PERITONEAL DIALYSIS (Greek peritonaion peritoneum; dialysis; synonym: peritoneal dialysis, peritoneal lavage) — a method extrarenal clarifications of an organism from products of metabolism, excess of water and electrolytes, exogenous toxins by means of diffusion and osmosis through a peritoneum as a natural semipermeable membrane.
Items of — the most effective way of intrakorporalny dialysis, carry out it washing of an abdominal cavity the special dialyzing solution. The principle of a selective concentration equilibration of substances through a semipermeable membrane is P.'s basis of. At introduction to an abdominal cavity of isotonic salt solution the substances which are contained in blood diffuse with various speed through a peritoneum in solution and thus can be removed from an organism, at the same time useful substances can be entered into an organism. Hypertonic salt solution causes also osmotic ultrafiltration. The fluid influx in an abdominal cavity proceeds before full alignment of concentration of osmotically active agents in solution and a blood plasma. Big surface of a peritoneum (at the person it makes about 20 000 cm 2 ), a thin mezotelnalny cover, plentiful krovo-and a lymph flow create an opportunity for considerable transperitoneal movement of substances with various molecular weight, including water, electrolytes, products of a proteinaceous catabolism.
History P. of contains more than 100 years. In 1877 F. R. G. Wegner made experiments on washing of an abdominal cavity at animals, using strong solution of sucrose; he observed increase in volume of wash liquid due to filtering of water from blood. In 1923: G. Ganter proved experimentally and the first applied in P.'s clinic of at uraemia. However regular use of P. of began later when Maxwell (M. N. of Maxwell, 1959) and Boen (S. T. Voyep, 1962) improved the equipment P. of, and Weston (H. E. Weston, 1965) and Tenkhoff (H. Tenck-hoff, 1968) developed easy and safe ways of catheterization of an abdominal cavity. P.'s distribution by was promoted by creation by Boe-nom, Tenkhoff, etc. special devices for P. to, and also Popovic's proposal (R. Popovich, 1976) who applied the simplest way of constant out-patient P. of which is not demanding daily participation of medical personnel and use of the expensive equipment.
In our country one of the first K. A. Velikanov in 1957 applied peritoneal dialysis. The domestic device for peritoneal dialysis — DIAP-90 is created.
Indications to P. of in effect same, as well as to to a hemodialysis (see) — the acute and chronic renal failure which is followed by the expressed azotemia, a decompensated metabolic acidosis, an overhydratation, a hyperpotassemia. When the hemodialysis is contraindicated because of risk of bleeding or hypersensitivity to heparin, napr, at hemorrhagic diathesis, extensive destruction of soft tissues and bones, a hematencephalon, there are special indications to P. of. P.'s use by is reasonable at a renal failure owing to a septic endocarditis when heparin is contraindicated, and also at hemolitic anemia in connection with the lowered tolerance of blood to a mechanical injury.
Resort to P.'s treatment by temporarily at small children if there are no conditions for imposing of the arteriovenous shunt or a fistula, and also at people of advanced age with the expressed atherosclerotic obliteration of peripheral arteries (is more often at suffering from a diabetes mellitus). By means of P. can begin treatment of a renal failure at the nontransportable patient or in the absence of an opportunity to apply a hemodialysis.
The item of is shown at exogenous poisonings as an independent method or as addition to other methods of a detoxication when the dose of poison is potentially deadly, and conservative therapy is insufficient. Items of apply at poisoning with halogenated hydrocarbons, amino compounds, organophosphorous insecticides, simple and complex alcohols, salts of heavy metals, barbiturates, alkaloids, fenotia-zinovy, salicylates. Less often than P. apply concerning the isolated disturbances water, electrolytic, acid-base equilibrium when they cannot be eliminated in the conservative way. In particular, this method the hypercalcemia can treat acute), a gipermagniyemiya, a hyperpotassemia, and also hypostases of a renal and cordial origin, a decompensated metabolic acidosis.
