OVERVIEW
Mechanical complications of peritoneal dialysis are complications of malposition, occlusion, displacement, or encapsulation of the guide tube resulting in perforation of abdominal organs, leakage of dialysate, and poor drainage. They can occur in both the early and late stages of peritoneal dialysis placement. Timely detection and management of these complications is important to improve the quality of life of dialysis patients and to increase the survival rate of peritoneal dialysis patients.
Etiology
1. Perforation of abdominal organs
Intra-abdominal adhesions may be present in patients with previous laparotomy, or increased pressure due to abdominal distension may lead to bowel perforation.
2. Abdominal pain
It is often caused by too rapid injection or discharge of peritoneal dialysis solution, too deep or too tight placement of dialysis tubing compressing the pelvic floor tissues, too hypertonicity of the dialysis solution, too high or too low temperature, and too low pH value.
3. Leakage of peritoneal dialysis fluid
(1) Early peritoneal dialysis fluid leakage: related to surgery, commonly caused by poor ligation of peritoneal purse-strings, or no peritoneal tissue between the ligature line near the catheter wall, or peritoneal tear caused by coughing.
(2) Late peritoneal dialysis fluid leakage: mostly related to mechanical factors.
4. Poor drainage of peritoneal dialysis fluid Catheter blocked, displaced or wrapped.
5. hemorrhagic complications Uremic retention leads to coagulation dysfunction, and preoperative use of anticoagulants is a high-risk factor for this disorder. For patients with potential bleeding tendency, incomplete intraoperative hemostasis is an important reason for the emergence of this syndrome in catheter placement.
Symptoms
1. Perforation of abdominal organs
(1) Intestinal perforation: during tube placement, fecal-like material appears or foul-smelling gas is detected inside the trocar needle and peritoneal dialysis catheter.
(2) Bladder perforation: When dialysis exchange is performed after the operation, lower abdominal discomfort, signs of urinary tract irritation may appear, or the patient may urinate immediately after the dialysis solution is instilled.
2. Abdominal pain
It often presents as limited or diffuse abdominal pain. A few patients may have pain in the perineum and perianal area, especially when filling in the peritoneal dialysis fluid or when the drainage fluid is about to end.
3. Leakage of peritoneal dialysis fluid
(1) Early peritoneal dialysis fluid leakage: occurring within 30 days of tube placement, manifested as leakage around the catheter, limited edema of the anterior abdominal wall, reduced drainage, and in severe cases, edema of the labia majora, scrotum, and penis.
(2) Late leakage of peritoneal dialysis fluid: Leakage that occurs 30 days after the start of peritoneal dialysis is less common.
4. Poor drainage of peritoneal dialysis fluid
(1) Omentum obstruction catheter: manifested as poor drainage of dialysis fluid in and out. Unidirectional obstruction occurs when the greater omentum obstructs the lateral holes below the center of the catheter and blocks the lumen of the catheter. It is usually more common in straight rows of tubing than in convoluted tubing.
(2) Protein clot or fibrous mass obstruction of the catheter: early obstruction is often blood clots and other obstructions, which are relieved after a few days. Fibrous mass obstruction is seen later in the course of abdominal dialysis.
(3) Poor catheter drainage in female patients: the presentation is similar to that of large omental wraps.
(4) Catheter displacement: the abdominal segment of the catheter drifts out of the true pelvis, commonly known as drifting catheter, which mostly occurs within 2 weeks after surgery. The manifestation is that the dialysate infusion is normal and the water discharge is impaired.
5. Hemorrhagic complications: The incidence of hemorrhagic complications is rare, ranging from 1% to 23% during open surgery, and the incidence of more bleeding is about 2%. Bleeding site is common in abdominal forearm hematoma, and some patients can see bleeding at the catheter of abdominal dialysis.
Examination
The examination for mechanical complications of peritoneal dialysis includes physical examination, general tests such as blood counts, pathologic examination of exudates, and imaging tests such as ultrasound and radiographs.
The cause of the various clinical symptoms can be determined and the appropriate diagnostic and therapeutic options can be determined.
Diagnosis
Combining the patient’s history and physical examination, pathologic examination, etc., and monitoring of peritoneal dialysis, the corresponding mechanical complications of peritoneal dialysis can be diagnosed.
