Manual pd no longer works

I have been on pd for 15 months using a homechoice cycler using 2 5L bags doing an exchange at 1pm and then at 7 pm for 10 hours that is 3 exchanges per night plus a last fill i averaged dwell time of 2:44 at each onw with 5-10 minutes of lost dwell time now i avg 2:27 dwell time and 50-110 minutes lost dwell time my fill time is still going strong but i can no longer still to drain and can no longer do a manual drain at all. i have had a xray and the cath is intact i took laxative i do heparin double for 2 days and have had my end of cath changed asu can see i am having trouble draining not filling any suggestions as my dr and nurses are dumfounded

Dear Peter

While we run about 20+ home PD patients, the majority being on APD with the Baxter Home Choice 2 system, I have to say that my primary interest and expertise is in home HD rather than home PD. I am not trying to duck your question, as it clearly looks like you are having significant issues, but it might be best if you asked Dori to direct this to her PD guru - Judith Bernadini.

That said, it is hard to know without seeing your xrays etc, exactly what is happening here but it sounds mechanical, to me.

I would want reassurance that when the catheter was said to be ‘OK’ that it was properly sited and not hoicked up into the (L) or ® upper quadrants or is lying anteriorly against the anterior abdominal wall.

I would want to know that it wasn’t just the first side holes that were ‘patent’ and that there wasn’t a fibrin plug occupying the bulk of the perforated tip.

And I would want to know - especially if you are young - if the catheter wasn’t omentum-wrapped.

Sometimes, it can need quite careful examination to diagnose - or exclude - these 3 primary mechanical problems.

Your laxative use is wise as often faecal loading in the bowel can trap a catheter and effectively wall it off from the remainder of the peritoneal cavity.

Similarly, heparin will help prevent the further propagation (spread) of any fibrin obstruction present (but will not effectively remove one that is already there) … and while down-the-catheter anti-fibrinolytic agents are occasionally useful, they are more often useless.

Often a simple surgical stripping of the catheter is the most effective +/- re-siting and/or tethering of it.

I would suggest that the first three are fully excluded. You say ‘xrays’ … but there are xrays, and then there are XRAYS. It depends what was done, whether contrast was used, whether laterals have been done … etc, etc.

All that said, as before, I don’t lay any claim to being a PD expert. However, I do have 35 years of experience with PD in a 20-25 average patient number program, and from that experience, I would be starting with these three.

John Agar

aloha Dr Agar,

many thanks for ur reply for the record I am 64 late friday night my dr called and said my cath had moved from the lower to the upper quad my surgeon told him he has seen this before and has some tricks to fix it i will be seeing him this week thanks again and i will let u know how it all comes out Aloha Peter