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Peritoneal dialysis
There are three types of peritoneal dialysis. Continuous ambulatory
peritoneal dialysis (CAPD), the most common type, needs no machine
and can be done at home. Continuous cyclic peritoneal dialysis (CCPD)
uses a machine and is usually performed at night when the person
is sleeping. Intermittent peritoneal dialysis (IPD) uses the same
type of machine as CCPD, but is usually done in the hospital because
treatment takes longer. Prior to any peritoneal dialysis, a catheter
is placed in the patient's abdomen, running from the peritoneum
out to the surface, near the navel. This is done as a short surgery.
CAPD is typically done in the patient's home and workplace,
but can be done almost anywhere; a clean area to work, a way to
elevate the bag of dialysis fluid and a method of warming the fluid
are all that is needed. The main consideration is the very high
potential for infection with an open catheter; peritonitis is a
common complication, as are infections of the catheter exit site
or "tunnel" (path from the peritoneum to the exit site).
Because of this, patients are advised to take a number of precautions
against infection.
Step-by-step description of peritoneal dialysis
(a CAPD exchange):
The supplies and materials needed for an exchange
are gathered in one clean location. Notable amongst
these is a bag of dialysis fluid (also called dialysis
solution), a solution comprised of a known amount of
a glucose dissolved in water. The strength of this solution
determines the osmotic gradient, and therefore the amount
of water that diffuses out of the bloodstream. Common
strengths of glucose are 0.5%, 1.5%, 2.5% and 4.25%.
1.5% is approximately fluid-neutral; it neither adds
nor removes fluid and is used for patients who are primarily
concerned with waste removal rather than fluid regulation.
Higher concentrations lead to greater water removal.
Electrolytes are also present in the fluid to maintain
proper body levels. Patients weigh themselves, and measure
temperature and blood pressure daily to determine whether
the body is retaining fluid and, thus, what strength
of fluid to use. Dialysis fluid typically comes premixed
in a disposable bag-and-tube apparatus; no additional
equipment is needed. The apparatus consists of two bags,
one empty and one with the fluid, connected via flexible
tubing to a Y-shaped fitting. The bag is heated to body
temperature, to avoid causing cramping. Dry heat is
used; common methods include microwaves, heating pads
and solar radiation (often using the dashboard of a
car, for instance while travelling).
The patient, who performs the entire procedure themselves,
dons a disposable surgical mask, scrubs their hands
using antibacterial soap, and tucks a clean towel into
the waistband of their pants to protect their clothing.
The bag of dialysis fluid is removed from the protective
packaging, and is hung from an IV stand or other elevated
location, such as a coat hook. The tubing attached to
the bag of fluid is uncoiled, and the second (empty)
bag is placed on the floor. The Y-shaped connector is
attached to the catheter tip; a protective cap must
be removed from both of these before the connection
is made, and the two portions of the connector are not
permitted to touch anything, to avoid possible contamination.
Once connected to the system, the patient clamps the
tubing connected to the full bag of dialysis fluid and
then releases the twist valve located in the tip of
their catheter; this permits fluid to flow into or out
of the peritoneal cavity. Because the full bag of fluid
is clamped off but the empty bag is not, the effluent
(used dialysis fluid) from within the peritoneum can
drain out of the catheter and into the lower, waste
bag. Emptying the abdomen of fluid takes approximately
fifteen minutes, and the patient is free to perform
tasks such as reading, watching television and browsing
the internet.
When the abdomen has drained, the lower, drain, bag
is clamped off. The twist valve in the catheter is also
closed. The clamp is then removed from the upper tubing,
permitting dialysis fluid to drain out. The clamp to
the drain bag is briefly opened and some fluid is drained
directly from the upper bag into the lower bag. This
clears the line of air and other impurities. The drain
line is then clamped off and the twist valve on the
catheter end is opened. This permits fluid to enter
the peritoneum. Filling the abdomen with fresh fluid
takes about fifteen minutes, and the patient enjoys
the same freedoms as while draining.
Once the entire bag of fluid (an amount varying primarily
based on body size, ranging from 1500 to 3000 mL) has
been introduced to the abdomen, the patient then cleans
their hands again (typically using an antiseptic alcohol-based
cleanser) and puts the surgical mask on. The Y-connector
is detached from the catheter tip and a protective cap
is placed on the end of the catheter.
The effluent is inspected after a dialysis exchange
is complete; a cloudy effluent indicates probable peritoneal
infection. The effluent is drained into a toilet, and
the various dialysis supplies are discarded with normal
garbage.
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