function

ISPD recommends a break-in period of at least 2 weeks before elective PD start (1B). The 2024 SAGES guideline similarly conditionally favours traditional over urgent start in adults when the patient can safely wait, although the evidence certainty is very low. Earlier use is associated particularly with more leak and early mechanical events. [1,3]

When dialysis cannot safely be deferred, ISPD recommends a modified prescription using low-volume exchanges with the patient supine when PD is started before 2 weeks (1C). Urgent-start PD is therefore not “normal PD sooner”; it is deliberately low-pressure PD designed to protect a fresh abdominal-wall tract. Detailed urgent-start prescriptions, escalation and inpatient scenarios belong to Chapter 17. [1,3]

Table 5.12 - Elective versus urgent catheter use.

THRESHOLD DISCIPLINE The 2-week interval is a guideline-supported break-in standard for elective start, not a biological switch at day 14. Healing, concomitant surgery, leak risk and clinical urgency still matter. [1,3]

12. Mature exit-site care: clean, inspect, immobilise

The 2023 ISPD catheter-related infection update provides the current preventive framework. It recommends topical antibiotic cream or ointment at the catheter exit site daily (mupirocin or gentamicin; 1C), notes that no cleansing agent has proved superior to another (2B), recommends cleansing at least twice weekly and after showering or vigorous exercise (1C), and recommends catheter immobilisation to prevent traction injury (1C). [2]

A dressing cover is not mandatory after routine exit-site care and topical antibiotic application once beyond the immediate postoperative context (2D); evidence comparing dressing systems is low certainty, and a 2024 network meta-analysis found no basis for a strong universal dressing recommendation. Local climate, skin sensitivity, dust/pet exposure, sweating and patient preference can legitimately modify the dressing plan. [2,11]

Exit-site care must continue even if PD is temporarily interrupted or discontinued while the catheter remains in place. “Not currently using the catheter” does not mean the skin tunnel is no longer a foreign-body interface. [2]

Table 5.13 - Mature exit-site preservation bundle.

ACCESS-CARE RULE The exit site should be boring: stable colour, no purulent drainage, minimal trauma, no tension and a routine the patient can perform consistently.

13. Read the exit site correctly: irritation, infection and tunnel disease are different

A newly placed catheter can have mild erythema, and a mature site can become red after traction, dressing allergy or a change in cleansing materials. ISPD therefore does not define exit-site infection by redness alone. Definitive exit-site infection is purulent discharge at the catheter-epidermal interface, with or without surrounding erythema. Tunnel infection is inflammation such as erythema, swelling, tenderness or induration along the subcutaneous catheter pathway, with or without an ultrasound fluid collection. [2]

This distinction prevents two opposite errors: giving repeated antibiotics for mechanical dermatitis, and dismissing deep tunnel disease because the skin opening looks modest. This chapter teaches recognition and immediate access protection; organism-specific treatment, antibiotic duration, cuff shaving/exit relocation and catheter-removal decisions are developed in Chapter 11. [2]

Table 5.14 - Exit-site finding -> interpretation.

14. Catheter function: separate fill, dwell and drain

Catheter function should be described rather than labelled. Is inflow slow? Is outflow slow? Are both impaired? Is drainage positional? Does the patient have end-of-drain pain? Is the cycler producing repeated low-drain alarms? These phenotypes localise the likely mechanism more effectively than the phrase “poor catheter.” [1]

Outflow dysfunction is more common than isolated inflow failure. A catheter may fill because positive hydrostatic pressure pushes dialysate past a partial obstruction, yet fail to drain by gravity. Conversely, an intraluminal fibrin plug or tubing kink often produces two-way resistance. The exact pattern should be documented before any salvage procedure. [1]

Table 5.15 - Flow phenotype -> first hypotheses.

15. Constipation and bladder distension: fix the common reversible causes first

ISPD identifies constipation as the most common cause of PD catheter outflow dysfunction. A stool-filled rectosigmoid colon can directly block side holes or displace the catheter tip away from a favourable drainage position. Urinary retention can compress the catheter less commonly. These diagnoses matter because they are both common and reversible without access intervention. [1]

Before ordering catheter manipulation for an outflow problem, ask about stool frequency/consistency, recent opioid or iron use, abdominal fullness and urinary symptoms. Examine the abdomen and review a plain film when appropriate. A catheter that drains normally after bowel decompression did not need a catheter procedure. [1]

Table 5.16 - Bowel/bladder clues.