Among indications to P. of a specific place is held by diffuse purulent peritonitis. In this case by the beginning of dialysis treatment the source of peritonitis shall be eliminated.
are subject to Long dialysis treatment patients, only emotionally steady, capable to cooperation. Items of do not carry out by the patient with dystrophy, malignant new growths, hemoblastoses, incurable heart or pulmonary failure, cirrhosis, hemiplegia, contagious persistent infection. The item of is contraindicated at suspicion on damage or a disease of abdominal organs and a diaphragm, at paralytic Ilheus, the delimited peritonitis, an infection of an abdominal wall, a kolostoma. Catheterization of an abdominal cavity and P.'s carrying out of are at a loss in the presence of extensive peritoneal unions, a gepatosple-nomegaliya, big polycystic kidneys, pregnancy, hems of a front abdominal wall.
For P.'s carrying out of enter a special catheter into an abdominal cavity. Usually pour in solution and pour out alternately through one catheter, but sometimes, napr, at a flowing irrigation at patients with peritonitis, use two catheters or take away solution on a drainage. Make catheters of polyvinyl chloride, nylon or silastic, rubber catheters do not use as they irritate a peritoneum, promoting formation of unions and loss of protein with solution. For the purpose of improvement of irrigational properties and the prevention of obstruction by an epiploon or fibrin the catheter in an abdominal part is in addition perforated from sides. Necessary conditions are dense contact of a catheter with fabrics of an abdominal wall and safety concerning bacterial pollution. In acute cases when long dialysis treatment is not required (acute P. of), for catheterization of an abdominal cavity use the stylet catheter offered by Weston in 1965. Length of a catheter of 27,5 cm, thickness of 3 mm, its gleam is inserted the pointed metal mandrin stylet.
Before a puncture the patient empties a bladder and holds a dorsal decubitus. All procedure is performed with observance of an asepsis under a local anesthesia with premedication. The place for catheterization (on the centerline of a stomach is 3 — 4 cm lower than a navel or in Mac-Berney's point at the left) is infiltrirut by 1% solution of novocaine to a peritoneum. By a narrow scalpel do the pricking section 4 — 5 mm long to an aponeurosis. For the prevention of an internal injury a stylet create artificial ascites or a pneumoperitoneum. For this purpose through a section the fine shortly ground needle punktirut an abdominal cavity and enter 1000 — 2000 ml of the dialysis fluid or C02 which is warmed up to t ° 37 °. The peritoneal catheter is washed out solution of heparin, insert into it a stylet and entered perpendicularly to an abdominal wall into a section. The patient actively reduces at this time muscles of a stomach. Carefully advancing a stylet, perforate an aponeurosis and a peritoneum. At the time of perforation the doctor feels easy click. Having delayed a stylet, enter through a puncture into an abdominal cavity a catheter, sending it the end to a small pelvis. Introduction of a catheter shall not cause in the patient of discomfort or pain. The developing pains in epigastriums are connected usually with a tension of an epiploon, dorsodynias are caused by a tension of a mesentery and meet at catheterization in the right flank more often. If the end of a catheter presses down a rectum, there are pains in rectal area. In all cases for elimination of pains happens to improve enough situation of a catheter in an abdominal cavity. When the catheter is established in the relevant provision, check its passability. For this purpose delete a stylet, attach through a transitional part Y-shaped system for P. of and pour in about 500 ml of solution in an abdominal cavity. At the correct arrangement and good passability of a catheter solution freely arrives and follows from an abdominal cavity. The outside end of a catheter shall stand over skin of a stomach no more, than on 2 cm. Fix a catheter by means of a circular purse-string seam; pulling together the ends of a ligature, immerse edges of a skin section in a seam. The catheter is fixed in addition over an aseptic bandage a strip of a plaster to skin.
After the end of dialysis the catheter can be left in an abdominal cavity; in this case a transitional part is blocked a roller clip and cut sterile scissors, wrapped the napkin moistened in an antiseptic agent, bent and fixed a plaster. In case of removal of a catheter the wound in an abdominal wall is closed seams or metal brackets. Repeated catheterization is done not closer by 3 cm from the place where the previous catheter was established.