Treatment
1. Perforation of abdominal organs
(1) Intestinal perforation: it is relatively rare, but once it occurs, the consequence is very serious, so it should be diagnosed in time and treated effectively. Intestinal perforation caused by peritoneal dialysis tube placement is generally small, and can heal by itself in 24~48h after operation. On the postoperative day, strict fasting, intravenous combined use of antibiotics, and extragastrointestinal nutrition therapy to maintain water, electrolytes and acid-base balance imbalance. On the 2nd postoperative day, if the patient’s condition is stable, appropriate oral intake of fluids can be given and slowly transitioned to normal diet. If fever, vomiting or signs of peritoneal irritation occur, timely surgical intervention should be performed.
(2) Bladder perforation: immediate surgical intervention once diagnosed.
2. Abdominal pain Slow down the rate of fluid instillation and fluid drainage. if the pain is severe or lasts for a long time, the intra-abdominal segment of the catheter should be pulled outward for about 1 cm. too high or too low a temperature of the dialysis fluid can cause diffuse abdominal pain, so it is best to control the temperature of the dialysis fluid at about 37℃. Peri-incisional pain that occurs after tube placement can be controlled with analgesics. If the LD tube is not properly placed, sometimes surgical re-tubing may be necessary.
3. Leakage of peritoneal dialysis fluid
(1) Early leakage of peritoneal dialysis fluid: prophylactic antibiotics can be used to suspend continuous ambulatory peritoneal dialysis, and switch to small-dose ambulatory intermittent peritoneal dialysis or nocturnal intermittent peritoneal dialysis. If the leakage is more, stop the abdominal dialysis for two weeks and switch to hemodialysis.
(2) Late leakage of peritoneal dialysis fluid: the treatment of late leakage is the same as that of early leakage, conservative treatment is usually ineffective, and surgery is often needed.
4. Poor drainage of peritoneal dialysis fluid
(1) Omental obstruction of catheter: it can be treated conservatively by strengthening the activity and flushing the catheter under pressure. When the conservative treatment is ineffective, it is usually necessary to place the catheter again surgically.
(2) Protein clot or fiber blocked catheter: saline or heparin saline pressure flushing catheter, saline and urokinase injected into the catheter to be retained for 12 to 24 hours after re-opening the tube, often with good results.
(3) Catheter displacement: taking laxatives or enemas to promote intestinal peristalsis; abdominal massage under X-ray fluorescence screen or using the Fogarty catheter to guide the return of the catheter; laparoscopic reset under direct vision. If the catheter cannot be repositioned by the above non-surgical methods, reoperation is required.
5. Hemorrhagic complications Different treatment measures are taken according to the site and degree of bleeding. The main treatment for bleeding at the abdominal wall and outlet is to stop bleeding by compression. If there is bloody drainage fluid, the abdominal cavity can be repeatedly flushed with unheated peritoneal dialysis fluid to reduce bleeding; avoid the use of anticoagulant drugs; after instilling cold peritoneal dialysis fluid into the abdominal cavity, bandage the abdomen with abdominal band under pressure; if the drainage fluid is still bloody after the above treatment, the wound should be opened to stop bleeding at the bleeding site.
Prevention
1. Perforation of abdominal organs
(1) Intestinal perforation
Preoperative night enema or use of laxatives during tube placement can prevent the occurrence of intestinal perforation, and puncture tube placement should be avoided. In order to avoid perforation of the cecum, the catheter should be inserted on the left side of the cecum, and puncture placement should be avoided as much as possible.
(2) Bladder perforation: Ensure that the patient has completely emptied the bladder before surgery. Patients with diabetes mellitus or other previous neurologic history should have a preoperative catheter.
2. Abdominal pain
Don’t inject or release peritoneal dialysis fluid too fast, avoid placing the dialysis tube too deep or too tight, and the temperature of the dialysis fluid should be appropriate.
3. Abdominal dialysis fluid leakage
(1) Improve the technique of tube placement, avoid too loose ligation of peritoneal purse-string or ligature line close to the peritoneal tissue without peritoneum between the walls of the catheter.
(2) Try to avoid peritoneal tears caused by violent coughing.
4. Poor drainage of peritoneal fluid
(1) Remove the expanded greater omentum from the peritoneal port site or place the end of the greater omentum in the peritoneal load port while ligating and fixing it around the catheter to reduce the incidence of wrapping.
(2) Improve the technique of catheterization to avoid subcutaneous tunnels forming a right-angled twist at the exit of the peritoneal catheter or tightening the purse-string ligature too much.
5. Hemorrhagic complications
(1) Evaluate the patient’s coagulation status before surgery, stop using drugs that may affect the patient’s coagulation, and use vasopressin prophylactically for patients with coagulation dysfunction before surgery.
(2) Choose the appropriate incision site, avoid the incision site is too outward, avoid damage to the blood vessels during the operation and completely stop bleeding, prevent the patient from coughing violently after the operation.