COMMON-CAUSE RULE Constipation should be actively prevented, not rediscovered after the catheter stops draining.

16. Imaging: ask a specific mechanical question

A plain abdominal radiograph is often the first useful test after simple bedside causes have been excluded because it can show fecal loading, catheter migration and obvious kinking. It does not diagnose omental wrapping or every adhesion, and radiographic pelvic position does not guarantee freedom from tissue obstruction. [1,3]

Catheterography can assess contrast flow and sometimes enables guidewire manipulation. Ultrasound is particularly useful for exit-site/tunnel assessment and selected abdominal-wall or fluid-collection questions. CT peritoneography is reserved for leak, hernia or complex anatomic questions rather than routine poor drainage. Imaging should answer a hypothesis—not substitute for one. [1,2]

Table 5.17 - Test -> question -> limitation.

17. Intraluminal fibrin and tubing kinks: two-way resistance has a different logic

When both inflow and outflow are restricted, first trace the external circuit for closed clamps, transfer-set problems and obvious compression. If external causes are excluded, an intraluminal fibrin plug or catheter kink becomes more likely. Blood in the effluent after insertion, peritonitis or inflammation can promote fibrin deposition. [1]

ISPD supports attempting fibrinolytic therapy when imaging has excluded displacement/kink, bladder distension and constipation and intraluminal debris is suspected. Exact flush volumes, drug concentration and dwell technique are device- and programme-specific and should follow a validated local protocol; they should not be improvised from a textbook. Persistent two-way obstruction after appropriate lumen treatment warrants structural reassessment. [1]

Table 5.18 - Two-way obstruction sequence.

18. Salvage: preserve a working access when the cause is correctable

Catheter salvage should progress from low-risk reversible causes to interventions that can correct the suspected mechanism. The 2019 ISPD guideline recommends a logical sequence from conservative/noninvasive approaches toward more aggressive intervention. SAGES 2024 conditionally supports either nonoperative or operative salvage, acknowledging very low certainty evidence. [1,3]

Fluoroscopic guidewire manipulation is attractive because it is minimally invasive and can restore patency or reposition the catheter without general anaesthesia. Contemporary series show useful success in selected patients, but recurrence is substantial when the underlying problem is omental wrap or adhesions. Laparoscopic rescue is more invasive but can diagnose and directly treat migration, omental entrapment and adhesions. The urgency of dialysis and local availability should determine how long to persist with low-success repeated manipulations. [1,3,12,13]

Table 5.19 - Rescue option -> strength -> limitation.

SALVAGE RULE Do not perform repeated interventions just because they are available. Each intervention should have a named mechanism, expected benefit and stopping rule.

19. Pericatheter and other dialysate leaks: access failure can occur outside the lumen

A catheter can fill and drain yet still fail as an access because dialysate escapes from the peritoneal cavity. Early pericatheter leak is promoted by a fresh tract, high intraperitoneal pressure and early routine-volume use. It may present as clear fluid at the exit, abdominal-wall or genital swelling, unexpected weight gain or apparent loss of instilled volume. [1]

The 2-week elective break-in is partly intended to reduce this risk. When urgent-start PD is necessary, low-volume supine exchanges reduce pressure on the new tract. Detailed diagnosis and management of abdominal-wall, pleuroperitoneal, genital and occult leaks are deferred to Chapter 12. [1,3]

Table 5.20 - Leak clues that should trigger an access pathway.

20. Fill and drain pain: function includes comfort

A catheter that technically flows but produces severe pain is not a successful access. End-of-drain pain can occur when a tip lies too deep in the pelvis or when hydraulic suction brings sensitive peritoneal structures against side holes during APD. Constipation, inflammation, migration and local anatomy can amplify the symptom. [1]

Describe when pain occurs: during inflow, throughout dwell, or only at final drainage; whether it is positional; whether it began with a new cycler prescription; and whether effluent or abdominal findings suggest infection. Prescription strategies such as tidal drainage may reduce suction-related pain, but detailed APD optimization is deferred to Chapter 9. Persistent anatomic pain may require catheter reassessment or repositioning. [1]

Table 5.21 - Flow pain phenotype.

