PD Catheters and Access

The contract between this chapter and the reader.

1. 1. Describe PD catheter design — cuffs, tip, swan-neck, exit direction — and choose features that reduce complications.
2. 2. Compare the insertion techniques (open, laparoscopic, percutaneous) and their indications.
3. 3. State the principles of a well-placed catheter.
4. 4. Plan the break-in period and a safe initiation of PD.
5. 5. Diagnose catheter malfunction by distinguishing inflow, outflow, and bidirectional failure.
6. 6. Manage the causes of outflow failure in the correct order.
7. 7. Recognise and manage an early pericatheter leak.
8. 8. Document an insertion and a break-in plan.

A sixty-second reading. Each bullet stands alone.

• A PD catheter is a cuffed silicone tube; the deep cuff anchors in the rectus muscle and the tip sits in the true pelvis.
• Swan-neck designs and a downward-directed exit site reduce migration and exit-site infection.
• Insertion may be open surgical, laparoscopic, or percutaneous; laparoscopy allows fixation, adhesiolysis, and omentopexy and lowers malfunction.
• Percutaneous placement suits a virgin abdomen and is low-cost; avoid it where prior surgery or adhesions are likely.
• Give antibiotic prophylaxis before insertion — it reduces early peritonitis.
• Implant at least two weeks before routine use to let the wound heal and reduce leaks; urgent-start PD uses low-volume supine exchanges.
• The first question in malfunction is inflow versus outflow versus both.
• Constipation is the commonest reversible cause of outflow failure — treat it first.
• A plain abdominal X-ray shows tip position and faecal loading and guides most malfunction.
• Fibrin or clot occlusion responds to flushing and heparin; tip migration or omental wrap may need repositioning or laparoscopy.
• Early pericatheter leak is managed by reducing volume, supine exchanges, or temporary rest to allow healing.
• Feculent effluent at insertion means bowel perforation — a surgical emergency, not a catheter problem.

The medical core. An expert should agree access and troubleshooting are fully covered here.

Why it matters at the bedside

Agood catheter is invisible — it drains, it doesn't leak, and it doesn't get infected — and almost everything that makes it so is decided at selection and insertion. Get the design, the technique, and the break-in right, and most of the trouble that ends PD never starts.

The catheter and why its design matters

• The standard catheter is a soft silicone tube with one or two Dacron cuffs; the deep cuff is anchored in the rectus muscle and the superficial cuff sits in the subcutaneous tunnel. The intraperitoneal segment has side holes and ends in the pelvis.
• The tip is straight or coiled, and the inter-cuff segment is straight or swan-neck. A swan-neck arc lets the exit site point downward, which lowers exit-site infection and resists migration.
• A downward- or laterally-directed exit, away from the belt line and skin folds, is one of the simplest ways to reduce later infection.

Choosing the insertion technique

• Open surgical. A mini-laparotomy under direct vision reliably seats the deep cuff; it needs theatre time.
• Laparoscopic. Allows rectus-sheath tunnelling, adhesiolysis, omentopexy, and tip fixation, and gives the lowest malfunction and migration rates; preferred where adhesions or prior surgery are a concern.
• Percutaneous. A bedside Seldinger technique, often nephrologist-led and image-guided; low-cost with good outcomes in a virgin abdomen, but avoided where adhesions are likely.

Principles of a good placement

• Whatever the technique: antibiotic prophylaxis before incision; an emptied bladder and bowel; a pre-marked downward exit; the deep cuff in or under the rectus muscle; the tip in the true pelvis; and confirmation of flow before leaving.

The break-in period and starting PD

• Where possible, implant the catheter at least two weeks before routine use so the wound and cuffs heal; this is the single best protection against early leak.
• When dialysis cannot wait, urgent-start PD uses low-volume supine exchanges, increasing gradually, with close attention to leak.

When the catheter fails — a diagnostic approach

• Classify the problem first: inflow failure, outflow failure, or both. Bidirectional failure suggests kinking or malposition; isolated outflow failure points to constipation, migration, omental wrap, or clot.
• A plain abdominal X-ray answers most questions at once — it shows the tip position and the degree of faecal loading.

Outflow failure — causes in order

• Treat constipation first: it is the commonest reversible cause, and laxatives often restore flow. Next consider fibrin or clot — flush and use heparin. If the tip has migrated out of the pelvis or the omentum has wrapped the catheter, repositioning, usually laparoscopic, is needed.

Pericatheter leak

• An early leak — dialysate at the exit or wound with reduced drainage — usually reflects use before healing or volumes that are too large. Reduce or stop the fill, switch to supine low-volume exchanges, or rest the catheter (bridging on haemodialysis if needed) to let it seal.

Procedural pitfalls

• The dangerous events are at insertion: feculent effluent or peritonism signals bowel perforation and is a surgical emergency, and frank urine in the effluent signals bladder injury. Never force a catheter against resistance, and never start full volumes on a fresh catheter if it can be avoided.

Five fully-built tables.

Table A — Catheter design features

Table B — Insertion techniques

Table C — Principles of a good placement

Table D — Causes of outflow failure

Table E — Early complications

Visualise & Map

Numbered rules. These numbers are the cross-reference handle for the cases and flowcharts.

Clinical Reasoning

Four cases. Each stops you at a decision before it answers it.

Exhaustive. Every rule in the chapter is here.

Safety & Evidence

Panel A — Red flags

Panel B — NEVER DO

Anti-patterns clinicians fall into. Each becomes a Level 22 distractor.

The grade reflects strength of evidence, not importance.

Apply & Test

Copy-paste chart notes that map to the real procedures in this chapter.

Template 1 — Catheter insertion note

• Indication and consent; antibiotic prophylaxis given: agent ___, time ___.
• Technique: open / laparoscopic / percutaneous; operator ___.
• Catheter: type ___; cuffs ___; tip ___; swan-neck yes/no.
• Deep cuff sited in rectus: yes/no; tip confirmed in pelvis: yes/no.
• Exit site: direction ___; flow confirmed at end: yes/no.
• Complications: none / ___. Plan: break-in from ___.

Template 2 — Break-in / initiation orders

• Start date (target ≥ 2 weeks post-insertion, or urgent-start protocol).
• Position: supine for early exchanges.
• Fill volume: start ___ mL; increment schedule ___.
• Exit-site care instructions; watch for leak.
• Escalation triggers: leak, poor drainage, pain.

Template 3 — Malfunction assessment note

• Problem: inflow / outflow / both; onset ___.
• Bowels: ___; plain abdominal X-ray: tip position ___; faecal loading ___.
• Working cause: constipation / clot / migration / omental wrap / kink.
• Action: laxatives / flush + heparin / reposition / surgical.

Pre-rounds compression. Rules only.

Active recall. At least one card per objective.

Micro-teaching for rounds. Two scenarios, five steps each.

Eight items, each anchored in this chapter. At least one per objective.