Complications arising soon after the catheter implantation are frequently related to the catheter implantation procedure per se, due to congenital anatomic abnormalities and to the increased intraabdominal pressure (IAP) generated by infusion of dialysate into the peritoneal cavity.
Pain. The most common pain is usually incisional or pain associated with manipulation of the catheter during the procedure. Pain associated with infusion of solution may be due to hypersensitivity to the low pH of conventional solutions, to placement of the catheter in a functional or anatomic compartment (e.g. limited by adhesions) or to position of the catheter tip against the pelvic wall, bladder or rectum. Infusion of air at the time of catheter insertion or during connections can also cause transient pain. The latter can be confirmed by resolution of the pain after moving the tip of the catheter to another location or replacing the catheter with a shorter one.
Bleeding. Bleeding can result from laceration of anterior abdominal wall vessels (i.e. inferior epigastric artery) or less frequently, puncture of intraabdominal vessels (mesenteric, inferior vena cava, aorta, iliac). Arterial bleeding from needle insertion into a blood vessel is usually easy to recognize and most of the time can be controlled by simply removing the offending instrument from the vessel. Laceration of the vessel will require immediate intervention and ligation through either laparoscopy or laparotomy. Venous bleeding may be more difficult to identify and control since veins do not have a muscularis layer. The recommended approach depends on the severity of the bleeding. Frequent exchanges and the use of intraperitoneal (i.p.) heparin to prevent clotting are generally used until the effluent clears or surgical intervention is deemed necessary.
Perforations. Perforation of an internal organ during catheter implantation should always be considered if pain, peritonitis or bleeding is observed. Paralytic ileus or obstruction, polycystic renal disease and internal herniae are predisposing factors. The diagnosis of a perforated organ is often evident immediately after the event, but unfortunately may remain silent for some time, leading to other complications. The most obvious signs of perforation are: the return of intestinal content or urine through the catheter or stylet, a hissing sound from gas release, fetid smell from fecal material, instant urge to urinate or vaginal release of peritoneal fluid. Peritoneoscopic or surgical implantation of the catheter should both reduce the incidence of perforation and provide a prompt diagnosis. Direct visualization is also helpful in deciding whether to abort the procedure and treat the patient with conservative means (antibiotic coverage and observation) or with exploratory laparotomy and repair. Through and through perforations of the small intestine or bladder after blind insertion of the catheter may remain silent for some time after the procedure and may be associated with good initial function of the catheter, making the diagnosis more elusive.
Leaks. The incidence of pericatheter leaks has been variously reported to be 0 to 40%. Pericatheter leaks may not be apparent in the immediate post insertion period unless a full (2 L in adult patients) exchange is performed. Undernourished and immunosuppressed patients, diabetics and individuals with very weak anterior abdominal walls are most prone to develop this complication. Catheter leaks can be prevented with the use of tightly secured purse string sutures at the site of entrance of the catheter into the peritoneal cavity, by precisely placing the catheter cuffs and by avoiding the use of full infusion volumes, particularly in the sitting and standing positions, until the catheter is totally healed. Many clinicians recommend a rest period of several weeks after catheter insertion whenever possible to assure optimal healing.
Joffe reported the use of fibrin glue to control catheter leaks after failure to recover with conservative therapy2. The technique consisted of injecting 2 ml of the ready-made fibrin adhesive system using a concentration of thrombin of 4 IE/ml into the area of the external cuff. The success rate in a small series was 83%.
Subcutaneous fluid leaks can also migrate and cause abdominal wall or genital edema. In order to distinguish a subcutaneous fluid accumulation from a patent processus vaginalis, a scintigram or CT scan is recommended.
A leak around the internal cuff may dissect the anterior abdominal wall, causing an accumulation of fluid around the catheter incision site resembling a hernia. The diagnosis can be established by ultrasound, scintigraphy or contrast media injection into the catheter followed by drainage. The problem can be corrected by revision of the insertion site and reapplication of an effective purse string suture in proximity to the internal cuff of the catheter.
Obstruction. The most common type of obstruction is a one way or the ball-valve type caused by proximity of the distal portion of the catheter to the omentum or intestine allowing infusion of the solution, but slow or no outflow due to due to the negative pressure caused by the external obstruction. Migration of the catheter can also cause of poor outflow. Migration has been shown to be associated with poor orientation of the catheter’s tunnel resulting in misdirection of the catheter into the upper abdominal quadrants due to the catheter spatial memory3,4. Although catheter manipulation often restores good catheter position, recurrence of migration is common and requires reinsertion with special attention to tunnel orientation. The use of a titanium weight at the end of the catheter or front-loading, or laparoscopic salvage of the catheter with reposition and securing the internal tip of the catheter in the true pelvis with a stitch can prevent or correct this complication. Omental wrapping can occur at any time after catheter insertion. Conservative therapy with enemas, change in position and ambulation often remedy this problem. Persistent obstruction may require catheter manipulation with reposition or replacement in extreme cases. Surgical laparatomy or laparoscopic epiplopexy of the greater omentum and epiploic appendices can be used in salvaging a dysfunctional catheter5.