21. Cuff extrusion and external catheter damage: small defects can become access emergencies

Superficial cuff extrusion is often a mechanical problem before it becomes an infectious one. Excessive bend stress in the subcutaneous tract, a superficial cuff placed too close to the exit, or chronic piston-like catheter motion can push the cuff outward. Once exposed, the porous cuff becomes difficult to keep clean and can act as a bacterial reservoir. [1]

External tubing can also crack, separate or be cut. A damaged catheter is both a leak and contamination event. Depending on the location and device, validated repair kits or splicing may preserve the access, but this requires trained staff, manufacturer-compatible components, contamination assessment and peritonitis prophylaxis as indicated. Do not tape a leaking catheter and continue exchanges. [1,8]

Table 5.22 - External access defect -> response.

22. Long-term access preservation: make good function the default

Catheter maintenance is mostly a system of small repeated actions: stable bowel habits, immobilisation, consistent exit-site care, protection of the external limb, rapid response to new drainage changes and periodic competency review. The 2026 ASN core interventions for PD-related infection prevention reinforce programme-level surveillance, standardized staff and patient training, routine infection-prevention assessments and antimicrobial prophylaxis. [7]

Patients should know their own baseline: how the exit site normally looks, how quickly bags usually drain, which positions are normal, what the catheter feels like under clothing, and which changes require same-day contact. A photo of a mature healthy site and a written “call now” list can make subtle change more visible than generic instructions. [2,7]

Table 5.23 - Patient self-check: five things to know.

23. Access programme quality: measure what happens after insertion

An access service should audit more than the number of catheters inserted. ISPD recommends monitoring catheter outcomes, mechanical events and insertion-related complications. The 2023 infection guideline recommends annual monitoring of catheter-related infection incidence and suggests that insertion-related exit-site/tunnel infection within 30 days should remain below 5% of inserted catheters (2C). The overall exit-site infection rate target is no more than 0.40 episodes per patient-year at risk (2C). [1,2]

These are programme quality targets, not patient-level treatment thresholds. A centre with frequent early leaks, poor primary function or emergency catheter replacements should investigate mapping, insertion technique, constipation pathways, postoperative handoff and rescue availability rather than attributing every event to “bad catheters.” [1,2]

Table 5.24 - Access programme dashboard.

QUALITY RULE A programme that cannot tell why its catheters fail cannot improve its catheter outcomes.

24. Clinical pearls

PEARL 1 The insertion site determines the pelvic position; the exit site determines whether the patient can care for the catheter.

PEARL 2 Map the patient sitting before the patient is anaesthetized and supine.

PEARL 3 If a standard catheter cannot give both pelvic tip and good exit site, change the catheter - not the anatomy.

PEARL 4 Constipation is the commonest outflow problem and belongs in access prevention, not only troubleshooting.

PEARL 5 A normal fill with poor drain localises differently from two-way obstruction.

PEARL 6 A low-drain alarm is a symptom; the cycler cannot diagnose constipation, migration or omental wrap.

PEARL 7 Exit-site erythema alone is not definitive infection; purulent discharge is the key ISPD diagnostic criterion.

PEARL 8 Traction injury is preventable. Immobilisation is an infection-prevention intervention as well as a comfort measure.

PEARL 9 Image-guided manipulation is valuable when the mechanism is amenable; repeated recurrence should prompt definitive pathology-directed rescue.

PEARL 10 A catheter that flows but causes severe pain is not a satisfactory access.

25. Mini-cases: decisions, not hardware trivia

Case 1 - Obesity and the invisible exit site

A 52-year-old with obesity chooses PD. A standard catheter placed from the lower abdomen would leave the exit site under a deep pannus where the patient cannot see it while seated.

REASONING QUESTION Is this patient unsuitable for PD?

INTERPRETATION No. The problem is exit-site geometry, not PD eligibility. A lower hidden exit would increase care difficulty, moisture and traction risk.

MANAGEMENT DECISION Perform formal preoperative mapping and choose a catheter/route that preserves pelvic tip position while relocating the exit to a visible upper-abdominal or remote site if needed.

TEACHING POINT Use catheter design to fit the body; do not use the body as a reason to deny the modality.

Case 2 - Prior laparotomy and a request for “blind percutaneous” placement

A 64-year-old with two prior midline laparotomies has chosen PD. The proposed service has immediate access to blind bedside percutaneous insertion but no ability to manage adhesions if encountered.

REASONING QUESTION What should change?

