How to avoid Peritonitis?

[KICKSTART]

Kristina everything you need for pd is supplied, in the UK. You will actually be 'taught' how to wash your hands using a special anti-bacterial soap in its own dispenser (its also quite expensive! .) Then i just made sure after i had completed every step i used the special hand gel ..again provided. If i touched anything  and i mean anything while setting up and connecting up i used the gel. One thing people may forget is that you must also scrub your nails. I also disinfected my work-surface (again with wipes provided) . Although i do not have OCD i was borderline when it came to setting up for pd !    Just a note ..the first indications of peritonitis are a cloudy bag (exchange fluid)

[kristina]

Thank you very much KK,
 
I gather from this and what I have read elsewhere,  that well-scrubbed and disinfected hands (and nails)
are better than disposable gloves. I get the feeling that the hands are the big weak link 
with regard to getting infections. I wanted to know if there was anything else to consider,
but it appears, the hands are the absolute priority as well as paying strict attention to the procedure.
There does not seem to be any tolerance here. As regards the bag, that must become a regular focal point.
 
Thanks very much for pointing these matters out, it is very much appreciated, Kristina.

[KICKSTART]

The only instance that gloves would be better is if they were 'sterile' ones and they dont provide those.

[kristina]

Thanks for the reply, KK, it seems then
that it is all down to clean hands
and being extremely precise
about handling the parts and equipment,
and as has previously been mentioned,
it seems logical to also keep the machine
and area around it also very clean.

Thanks very much for everybody’s input here,
it makes it very clear what is important,

thanks again from Kristina.

[ulrika]

My daughter Sandra has been on manual PD for almost 5 years, and have not had one bout of peritonitis yet. We live in Canada, and we went for training for 1 week before she started PD. I was very impressed with how they insisted on the importance of cleanliness, and yes, to always wear a mask....even for others who are in the room during exchanges. I was very concerned when we went to India last summer, because as we know it is not the most hygienic environment. But we all had a wonderful time, without even the slightest bit of stomach discomfort. Sandra choose PD because she felt it would enable her more freedom, and also, frankly she is deathly afraid of needles. One drawback is that, due to the liquids in her belly, she looks like she is 7 months pregnant, and is very often approached by strangers who asks her when she is due. This can be very uncomfortable, not least for person who asks. From what we understand, the reason for this is that Sandra is a "high absorber", and that she is a very tiny person. Over all, until Sandra gets a transplant, PD has worked very well for her.
I hope this helps a bit Kristina.

[kristina]

Thank you very much indeed for your reply, Ulrika.

It does seem more and more from reading the replies to questions about PD
that training is very important and even more than that is the vigilant cleanliness
when exchanging. Some people wear a mask and others don’t, but I think,
I would always wear a mask as the thought of Peritonitis along with a hospital-stay
is not what I would want to risk or go through.

Thanks again from Kristina.

[Stoday]

In the UK the target is a dose of peritonitis in 18 months. 

I've got a 100% certain way of avoiding peritonitis — I'm on hemodialysis. 

[Jie]

In the UK the target is a dose of peritonitis in 18 months. 

I think this information is outdated. A peritonitis per 18 months was based on the old style of tubing. The peritonitis is much less happening with the current tubing. 

[Riki]

Just a note ..the first indications of peritonitis are a cloudy bag (exchange fluid)

That's not true in every case.  When I had peritonitis, my bags were clear, except for a bit of fibrin.  And remember, if you still have a menstrual cycle, you'll get bloody bags just before you start as well.  That was the only indication I had, was a bloody bag 2 or 3 days before.

As for statistics on infections, I"m not sure how good they are.  in all the years I was on PD, I never had any infections at all until the nurses I have now took over my care.  When I was a kid, my mother did everything, but this last time, the nurses wanted to do everything, and I got exit site infections all the time, and I do believe it was one of the nurses not following procedure that caused my peritonitis infection.

[KICKSTART]

By the way Kristina , you keep calling me KK ...its KS ! 

[kristina]

Thanks Stoday, point taken.
But in my case, with my photosensitivity etc.,
HD-sessions at a centre would be unbearable for me,
so it looks as though PD would be the better of two survival methods.
 
It seems everyone is trying to find a way
round the problems associated with all the types of Dialysis,
but one way or another, problems will occur, with whatever method is chosen.
We have to work it out for ourselves,
but it is most important and absolutely brilliant
that though IHD we can get many different suggestions and opinions.
And therefore the decision, as to what type of Dialysis to have,
if and when we start, is made a little easier.