In 1968 H. Tenckhoff offered a catheter which can be implanted into fabrics of an abdominal wall on short (acute P. to) and a long time (chronic P. to). The catheter is made of silastic, length of its 32 cm, including an outside part — 10 cm, hypodermic — 7 cm, intra belly — 15 cm, its about a half is perforated. The catheter of such standard size is used practically at all adults. For undersized it is shortened at the expense of an intra belly part; at high patients the place of implantation is shifted from top to bottom that the end of a catheter in all cases was located in a cavity of a small pelvis. Length of a catheter for children is determined by distance between a navel and a symphysis, at the same time shortened in proportion hypodermic and vnu-tribryushny speak rapidly, leaving outside 10 cm long. The perforated end of a catheter for children shall be not less than 2 cm. On a catheter for acute dialysis in a hypodermic part paste one coupling from dacron velor, on a catheter for chronic dialysis — two couplings, having the second at an intra belly part. Being shipped under, skin, couplings are sprouted connecting fabric and fix a catheter.
H. Tenckhoff's catheter can be entered at a laparotomy, a puncture of an abdominal wall with direct vision (peritoneoskopiya) or «blindly» using a special trocar. The last way is most widespread. At adults apply premedication and a local anesthesia, children have an anesthesia. On the centerline of a stomach by 3 — 4 cm lower than a navel do a skin section 6 — 8 mm long and bare an aponeurosis. Then by means of children's a stylet catheter or shortly ground needle punktirut an abdominal cavity and pour in up to 2000 ml of the warmed-up dialysis fluid. Having finished injection, the stylet catheter is not deleted, it can be used as the conductor for introduction of a trocar that allows to avoid a repeated puncture.
The trocar is arranged in the form of a small funnel and has narrow and wide speak rapidly. A narrow part is intended for perforation and carrying out in an abdominal cavity of a catheter, wide — for placement in fabrics of the dacron coupling pasted on a catheter. The case of a trocar (tube) consists of two longwise the divided parts and the tube which is put on them. The trocar collected on a stylet catheter is entered into an abdominal cavity until it reaches a wide part of an aponeurosis. Delete a stylet catheter. The Silastikovy catheter is strengthened mandrin and entered on a trocar into an abdominal cavity. Small resistance in a narrow part of a trocar is easily overcome by rotation of a catheter. Without effort advance a catheter in the caudal direction until it reaches the end of a small pelvis. Having finished introduction, check passability of a catheter then delete a trocar from an abdominal cavity. Important at this moment to warn the shift of a catheter and vyskalzyvany couplings on a surface. A hypodermic part of a catheter is placed to the left of the centerline, hollow having bent it that the outside end was turned from top to bottom. In a projection of the second coupling do an additional skin section and connect both sections a hypodermic tunnel in which drag a catheter. The second coupling have under skin in 1 and from a section. Double-check passability of a catheter and close a wound two-row seams. The catheter is equipped with a clip, the handle (union) and the adapter. If catheterization does not precede directly P. to, in an abdominal cavity pour in 200 — 300 ml of the solution containing 100 PIECES of heparin on 1 l, press a catheter, pour in an outside part of its antiseptics and close a cap obturator. In this way arrive every time after the termination P. of. Heparin is added to solution in interdialysis time within the first two weeks while there is a threat of obstruction of a catheter of fibrin. In the same time avoid overflow of an abdominal cavity a dialysis fluid because of danger of infiltration of fabrics of an abdominal wall therefore at P. pour in no more than one liter of solution, respectively shortening exposure time up to 10 minutes.
For removal of a catheter it is necessary to allocate before couplings with the connecting fabric surrounding them and to remove a catheter from an abdominal cavity. Wounds close two-row seams. In case of infection of a hypodermic tunnel in an abdominal cavity pour in 500 ml of a dialysis fluid with an antibiotic and delete a catheter. Edges of a wound exsect and drain. If in the course of treatment peritonitis develops, then it is not the indication to removal of a catheter, it is used for treatment of peritonitis.