INTERPRETATION Prior surgery does not exclude PD, but it raises the probability that intraperitoneal visualization or adhesiolysis may be useful and makes blind entry less attractive.

MANAGEMENT DECISION Refer to an experienced access pathway capable of image-guided or laparoscopic placement and rescue rather than proceeding for convenience alone.

TEACHING POINT Technique choice is an anatomy-and-capability decision, not a waiting-time contest.

Case 3 - The catheter fills but will not drain

Three months after starting PD, a patient has normal inflow but progressively incomplete drainage. He has not opened his bowels for four days and recently began opioid analgesia.

REASONING QUESTION What is the best first hypothesis?

INTERPRETATION Constipation-related rectosigmoid compression or catheter displacement is more likely than sudden catheter failure.

MANAGEMENT DECISION Correct constipation, review the external circuit and reassess drainage before requesting invasive catheter manipulation; obtain a plain film if dysfunction persists.

TEACHING POINT The common reversible cause comes before the catheter laboratory.

Case 4 - Two-way obstruction with fibrin

After a bloody postoperative flush, a new catheter becomes difficult both to fill and drain. External clamps and transfer set are normal; film shows no migration or kink.

REASONING QUESTION What mechanism fits the phenotype?

INTERPRETATION Intraluminal fibrin/debris is plausible because resistance is two-way and structural displacement has not been demonstrated.

MANAGEMENT DECISION Use the centre’s approved catheter-flush/fibrinolytic protocol and reassess. Persistent obstruction should progress to structural imaging/rescue rather than repeated blind flushing.

TEACHING POINT Two-way resistance points to lumen or kink before it points to constipation alone.

Case 5 - Red exit site after a new dressing

A stable PD patient develops a 1-cm area of erythema after changing adhesive dressings. There is no purulent discharge, tenderness, swelling or tunnel pain.

REASONING QUESTION Is this definitive exit-site infection?

INTERPRETATION No. ISPD does not define ESI by erythema alone; contact irritation or traction are plausible.

MANAGEMENT DECISION Remove the likely irritant, ensure catheter immobilisation, document the site and reassess closely for purulent drainage or progression. Escalate if infection features develop.

TEACHING POINT Avoid both antibiotic reflexes and complacency: redness requires context and follow-up.

Case 6 - Recurrent guidewire salvage

A catheter has required two fluoroscopic repositioning procedures in six weeks and again migrates with poor outflow. The patient needs reliable dialysis now.

REASONING QUESTION Should a third identical manipulation be the default?

INTERPRETATION Repeated recurrence suggests an unresolved mechanical driver such as omental entrapment, unstable trajectory or adhesions.

MANAGEMENT DECISION Discuss timely laparoscopic diagnosis and pathology-directed rescue versus replacement rather than repeating a low-durability intervention without a new hypothesis.

TEACHING POINT Salvage has a stopping rule: recurrence is information about mechanism.

26. Common pitfalls - and the correction

Table 5.25 - High-frequency errors in PD catheter care.

27. Active recall: MUST MEMORIZE / MUST REASON / USE AS REFERENCE

MUST MEMORIZE

Table 5.26 - Must memorize.

MUST REASON

Table 5.27 - Must reason.

USE AS REFERENCE

Table 5.28 - Use as reference, not rote memory.

28. Flashcards: active recall

1. Q: What is the patient-important catheter outcome? A: Reliable, comfortable fill/drain with a maintainable low-risk exit site and durable access.

2. Q: What does preoperative mapping link? A: Pelvic tip target, insertion site, catheter length/tunnel and exit-site location.

3. Q: Why is the umbilicus a poor sole landmark? A: It varies with body habitus and does not reliably predict pelvic catheter position.

4. Q: When should an extended catheter be considered? A: When a standard catheter cannot provide both correct pelvic tip and satisfactory exit site.

5. Q: What does SAGES 2024 say about advanced laparoscopy? A: Conditionally favours it over basic/open insertion, but certainty is very low.

6. Q: What does Cochrane 2023 say about insertion technique? A: Evidence is insufficient to identify a universally superior technique for dysfunction/outcomes.

7. Q: Peri-insertion antibiotic timing? A: Immediately before catheter insertion per ISPD.

8. Q: Elective break-in? A: At least 2 weeks.

9. Q: Urgent-start posture? A: Supine with low-volume exchanges.

10. Q: Most common outflow problem? A: Constipation.

11. Q: Normal fill, poor drain suggests? A: Outflow mechanism such as constipation, migration or tissue/omental obstruction.