Thank you Jie, what is different about the tubing?
Just by chance I saw a PD-tube which flexible plastic
and the end of it was coiled round and the tube had lots of holes in it
and there were two small collars
which served to anchor the tube against the lining,
but the tube still came out through the skin.
Is this the latest type of tube?
 
I read that the sticky dressing placed over the entry point
also held the connection point.

Thanks Riki, that’s interesting,
I read that one knows of an infection if the bag is clouded.
What are the indications of an infection if the bag is clear?

So sorry KS, a senior moment...or two...thanks for correcting me.

Thanks again for all the replies, Kristina.

[KICKSTART]

Kristina the tube you describe is the tube that is used .. as far as im aware its been in use for a long time. Myself i can only tell you that my tube WAS stitched in place. I expect different countries have different methods. But in reality it needs to be stitched at some point otherwise it would just slide out ! Where it exits your body, that small collar you describe is most certainly to have a stitch or two to stop it coming out , if it isnt stitched elsewhere to stop it flipping upwards inside. The dressing , you will hear many on here say they remove it and dont wear one after the exit site is healed , over here we are told to NEVER leave the exit site uncovered and that is what this dressing is. You will remove it regularly and clean the exit site and then replace the dressing. All this and supplies are covered in your pd training. I can appreciate your difficulties with hemo , but please note pd will not last forever ...how long it will last no one can say. So at some point you will find yourself on a hemo unit , like me !

[ulrika]

Sandra, myself and my granddaughter Kylie just finished participating in a documentary which deals with organ selling in India....It also shows Sandra doing her PD...the documentary premiered today at a film festival in Amsterdam.
Here's a link showing a trailer of the film:
http://www.themarketfilm.com/trailer.html

[KICKSTART]

By the way Kristina , forgot to mention ...you wont be able to have a bath , also we are advised against swimming. Although i do know a lot of people in the US still swim. I never did either of these while on pd . So how did i keep clean ? I managed to get some large waterproof patches that covered the whole of my exit site and dressing , so it was quick showers for me !

[Jie]

The tube coming out of body has not been changed much. The change is the filling/draining tubes. During the early years, it was one tube for both draining and filling. The peritonitis rate was about one per 12 months for the earlier single tube. After some changes, the peritonitis rate was improved to one in 18 months. Now we have a Y-tube, which further reduces the peritonitis rate. The cycler reduces peritonitis rate further.

[kristina]

Thanks KS for your detailed reply,
which highlights the infection aspect of PD.
With regard to HD, my hope is,
that Home-HD will answer
my problem of going to an HD-centre.

This point about washing raises the question
of whether PD with the exit-site in the chest
is a better option which allows a person to sit in a bath.
But, I tend to agree with you that protecting the abdomen-exit
and having a quick shower is probably a more reliable option.
Thanks once again.

Thank you Ulrika for the film-trailer by Rama Rau.
The film certainly highlights the tremendous desperation of people
on both sides, which gives rise to the commercialization of human organs.
How this could be regulated for the benefit of both parties,
seems to be a problem of unbelievable proportions...

Thanks very much for the information, Jie,
I shall have to investigate this further,
as I don’t know yet precisely what a Y-tube is.

Thanks again from Kristina.

[KICKSTART]

Kristina you do not have a pd tube placed in your chest ! I think you are getting it confused with a chest cath for hemo !  As for this Y tube that is mention , i have asked around and no on has ever heard of it ?

[kristina]

Thanks for replying KS.

No, I am not confusing it with an HD-catheter.
The information I provided, I found on the Internet:

The method of PD via an exit site in the chest is called
“The Presternal PD Catheter”, nicknamed the “Bathtub” PD-catheter,
which came about in the early 1990’s.

So it may not be widely known yet.

The tube reaches down into the abdomen
and is said to act just the same as the normal abdominal PD.
The advantages are said to be that there are
less germs in the chest and therefore safer
than entry into the abdomen where there are more germs.

Also the chest does not move as much as the abdomen,
so there is less problem with the exit site.
Also, there is not the interference with clothing
as there is with the abdominal PD (e.g. the belt of trousers etc.).

Patients using “The Presternal PD catheter-method” can take a bath.

This information I found on the Internet, but I have no feed-back
from any patients using this, or who have used it.

I would be interested to learn if “The Presternal PD-catheter-method”
is used both in the day or during the night?

As for the Y-tube perhaps someone may enlighten us?

