Insertion of the PD Catheter

Catheter type

Surgical techniques

Early exit site care

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• Local expertise at individual centres should govern the choice of method of PD catheter insertion. For chronic dialysis a permanent peritoneal dialysis catheter should preferably be implanted surgically in theatre by a surgeon with experience in the placement of PD catheters
• As an alternative to standard surgical insertion, laparoscopic PD catheter insertion may be done with the advantage of a less-invasive procedure and a smaller peritoneal perforation
• Surgical support should be available for catheter insertion, replacement or removal as necessary
• The catheter should be inserted 2-3 weeks before starting peritoneal dialysis
• The location of the exit site should be determined in advance of the surgical procedure
• Preoperative bowel preparation and showering or bathing with an antiseptic soap may help to reduce the risk of postoperative infections.

Catheter type

• Tenckhoff type catheter are preferred in children
• Single and double cuff, straight and coiled Tenckhoff catheters are available and there is no agreement on which particular catheter functions better or is associated with fewer complications (blockage, migration and frequency of peritonitis/exit site complications) in children across all age groups.³
• There is no benefit of coil catheters over straight catheters with respect to the prevention of catheterrelated infections
• Coil catheters may have the advantage of improved drainage and less obstruction of drainage of fluid
• In infants, coil catheters with single cuffs are preferred
• In older children swan-neck catheters with downward directed exit sites are preferred.

Surgical technique

• Antibiotic prophylaxis directly before peritoneal catheter placement decreases the risk of early peritonitis. Recommendation: Cefazolin 25 mg/kg IV. Antibiotic choice depends on centre-specific susceptibility patterns vs. risks of emergence of bacterial resistance
• A paramedian incision is preferred to avoid herniation or dialysate leakage
• A partial omentectomy reduces the risk of catheter blockage
• When using a catheter with two cuffs, the distal (outer) cuff should be situated approximately 2 cm from the exit site to decrease the risk of cuff extrusion
• Sutures should not be placed at the exit site because of the risk of bacterial colonization and increased risk of exit site/tunnel infection
• The exit site should be round and small for a snug fit of the catheter
• In infants the exit site should be directed upwards, outside the diaper area and away from site of stomas (gastrostomy, ureterostomy)
• In toilet trained children a downward pointing exit site is recommended to decrease the risk of peritonitis. It should also be placed away from the belt line and stomas (gastrostomy, ureterostomy)
• The catheter drainage should be checked in theatre
• It should be flushed with 10 ml/kg dialysate until the dialysate is clear then capped off
• Thereafter the catheter should be flushed weekly until use
• The catheter should be securely anchored close to the exit site to minimize movement. Movement of the catheter in the tunnel prevents healing, and results in leaks, exit site infection and granulomas.

Early exit site care

• Catheter dressings should not be removed during the first postoperative week
• Thereafter, the exit site should be cleaned once a week for the first 3 weeks. Dressing changes should be done by experienced personnel
• The exit site should be cleaned aqueous chlorhexidine 0.05%, followed by water. Strong agents such as hydrogen peroxide and povidine iodine should be avoided because they are cytotoxic and can be damaging to granulation tissue
• Apply a topical antibiotic cream (Bactroban/gentamicin) at the time of the weekly sterile dressing
• Avoid showering or bathing during the healing phase
• Perioperative catheter care and catheter complications (leaks, hernias, obstruction) should be managed according to the International Society of Peritoneal Dialysis (ISPD) guidelines at www.PDIconnect.com.

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Van Biljon I, Bhimma R, Gajjar P, McCulloch M, Nourse P. Guideline for Chronic Dialysis in Children in South Africa. South African Renal Society; 2015.