12. Q: Both inflow and outflow poor suggests? A: External obstruction, kink or intraluminal fibrin/debris.

13. Q: First imaging for persistent mechanical dysfunction? A: Often a plain abdominal film after bedside causes are addressed.

14. Q: Role of fluoroscopic manipulation? A: Minimally invasive recanalization/repositioning in selected dysfunction; recurrence can occur.

15. Q: Role of laparoscopy in salvage? A: Direct diagnosis and correction of omentum, adhesions, migration and other intraperitoneal causes.

16. Q: Definitive ESI? A: Purulent discharge ± erythema.

17. Q: Erythema alone? A: Not definitive ESI; assess trauma, allergy, recent placement and evolution.

18. Q: Catheter immobilisation? A: Prevents traction/friction injury and supports infection prevention.

19. Q: Mature dressing always required? A: No; cover is not mandatory after routine care in ISPD 2023.

20. Q: Exit care when PD is paused? A: Continue while catheter remains in place.

29. Rapid troubleshooting: catheter problem -> mechanism -> next step

Table 5.29 - One-minute catheter troubleshooting.

30. Final revision sheet

TEN TAKE-HOME RULES 1) Map the patient before choosing the catheter. 2) Plan pelvic tip and exit site as one mechanical system. 3) Use an extended catheter when standard geometry forces a bad exit. 4) Technique choice depends on anatomy, urgency, anaesthetic risk and expertise; evidence for a universal winner is low certainty. 5) Give antimicrobial prophylaxis immediately before insertion. 6) Respect a 2-week elective break-in; urgent start is low-volume and supine. 7) Immobilise the catheter and maintain a consistent exit-site care routine. 8) Purulent discharge defines ESI; erythema alone does not. 9) Constipation is the commonest outflow problem. 10) Salvage the mechanism before replacing the access.

Table 5.30 - One-minute bedside synthesis.

Table 5.31 - Catheter-access verification checklist.

FINAL MENTAL MODEL Map -> choose device -> choose technique -> prepare -> place and prove -> heal -> maintain -> localise failure -> rescue mechanism -> verify durable function.

Rapid oral viva

• Explain why preoperative catheter mapping should use bony landmarks and sitting examination rather than the umbilicus alone.

• Compare advanced laparoscopic and image-guided percutaneous insertion using evidence certainty, anaesthetic burden and anatomy.

• Give the least-invasive differential for normal inflow with poor outflow.

• Explain why constipation can stop a catheter draining and why it must be prevented from the perioperative period.

• Distinguish a fibrin plug from catheter migration using the inflow/outflow phenotype and imaging.

• Walk through the response to purulent exit-site discharge versus erythema after traction.

• Explain the rationale for the 2-week break-in period and how urgent-start PD changes the prescription.

• Defend catheter salvage versus replacement in a patient with recurrent malfunction.

SCOPE BOUNDARY This chapter teaches catheter selection, placement logic, access preservation and first-line mechanical reasoning. Detailed PD initiation is Chapter 6; adequacy/RKF Chapter 7; volume/UF failure Chapter 8; CAPD/APD prescription optimization Chapter 9; peritonitis Chapter 10; exit-site/tunnel infection treatment Chapter 11; and comprehensive mechanical complications/leaks Chapter 12.

31. Selected authoritative references

1. Crabtree JH, Shrestha BM, Chow KM, et al. Creating and Maintaining Optimal Peritoneal Dialysis Access in the Adult Patient: 2019 Update. Perit Dial Int. 2019;39(5):414–436. https://doi.org/10.3747/pdi.2018.00232. PMID: 31028108.

2. Chow KM, Li PKT, Cho Y, et al. ISPD Catheter-related Infection Recommendations: 2023 Update. Perit Dial Int. 2023;43(3):201–219. https://doi.org/10.1177/08968608231172740. PMID: 37232412.

3. Haggerty SP, Kumar SS, Collings AT, et al. SAGES peritoneal dialysis access guideline update 2023. Surg Endosc. 2024;38(1):1–23. https://doi.org/10.1007/s00464-023-10550-8. PMID: 37989887.