Additional opportunities for reduction of risk of a peritoneal infection and fuller rehabilitation of patients open during the use of a hypodermic peritoneal catheter. Its advantage consists that it is not reported with external environment. A hypodermic part of a catheter represents the reinforced silastikovy cylinder covered outside with dacron velor. The silastikovy tube with side perforation departs from it, to-ruyu place in an abdominal cavity. Hypodermic catheters happen one - and two-section. For P.'s carrying out of the hypodermic segment is punktirut a needle. Along with constant catheters at chronic P. apply the replaced catheters; for their free introduction in 1963 of Barry (Vaggu) with soavt, suggested to establish a cannula in an abdominal wall. The advanced transparietal cannula, like H. Tenckhoff's catheter, is made of silastic with dacron couplings for strong connection with fabrics; also devices for its reliable sealing are provided. It is reasonable to apply a peritoneal cannula at frequent obstruction of a catheter fibrin.
The existing dialyzing solutions differ from each other a little. On the main components they are close to to a blood plasma (see), but have - more high osmotic pressure. Most often use solution of the following structure: add to 1000 ml of a distilled water 5,67 g of sodium chloride, 3,92 g of sodium lactate, 0,257 g of calcium chloride, 0,152 g of magnesium chloride, 15,0 g or 42,5 g of glucose. It corresponds to 132 mmol/l of sodium, 3,5 mmol/l of calcium, 1,5 mmol/l of magnesium, 102 mmol/l of chlorine, 35 mmol/l of a lactate; at absence at the patient of a hyperpotassemia add 0,22 — 0,29 g (3 — 4 mmol/l) of potassium chloride to solution. The general osmolarity of solution from 1,5% of glucose 347 mosm/l, from 4,25% — 686 mosm/l, pH 5,5. Depyrogenized, sterile, non-toxic solution, free of bacteriostatic agents and additional buffer solutions is good for the use. If necessary the composition of the dialyzing solution is altered, as buffer solution instead of sodium lactate use acetate or sodium bicarbonate in equivalent quantities that is convenient at treatment of ketoacidosis, some poisonings demanding alkali reaction of solution. For the purpose of increase in elimination of poisons add a protein or albumine to the dialyzing solution, etildiamintetratsetat sodium, Unithiolum, vegetable oil. In order to avoid heavy dehydration and apply a dialysis fluid to decrease in loss of own protein with it is admissible the minimum osmolarity which is required for removal of necessary volume of liquid. At the same time it must be kept in mind what with each two liters of the solution containing 1,5% of glucose in addition is removed from an organism of 100 ml of liquid, and with the solution containing 4,25% of glucose — 500 ml of liquid. Solution before introduction to an abdominal cavity is heated to i ° 37 °. In a number of the countries solution is prepared in the industrial way in plastic containers with a capacity up to 2 l.
The simplest system P. of consists of two large bottles on 2 l and the T-shaped tube connecting them. Large bottles close the rubber condensed bungs with an air duct and the union, fill one of them with solution, establish on a support, attach to a catheter at the patient and slowly pour in solution in an abdominal cavity. Having waited for exposure time, the empty large bottle is lowered so that solution followed from an abdominal cavity independently. The used solution in large bottles is alternately replaced with fresh and repeat manipulation as long as it is necessary for obtaining medical result. The one-time system for P. is simpler and more reliable than from a plastic container and a direct tube. The soft cover of a container is emptied and filled with solution, remaining hermetically closed that reduces a possibility of bacterial pollution of solution.
This method is simple, but has a number of shortcomings, first of all — risk of development of peritonitis, besides, this procedure is labor-consuming. These shortcomings can be avoided during the use of devices for P. Several types of the devices differing in functional parameters and extent of automation are developed. Semi-automatic devices allow to keep tightness, to maintain a certain temperature of the dialyzing solution, to measure amount of the deleted liquid from an abdominal cavity, to provide sterility of solution. The last is reached by use bacterial filters (see). Automatic devices can work according to the programmed scheme. At the same time continuous preparation and fine motion of structure and temperature of solution is provided.
Ways of peritoneal dialysis
two main ways P. of were originally known: constant, or permanent, offered by Vegner, and alternating, or intermittent, offered by Gunter. The terms «constant» and «alternating» are used only in relation to the scheme of separate dialysis here.
