Inadequate drainage


#1

My dad had a presternal catheter implanted 3 weeks ago. This past Monday he started PD training. He has had problems with the drain time taking like 2 hours and sometimes only half of the fluid put in will come out. No problems going in! Today, his PD nurse and a neph (ours has been on vacation for a month and is still gone) decided to get an xray and his catheter is in his left middle abdomen. They said it is supposed to be in his right lower abdomen. His nurse seems to think that the presternal will not work for him because his torso is so long (he is 6’7" and weighs about 275). So we have to stop our training (which means dialysis too and he was beginning to feel better). We have to go back to the surgeon Monday to see what he is going to do, including surgery that day if need be. Please help, any suggestions or opinions would be greatly appreciated!!
Ash


#2

Hi Ash,

I asked an expert nephrologist for you, and this is what he said:

It is very difficult to figure out what is going on. I presume that they talk about the catheter tip in the left middle abdomen. The tip should be in the true pelvis (low). Sometimes laxatives help by vigorous peristalsis of the descending colon to move the catheter tip to its proper position. If the catheter is wrapped by the omentum, then the surgeon needs to determine what to do.

So, one possibility is that your dad may be constipated, which would affect how the catheter would drain. And another is that omentum–a sort of “curtain” of tissue in the abdomen–may be interfering with the catheter.

Please let us know what you find out on Monday. I don’t know that there is any reason why your dad’s height would matter.


#3

My dad had inadequate draining of his presternal cath. He has only had the cath long enough to still be in training. Yesterday he had the repositioning surgery (it was in his left side) and also had an omentum wrapping and a huge fibrin clot in the catheter. No one did anything to the catheter for 18 days (flushings or anything). The surgeon said the omentum is stuck really well to the left abdominal wall so thats good as long as it will stay there. Has anyone ever had the repositioning surgery or the omentum wrapping and had to have another one? Or anyone with similar problems have any tips? He is so worn out from surgeries. He has had two in the past month for this catheter. He goes back to the neph thursday and probably will resume training friday with only 1000ml. Also, he is taking laxatives but sorbitol is what the recommended but is not working him well. Do yall have any suggestions?

Ashleigh


#4

Do the cycler machines usually drain slower than during manual exchanges? The PD nurse said it would take 12 hrs 45 mins to do 4 exchanges on the cycler. However, he is draining very well on manual exchanges. Has anyone every had problems with this before?


#5

Hi Ash. Hopefully someone who uses a cycler will jump in to answer this question for you. But in the meantime, I’ll tell you that usually the connection times we hear for CCPD are in the 9-10 hour range–and even then, it isn’t necessary to be hooked up to the machine for the whole time. It’s possible to connect, let the machine do a fill (put fluid into your dad’s peritoneum), then disconnect and dwell until it’s time for the next exchange. That way, if he’s willing to do an extra disconnect and connect, he doesn’t have to be so tied down. 12 hours is a long time!


#6

Hi Ash:

The cycler time will depend on how many exchanges is scheduled per night & the length of the dwell. I was scheduled for 9 hours each night when I was on - or three exchanges. The first thing the machine does is an initial drain, which takes 20-30 minutes, then it will fill, maybe 5-10 minutes, then it will dwell, the dwell time will depend on the doctors orders, I think mine was for 2 1/2 hours, though some are longer (while it is on dwell, you can disconnect from the machine completely if you want by using a flexicap on the machine end & a minicap on your tube end - you just need to be reconnected by the dwell time end, which includes another hand washing/masking session to reconnect). Then the machine will go to the next cycle of drain, fill, & dwell repeatedly throughout the night. It is all programmed by your dialysis nurse, and if you get good enough clearance, they may even reduce the dwell time or number of exchanges (Mine started out with four exchanges & I went to three before I got my transplant.)