4. Briggs VR, Jacques RM, Fotheringham J, Maheswaran R, Campbell M, Wilkie ME. Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients. Cochrane Database Syst Rev. 2023;2:CD012478. https://doi.org/10.1002/14651858.CD012478.pub2. PMID: 36810986; PMCID:PMC9946371.

5. Chui JN, Kim P, Cooper TE, et al. Percutaneous versus surgical catheter insertion for peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg. 2025;95(4):664–674. https://doi.org/10.1111/ans.19315. PMID: 39641197.

6. Wang X, Jin W, Li X, Ji W, Ren T. Percutaneous versus laparoscopic catheter placement for peritoneal dialysis: a meta-analysis. BMC Nephrol. 2025;26(1):687. https://doi.org/10.1186/s12882-025-04597-z. PMID: 41339808; PMCID:PMC12676859.

7. Perl J, Teitelbaum I, Warady BA, et al. Core Interventions for the Prevention of Peritoneal Dialysis-Related Infections. Clin J Am Soc Nephrol. 2026;21(8):1439–1444. https://doi.org/10.2215/CJN.0000000976. PMID: 41348491.

8. Li PKT, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–153. https://doi.org/10.1177/08968608221080586. PMID: 35264029.

9. Xie J, Kiryluk K, Ren H, et al. Coiled versus straight peritoneal dialysis catheters: a randomized controlled trial and meta-analysis. Am J Kidney Dis. 2011;58(6):946–955. https://doi.org/10.1053/j.ajkd.2011.06.026. PMID: 21872978.

10. Chow KM, Wong SSM, Ng JKC, et al. Straight Versus Coiled Peritoneal Dialysis Catheters: A Randomized Controlled Trial. Am J Kidney Dis. 2020;75(1):39–44. https://doi.org/10.1053/j.ajkd.2019.05.024. PMID: 31445925.

11. Feng C, Liu Y, Jin W, Lu M, Su CY. Effect of different exit-site care dressings on preventing peritoneal dialysis related infection from nontropical area: a systematic review and network meta-analysis. Ren Fail. 2024;46(2):2376331. https://doi.org/10.1080/0886022X.2024.2376331. PMID: 39011577.

12. Li P, Choo D, Deved V, et al. Salvage of Malfunctioning Peritoneal Dialysis Catheters: An Algorithm for Recanalization and Repositioning. J Vasc Interv Radiol. 2021;32(6):902–906. https://doi.org/10.1016/j.jvir.2021.03.522. PMID: 33771711.

13. Wong RCL, Cheung EWP, Wong A, Lee BKH, Cheng KK, Cho DHY. Efficacy and safety of repositioning malfunctioning peritoneal dialysis catheters with fluoroscopically guided guidewire manipulation. Clin Nephrol. 2025;104(3):159–169. https://doi.org/10.5414/CN111605. PMID: 40356439.

14. Crabtree JH, Chow KM. Peritoneal dialysis catheter insertion. Semin Nephrol. 2017;37(1):17–29. https://doi.org/10.1016/j.semnephrol.2016.10.004. PMID: 28153191.

15. Ouyang CJ, Huang FX, Yang QQ, et al. Comparing the incidence of catheter-related complications with straight and coiled Tenckhoff catheters in peritoneal dialysis patients: a single-center prospective randomized trial. Perit Dial Int. 2015;35(4):443–449. https://doi.org/10.3747/pdi.2013.00016. PMID: 24584608; PMCID:PMC4520727.

16. Johnson DW, Wong J, Wiggins KJ, et al. A randomized controlled trial of coiled versus straight swan-neck Tenckhoff catheters in peritoneal dialysis patients. Am J Kidney Dis. 2006;48(5):812–821. https://doi.org/10.1053/j.ajkd.2006.08.010. PMID: 17060001.

17. Wallace EL, Fissell RB, Golper TA, et al. Catheter insertion and perioperative practices within the ISPD North American Research Consortium. Perit Dial Int. 2016;36(4):382–386. https://doi.org/10.3747/pdi.2015.00089. PMID: 26493754; PMCID:PMC4934430.

SOURCE NOTE ISPD, SAGES, Cochrane and bibliographic sources were checked 1 September 2026. The 2019 ISPD document remains the principal comprehensive adult PD-access guideline identified in the current evidence search. Technique-specific procedural details, antibiotic choice/dose, fibrinolytic protocols, device repair and urgent-start prescriptions remain subject to current local policy, manufacturer instructions and trained specialist practice.