Further there were P.'s modifications by. It is accepted to distinguish:
1. Constant, or flowing, P. of which provides constant administration of the dialyzing solution in an abdominal cavity with a speed of 100 ml! mines and removal of liquid from a cavity with the same speed. Thus, within 1 hour the abdominal cavity is irrigated with 6 l of the dialyzing solution. Time of dialysis 12 — 18 hour. At this type of P. of enter 2 catheters into an abdominal cavity. Owing to high loss of protein, a possibility of disturbances of compliance between inflow and outflow of liquid from an abdominal cavity, formation of through traffic between drainages flowing P.'s efficiency of can be insufficient.
2. Recycling P. of is modification of flowing dialysis. For regeneration of dialyzate use the device an artificial kidney (see. Artificial kidney ). At this way P. of between an abdominal cavity and the device through 2 peritoneal catheters with a speed of 300 ml! mines 4 — 5 l of the sterile dialyzing solution circulate. Such system creates conditions for increase in efficiency of P. of, economy of the sterile dialyzing solution, prevention of microbic pollution of an abdominal cavity. In 1979 Mr. of Giordano (S. of Giordano) with soavt, suggested to apply special sorbents to regeneration of dialyzate.
3. The alternating (intermittent) P. providing introduction to an abdominal cavity of 2 l of the dialyzing solution, its leaving in it within 30 min. and removal of solution from an abdominal cavity. The average duration of each cycle makes about 50 min., of them injection of solution — 5 min., an ekvilibration — 30 min., drainage — 15 min. Simplicity of a technique, use of a single catheter, a possibility of periodic change of osmolarity and qualitative composition of the dialyzing solution, control of balance of liquid, decrease in losses of protein characterize merits of this way P.
of 4. Constant (permanent) P. is carried out by according to Popovic's proposal day by day round the clock. Solution is exchanged on 2 i by four times a day (at 7, 13, 19 and 24 hours). This way, despite the minimum expenditure of the dialyzing solution (56 l a week), provides quite adequate treatment. Simplicity and low cost value of treatment allow to use widely it in out-patient conditions.
Complications of peritoneal dialysis
Complications at introduction of a catheter: the wrong arrangement of a catheter in an abdominal cavity (not in a small basin), disturbance of tightness of the wound channel around a catheter, obstruction of a catheter, bleeding at damage of vessels, a perforation a catheter or a trocar of internals. Infectious complications arise at microbic pollution of an abdominal cavity during introduction of a catheter or dialysis fluids in this connection development is possible peritonitis (see).
Heart failure arises at a considerable delay of the dialyzing solution or owing to incorrectly picked up composition of solution; changes of a nervous system are shown in the form of a syndrome of «the broken balance», in this regard there is an increased intracranial pressure and wet brain.
P.'s use by according to strict indications, observance of rules of an asepsis, compounding of the dialyzing solution, constant overseeing by the patient, observance of rules of conducting dialysis make a basis of prevention of complications.
Results of use of peritoneal dialysis
the Standard criterion of efficiency of P. of is the clearance of substances (see. Clearance ), calculated by a formula:
With = (Sd*u) / (Sv*t),
where With — clearance of substance in ml/min., Sd — concentration of substance in the dialyzing solution; Sv — concentration of substance in blood; At — amount of the dialyzing solution in ml; T — exposure time of solution in an abdominal cavity in min.
The indicator of clearance allows to estimate P.'s efficiency of concerning removal of various substances, and also to compare it to other methods of clarification of an organism.
On the speed of removal of melkomolekulyarny products of a nitrogen metabolism (urea, creatinine, uric to - you) P. concedes to a hemodialysis by 4 — 6 times and it is necessary for obtaining identical result that P.'s time of made 30 — 36 hours a week. As for clearance of middlemolecular substances (500 — 5000 dalton), surpasses by P. in this respect a hemodialysis several times. Exception is only P. of with regeneration of dialyzate by means of the device an artificial kidney, at Krom elimination of these substances is limited to an artificial dialysis membrane. At constant out-patient P. of with use of 56 l of the dialyzing solution in a week total removal of nitrogenous metabolites of small molecular weight corresponds to requirements of an organism at a diet with protein content of 1 — 1,5 g/kg of body weight a day.