Let me know if you have any more questions about the cycler, it is VERY easy to use & as far as I’m concerned THE WAY to GO!! CJ


#7

Curious-why so long on the cycler? Why aren’t they teaching him CAPD first? Usually I train patients on CAPD for the first month and then do a PET ( peritoneal equilibration test ) to determine his transport characteristics and use this to set dwell times. Maybe, to answer my own question, he is very uremic and needs dialysis STAT. But I still would train him on manual exchanges, get some good dialysis, and then train on CCPD.


#8

Dear Jerseygirl,

He is training on manual exchanges too. Before his 2nd surgery, he did training for a week. After his surgery, we have been training and doing some at home since last Friday. Now the PD nurse says he is draining well on the cycler so she is doing a home visit tomorrow. I also have another question-Are you supposed to get more fluid out than you put in sometimes? For example, today he did the cycler and left with fluid in him(1500 ml) that we were supposed to do a manual drain at home. Tonight he got 3600ml out. During each exchange and cycler, he has been getting all or more of the fluid out. But this one was suprising because he has never gotten more “extra” fluid than 500 ml out. Any suggestions?


#9

Hi Ash

I was on CAPD for about 7 months before starting off on CCPD. Even now, when I travel, I go for CCPD.

Reg the time for initial drain and fill, it takes about 25-30 minutes for me (both drain and fill). This is followed by the dwell time.

I am on a nine hour schedule with four exchanges, each lasting about 1 hour and 37 minutes.

During my first two days of cycler usage itself, I have noticed that the output / drain using a cycler is slightly higher than what I could do manually. The cycler sucks out as much as it can. Even otherwise, even while doing manual, the drain is higher than what you put (as it is expected to be, unless your dad is able to urinate well).

When the drain volume was not enough, were you increasing any weight gain ? You are supposed to take weight after each session, to notice the variations in the weight and if it the drain is constantly on the lower side and the weight is going up, it indicates retention, which needs to be immediately reported.

During my initial days on CCPD, I had problems on draining and had used laxatives, which made it comfortable. Now, I do not see any problem.

All the best

Shyam


#10

Yes Ash, the goal is to get fluid off if he is over his target weight. My guess is they are still trying to establish a target weight for him. His ultrafiltration, or fluid loss, usually depends on the strength of dextrose solution you use. To take max off, use a 4.25%. It takes a while to determine the target weight. With 1500cc in and 3600cc out I’ll bet they left in a 4.25% that day. At least his drain problem appears resolved, my dear, and he is on his way! His target weight is the weight he feels best at - can sleep well, BP good, pulse good, no peripheral edema, no SOB. If he still makes urine that is good as well. but must be taken into account in finding a good TW for him. Hope this helps! How are you documenting his exchanges and fluid loss? He should be given a flow sheet to fill out. Good luck!


#11

Ash -
My guess would be the reason he hasn’t removed excess fluid off before, is because of the length of time the fluid has been left in, which is often the case when training.

PD is like adding sugar to a bowl of strawberries - - the longer the sugar sits or dwells, the more fluid it will produce; therefore the more that will drain out.

But yes, they will need to find an ideal weight, which is why you will have to weigh yourself at the same time every day. This will give you the knowledge you need to use on a daily basis determing which dialysite solution you will use for your exchange - or you may have to mix your solutions, like one yellow (1.5) and one green (2.5). I would use the red (4.25%) solution in VERY LIMITED circumstances - your PD nurse will go over that with you.


#12

I have the greatest team of nurses and Techs I found out in March of this year2018 Kidneys are failing and started Hemo didn’t look into Pd well i crapped up 3 times in that time twice in August and then one of the nurses said go do Pd and when she told me that no needles and less or no cramping and every other bonuses that same day kidney dr had me recommend for surgery home dialysis nurse came in next treatment to tell me how great it will be for me at age of 42 and she taught me manual first everyone should learn manual first I agree with you and you must be as Awesome as her my team I have of everyone doctors nurses techs dietician social worker to family and great friends I’m blessed my team at Dialysis I trust everything they say and what Surgeons I’ve been referred to! God Bless you!