Thanks again from Kristina.

[Jie]

The PD catheter can be in the chest. This is not very common, but it has some advantage for cleaning. I know a lady who had exit site in the chest and liked it. But there is some inconvenience for a lady: if she needs to clean it in a public area, like shared emergency room, her upper body is exposed.

As to the Y-tube, or Y set, if you have a manual bag, spread out the tube of the manual bag on a table, you will see the tube is "Y" shape. Or think this way: the two ends of Y are drain bag and solution bag, and the bottom is the tube connected the body. Don't worry about whether you can get a Y set or not. Nowdays, If you use manual bags, you have Y set. If you use cycler, you do need to consider the lengths of drain line and patient line. Different tubings come with different lengths. 

[KICKSTART]

Ah this ..Y tube , its just the standard bag of dialysis fluid you get for exchanges. I thought you were referring to some type of catheter. I doubt very much you will come across any chest caths , in all my years i have never known anyone to have one , so i expect they are not popular ,there must be some reason they are not widely used . To be quite honest , i think they would be pretty horrible , given the size of a pd cath, certainly for ladies ! At least at waist height you can pretty much keep it under wraps ! Movement was never an issue with one in tbh .

[chook]

What a lot of info there is here and I'm glad to say that I can tick all of the boxes for my PD routine. Definitely want to avoid peritonitis.
Don't know if anyone answered the query on the link between constipation and peritonitis: constipation slows everything down and over time will thin the walls of the bowels. The dialysis solution is sugar based and because of it's strength, can draw the 'nasties' through the bowel wall and into the peritoneum. In a sugar-loaded atmosphere, they go wild.
The other thing that I feel is not stressed enough to PD patients is NO LIFTING. Because the peritoneal wall is continually stretched by the fluids, it weakens and the result can be a hernia. I know - I now have a small one. And if it requires surgery, apparently I will have 4-6 weeks on haemo. Had I been told the consequences, I would have been MORE careful. (I think I was pretty careful anyway - child bearing can also weaken the peritoneum).

[kristina]

Thank you, Jie, for the explanation, of the Y-tube,
I can now visualize it. I hope we get a few more posts about the “Presternal” PD
as it seems to be rather uncommon. Thanks again.

Thanks KS, for the information,
again it would be helpful to get some feed-back
from anyone who is/has been on the “Presternal” PD. Thanks again.

Thanks very much for this posting, chook.
I have read about the hernia-issue
and that PD-patients have to be very careful,
but I don’t know how easily a hernia can occur
and whether it is more common in ladies than in gentlemen.
 
The travelling of “nasties” from the bowel into the peritoneum
and its consequences sounds awful.
 
I hope I understand it correctly
that this is more likely to happen with constipation
(I don’t understand why constipation should thin the bowel-wall)
- or is this one of the problems why PD can only be taken for a number of  years.
 
You imply there is something which thins the bowel-tissue. That doesn’t sound too good.

Thanks for pointing out that there should be no lifting for PD-patients.

Thanks again from Kristina.

[chook]

G'day again Kristina
I'm no medical expert but I would presume the bowel walls thin from the straining associated with constipation - I have never asked why they thin. You obviously have a more enquiring mind than me 
My renal nurses told me originally not to lift over 5kg and post hernia only 1 kg - that is a large tub of margarine. My greatest sin is lifting the grandchildren - try very hard to just sit and have cuddles but sometimes I HAVE to lift them - for their own safety, for example. I find it amusing that the bags of fluid for the Baxterovernight cycler weigh 6kg - go figure. Thankfully, hubby does all the lifting but not everyone on PD has a helpful other.

[Jie]

Sometime I carried all of my monthly supplies to my second floor; one box each time, which is more than 12kg. When I travel, I would have to carry over 50 lb items into the airplane. So, the weight restriction is not too strict. I have not had any hernia yet after such a lifting for more than 22 months. But is is a good idea to avoid to lift heavy items.

[kristina]

Thanks for coming back on these issues, chook,
It is a good piece of information about the limit on the weight one can lift.

The bowel-thinning issue disturbs me, but it is something new to me
as I haven’t heard or read about this before,
it would be interesting to get some more feed-back on this.
Thanks again from Kristina.
 
Thanks for the post, Jie. Maybe a consideration is
how one lifts something, in order to avoid a hernia.
Maybe one could lift slightly heavier items
with a more safe method like bending the knees perhaps,
keeping a straight back and don’t overstretch etc.

Thanks again from Kristina.