Data from Kohli HS, Barkataky A, Kumar RSV, et al. Peritoneal dialysis for acute renal failure in infants: a comparison of three

types of peritoneal access. Ren Fail. 1997;19:165; Kohli HS, Bhalla D, Sud K, et al. Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol. 1999;13:241; Matthews DE, West KW, Rescorla FJ, et al. Peritoneal

dialysis in the first 60 days of life. J Pediatr Surg. 1990;25:110; Wong KKY, Lan LCL, Lin SCL, et al. Small bowel herniation

and gangrene from peritoneal dialysis catheter exit site. Pediatr Nephrol. 2003;18:301.

382 Section IX ■ Miscellaneous Procedures

Fig. 53.4. A continuous arteriovenous hemofiltration

circuit.

b. Tenckhoff catheter

(1) Unclamp the transfer set. Observe either saline

or dialysis fluid, which was instilled at surgery,

draining. Allow to drain to completion. Connect

the short arm of the Y-Set to the transfer set.

(2) Follow steps a(2) through a(5) of step 10 above.

This procedure (step 10) usually results in a

positive fluid balance (the volume drained is

less than the volume infused). This retention is

acceptable.

F. Management

1. Establish a cycle time. This is usually about 60 minutes

and consists of a fill by gravity, dwell time of 45 minutes, and drain by gravity.

2. Establish a dialysis volume per pass. Starting volume is

usually 20 to 30 mL/kg.

3. Clamp the long arm of the Y-Set (outflow line).

4. Unclamp the inflow line.

5. Allow the dialysate to flow in as quickly as possible,

while carefully observing vital signs.

6. Clamp the inflow line.

7. Allow the fluid to dwell.

8. Unclamp the outflow when dwell time is completed.

9. Allow 5 to 10 minutes for draining.

10. Clamp the outflow line.

11. Repeat the cycle.

12. Increase the volume by 5 mL/kg/cycle slowly.

Maximum volume is 40 mL/kg if tolerated, attained

over 12 to 24 hours.

13. Continue to add 500 U of heparin/L of dialysate, until

dialysate effluent return is clear, with no evidence of

cloudiness.

14. Add 3 mEq/L of K if serum K level is ≤4 mEq/L.

Chapter 53 ■ Peritoneal Dialysis 383

G. Monitoring

1. Maintain hourly PD flow sheet.

a. Volume in

b. Volume out

c. Net/hr (+/–)

d. Net over the course of dialysis (+/–)

e. Intakes (enteral, parenteral)

f. Outputs (urine, gastric, insensible water loss, etc.)

2. Establish a desired fluid balance. Increase volume

slowly if negative balance is required. Reassess the state

of hydration frequently.

3. Measure serum glucose and potassium every 4 hours for

the first 24 hours or until stable, then twice a day. Obtain

other serum electrolyte levels twice daily. Check blood

urea nitrogen, serum creatinine, serum calcium, serum

phosphorus, and serum magnesium once a day.

4. Obtain cell count, Gram stain, and culture of peritoneal effluent every 12 hours.

5. Recognize that some drug dosages may need adjustments (19–21) (see Appendix E).

H. Complications

See Table 53.1.

Continuous Arteriovenous Hemofiltration in Newborns

A short discussion of CAVH and CVVH is included for

completeness. However, use of these modalities should be

limited to regional centers and performed by those with the

required expertise.

CAVH is an extracorporeal technique for removing

plasma water and dissolved solutes of <50,000 Da over an

extended period of time. With use of an arterial access line

of the largest possible diameter and a venous access line,

blood enters the extracorporeal circuit (arterial tubing,

hemofilter, and venous tubing) by way of the arterial line

and returns to the patient by way of the venous line (Fig.