Total obstruction during insertion is usually due to a catheter kink. The problem can be solved with manipulation using a flexible probe, or if persistent, by peritoneoscopic or surgical repositioning. Blood or fibrin clots following implantation should be treated with irrigations using heparinized solution. In extremes cases of a stubborn internal obstruction, direct intervention using a semi-flexible probe or brush under fluoroscopic control can be attempted.
Infections. Peritonitis as an early complication should raise the possibility of intraoperative contamination. Polymicrobial peritonitis with Gram negative organisms and/or yeasts is most suggestive of colonic perforation (see Treatment of Peritonitis). If bowel perforation is suspected, the diagnosis should be confirmed and appropriate surgical intervention with removal of the infected catheter is recommended.
Redness exceeding 13 mm in diameter and purulence with or without bloody discharge are the signs of an acute exit site infection. Swelling, erythema and tenderness over the tunnel tract are indications that the infection has extended to the tunnel between the internal and outer cuffs. The extent of the infection (abscess) can be further evaluated with a simple ultrasound of the anterior abdominal wall.
When signs of exit site infection are observed, a Gram stain and cultures should be obtained and appropriate empiric antibiotic therapy started. Warm hypertonic saline compresses may be useful and provide comfort in many cases. Failure to heal after specific antibiotic therapy based on cultures and sensitivities requires removal of the infected cuff or catheter removal and replacement. The surgical removal of the infected tissue, unroofing and cuff shaving have been practiced with some success by several experienced operators. However, replacement of the catheter to a clean site is the preferred option.
Herniae. Herniae may first appear following implantation of the catheter due to increased intraabdominal pressure. The traditionally quoted predisposing factors include malnutrition, immunosuppression, multiparity and a weak anterior abdominal wall. A recent survey including 75 U.S. and Canadian centers analyzed the data from 1864 patients6. Logistic regression analysis found no association between hernias and age, body surface area, PD modality, volume of dialysate, time of largest dwell (day/upright vs night/recumbent), or type of catheter used. Cystic disease conferred a 2.5-fold increase in risk for anatomic complications (p < 0.001); female gender conferred an 80% reduction in risk (p < 0.0001), and Kt/V > or = 2.0 conferred a 52% reduction in risk (p < 0.05) for hernia.
If the diagnosis is made during the procedure, it should be immediately corrected. If not, the infusion volume should be reduced and automated PD in the supine position should be favored until corrective surgery is scheduled. Incisional herniae are more common when the incision is performed over the linea alba and least frequent with paramedian insertions through the rectus muscle (see Placement of PD Catheters).
Hydrothorax. Hydrothorax typically occurs early in the course of therapy since it is frequently due to a congenital defects of muscle fibers of the diaphragm. The reported frequency varies between 1 and 10%. Diaphragmatic defects are possibly more frequent than this, but go unrecognized until fluid is present in the peritoneal cavity and intraperitoneal pressure (IAP) increases. Women are affected more commonly than men and the right side predominates. The first manifestations of hydrothorax are dyspnea or inadequate ultrafiltration. However, approximately 25% of instances are asymptomatic and diagnosed during routine physical examination of chest x-rays. The pleuro-peritoneal communication is best localized with injection of radioisotopes into the peritoneal cavity followed by scintigrams after infusion and post drainage. A low pleural fluid protein content is the most consistent biochemical finding. The available therapeutic options are: surgical closure of the communication, pleurodesis by talc insufflation, injection of oxytetracycline, autologous blood or other irritants or video-assisted thoracoscopic pleurodesis (VATS). VATS talc pleurodesis is a safe and reliable treatment that allows sustained continuation of PD with low recurrence rate7.
Genital edema. The most common causes of gential edema are pericatheter fluid extravasation into the preperitoneal space and a patent processus vaginalis. The latter complication frequently presents shortly after catheter insertion. The diagnosis is readily confirmed by scintigraphy, cannulography with contrast material or CT scanning. Surgical correction is most effective and allows continuation of PD in most cases.
Back to Complications of PD Catheters
References:
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Diaz-Buxo JA. Complications of peritoneal dialysis catheters: early and late. Int J Artif Organs 29:50-58, 2006
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Joffe P. Peritoneal dialysis catheter leakage treated with fibrin glue. Nephrol Dial Transplant 1993; 8: 474-76.
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Diaz-Buxo JA, Turner MW, Nelms M. Fluoroscopic manipulation of Tenckhoff catheters: Outcome analysis. Clin Nephrol 1997; 47: 384-88.
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Hwang SJ, Chang JM, Chen HC, Tsai MK, Tsai JC, Hsu CH, Hsaio PW, Tsai CY, Guh JY, Lai YH. Smaller insertion angle of Tenckhoff catheter increases the chance of catheter migration in CAPD patients. Perit Dial Int 1998; 18:433-43.
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Crabtree JH, Fishman A. Laparoscopic epiplopexy of the greater omentum and epiploic appendices in the salvaging of dysfunctional peritoneal dialysis catheters. Surgical Laparoscopy & Endoscopy 1996; 6:176-80.
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Van Dijk CMA, Ledesma SG, Teitelbaum I. Patient characteristics associated with defects of the peritoneal cavity boundary. Perit Dial Int 2005; 25: 367-73.
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Tang S, Chui WH, Tang AW, Li FK, Chau WS, Ho YW, Chan TM, Lai KN. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003; 18: 804-08.