The item of is not followed by loss and a mechanical injury of blood therefore anemia at patients is expressed to a lesser extent, than at treatment by a hemodialysis. At the same time at P. of the patient loses a significant amount of protein, amino acids, vitamins for one procedure that sometimes demands special treatment. At many patients with an end-stage of a chronic renal failure, thanks to dialysis treatment life expectancy increased for 5 years and more, part of them at the same time keeps in a varying degree working capacity.
Peritoneal dialysis at peritonitis
Peritoneal dialysis at peritonitis aims at removal from an abdominal cavity of inflammatory exudate, microbes, their toxins and suppression inf. process; The Item of promotes correction of the metabolic disturbances which are observed at this disease.
Expediency of long irrigation of an abdominal cavity at peritonitis is experimentally proved by X. F. Kaplan (1947) and G. of X. Gafurov (1957). Most often P. apply at the diffuse peritonitis caused by appendicitis, acute cholecystitis, a ruptured ulcer of a stomach and duodenum at the combined and combined injuries of abdominal organs, postoperative peritonitises, acute intestinal impassability. An absolute contraindication to its use is existence not eliminated inf. the center in an abdominal cavity, lack of confidence in reliable closing of defect in a wall of hollow body.
P.'s carrying out of is almost impracticable if the tamponade of an abdominal cavity since the liquid entered into it streams outside through defect of an abdominal wall is made.
P.'s technique of at peritonitis is based on three principles: the easiest and reliable way of introduction of a catheter to an abdominal cavity; use of the dialyzing solutions with sodium acetate, novocaine, heparin, antibiotics of the directed action; carrying out necessary number of sessions of P. of depending on the nature of a disease and specific features of the patient.
At a nizhnesredinny laparotomy (see. Laparotomy ) it is better to enter a catheter into a cavity of a small pelvis, stacking between a rectum and a bladder at men and between a rectum and a uterus at women.
Usually one catheter prosperity but for full carrying out P. of in the postoperative period. Nek-ry surgeons apply to drainage of an abdominal cavity (see. Drainage ) 2 catheters and more. However these offers were not widely adopted.
The main types of P. of applied at peritonitis are flowing and alternating without recirculation of a dialysis fluid.
At flowing P. on the catheter established in upper parts of an abdominal cavity enter the dialyzing solution in number of 10 l a day. Liquid follows from the lower catheter by gravity or it is aspirated by means of a suction. P. sick during the first hours of is in horizontal position; after introduction of 2 — 3 l of solution of the patient transfer to faulerovsky situation in order that liquid, irrigating abdominal organs and a parietal peritoneum, flew down from upper parts of an abdominal cavity in lower and then followed outside on the catheter established through the right side channel in a cavity of a small pelvis. At the alternating P. enter 2 — 3 l of liquid into an abdominal cavity, to-ruyu through 30 min. — delete 1 hour.
The quantity of cycles P. of depends on a condition of the patient and fluctuates from 3 to 8 within a day. Antibacterial therapy is performed by direct introduction to an abdominal cavity of antibiotics, preferential aminoglycosides, is more often than Kanamycinum. The dose of drug depends on its individual portability the patient, sensitivity of microflora to it (it is defined every 2 days). Also other synthobiotics of the directed action according to a species of the defined microflora and its sensitivity can be applied to these or those antibiotics. In parallel with the antibiotics entered into an abdominal cavity is created to lay down. concentration of antibiotics in blood by their introduction vnutriarterialno (cannulate of an omental artery), intravenously and intramusculary. Holding repeated sessions of P. of is caused by degree of the general intoxication, expressiveness of symptoms of irritation of a peritoneum, funkts, a condition of intestines, character of contents of an abdominal cavity. In assessment of efficiency of P. of the main attention is paid a wedge, to signs of subsiding of inflammatory process in an abdominal cavity and intoxication. Usually P. in a complex with the carried-out intensive care promotes reduction and elimination of symptoms of irritation of a peritoneum already on 2 — the 3rd days after
the operation Use of the Item. of considerably improves the result of treatment diffuse peritonitis (see).
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And. H. Kuchinsky, V. S. Timokhov, O. S. Shkrob.