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Module16: Modified Seldinger Peritoneal Dialysis Catheter Placement

Module 16: Modified Seldinger Peritoneal Dialysis Catheter Placement

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“This activity is jointly provided by Global Education Group and Kidney Academy.”

Target Audience The educational design of this activity addresses the needs of physicians and adjunct health care professionals (e.g., nurses, technologists) who treat kidney disease. Medical specialties addressed are relevant to transplant surgeons, radiologists, nephrologists, and vascular surgeons.

Statement of Need/Program Overview End stage renal disease (ESRD), specifically dialysis access, is a complicated condition treated by a variety of medical specialists with varied perspectives and skillsets. Population growth predictions suggest that the burden of providing maintenance dialysis in coming decades will be daunting. Access to reliable and applicable training in ESRD / dialysis access is limited, and significant treatment protocol disparity exists globally among professionals. The specialties performing dialysis access are fragmented into siloed societies with limited opportunity to understand the viewpoints of the other specialties serving the same patient. 

Educational Objectives

After completing this activity, the participant should be better able to:

  • Outline the principal features of the Percutaneous Modified Seldinger (PSPD) technique used for placement of Peritoneal Catheter (PD) 
  • Describe two key features that distinguishes this new approach from traditional Seldinger technique
  • List the advantages of PSPD over other PD catheter insertion options 
  • Explain the use of PSPD in urgent need for dialysis
  • Explain the ‘expanded’ indications for dialysis with the MSPD  technique
  • Discuss the risks of the PSPD technique and how to avoid complications
  • Identify patient factors where PSPD is contraindicated
  • Describe the value of Ultrasound in percutaneous PD catheter placement (also known as modified Seldinger PD catheter placement technique).



Faculty

Jan Swinnen, MD Vascular Surgeon / Dialysis Access Specialist at Westmead Hospital in Sydney, Australia. He is a qualified Sonographer (DDU Vascular) and runs the Westmead Vascular Ultrasound Lab. He is Professor of Surgery at Sydney University and has an interest in clinical research.

Luke Baker, MD Interventional Radiologist and Dialysis Access Specialist at Westmead Hospital in Sydney, Australia. He is Professor at Sydney University and has an interest in clinical research.  

Ingemar Davidson, MD, PhD, FACS Dr. Davidson is the founder of Kidney Academy, and focusing on organ procurement, organ transplantation, and dialysis access in ESKD patients, with published educational books and manuscripts on these topics.  


Physician Accreditation Statement 

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Kidney Academy.  Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation 

Global Education Group designates this enduring activity for a maximum of 11.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Term of Offering 

This activity was released on 9.6.2021 and is valid for one year. Requests for credit must be made no later than 9.6.2022. 

Global Contact Information 

For information about the accreditation of this program, please contact Global at 303-395-1782 or cme@globaleducationgroup.com.

Instructions to Receive Credit 

To receive credit for this activity, the participant must complete all sections and pass the post-test with at least 70% (11/15) questions answered correctly. The certificate will be available to download or print upon successful completion of the course material.

Fee Information & Refund/Cancellation Policy 

There is no fee at this time for Module 16

Disclosure of Conflicts of Interest

Global Education Group (Global) adheres to the policies and guidelines, including the Standards for Integrity and Independence in Accredited CE, set forth to providers by the Accreditation Council for Continuing Medical Education (ACCME) and all other professional organizations, as applicable, stating those activities where continuing education credits are awarded must be balanced, independent, objective, and scientifically rigorous. All persons in a position to control the content of an accredited continuing education program provided by Global are required to disclose all financial relationships with any ineligible company within the past 24 months to Global.  All financial relationships reported are identified as relevant and mitigated by Global in accordance with the Standards for Integrity and Independence in Accredited CE in advance of delivery of the activity to learners. The content of this activity was vetted by Global to assure objectivity and that the activity is free of commercial bias. 

All relevant financial relationships have been mitigated.

The faculty have the following relevant financial relationships with ineligible companies:

Name of Faculty or Presenter                                Reported Financial Relationship

               Jan Swinnen                                                      Nothing to Disclose

                Ingemar Davidson                                             Nothing to Disclose

                Luke Baker                                                       Nothing to Disclose

The planners and managers have the following relevant financial relationships with ineligible companies:

     NAME OF PLANNER OR MANAGER                       REPORT OF FINANCIAL RELATIONSHIP

                      Linda Borvabsky                                            Nothing to Report

                      Andrea Funk                                                 Nothing to Report

                      Libby Knight                                                  Nothing to Report 

                      Ashley Cam                                                    Nothing to Report

                      Therese Wykoff                                              Nothing to Report

                      Tom Davis                                                      Nothing to Report

                      Steve White                                                   Nothing to Report

                      Erichson White                                               Nothing to Report

 

Disclosure of Unlabeled Use 

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Kidney Academy do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

 

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INTRODUCTION
Module 16 is a detailed description of a Modified Percutaneous Seldinger Peritoneal Dialysis Catheter Access technique (PSPD) developed by Drs Jan “John” Swinnen and Luke Baker at Westmead Hospital, Sydney, Australia. There are 39 figures and 46 videoclips detailing the PSPD technique. The Indications and Contra-Indications and Advantages and Disadvantages of Peritoneal Dialysis (PD) as a form of Renal Replacement Therapy (RRT) will be briefly discussed, particularly with respect to PSPD (1,2,3). Seldinger PD will bypass several problems as it can be done under local anaesthetic, in a radiological or Cath lab setting, as an outpatient. Currently Seldinger PD as it is publicized is NOT standardized nor protocolized making it both a dangerous, ineffective, and not reproducible. The Modified Seldinger PD system of PD catheter placement is safe, is done through a single 5 mm skin incision, under local anaesthetic in an outpatient setting. In addition, it can be done on the sickest patients and patients on blood thinners, and the PD dialysis treatment can be started straight away without fear of fluid leaks.
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PRE-TEST
15 Questions  |  Unlimited attempts  |  0/15 points to pass
15 Questions  |  Unlimited attempts  |  0/15 points to pass pre-test of 15 questions
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SECTION 1: PERCUTAMEOUS SELDINGER PD CATHETER INSERTION TECHNIQUR (PSPD)
Module 16 is a detailed description of the modified Percutaneous Seldinger Peritoneal Dialysis Catheter Access technique (PSPD) developed by Drs Jan “John” Swinnen & Luke Baker at Westmead Hospital in Sydney, Australia. The Indications and contra-Indications and Advantages and Disadvantages of Peritoneal Dialysis (PD) as a form of Renal Replacement Therapy (RRT) is briefly discussed, particularly with respect to the place of PSPD. Other methods of PD catheter insertion – by Open Surgery, Laparoscopic Surgery or by various “Peritoneoscopic” techniques , as to how they compare to PSPD. This is covered in detail in module 6 of www.kidneyacademy.com (Sec. 11, Ref 6) Delivering PD to patients involves more than placing a PD catheter: needed are a team of PD nursing staff, PD training programs, equipment supply chains and crucially, a patient and a home environment suitable for home therapy. Introducing PSPD impacts all these factors in terms of quantities needed and how they are deployed.
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SECTION 2: PRE-OPERATIVE EVALUATIONS WITH ABDOMINAL ULTRASOUND
This is an essential pre-operative step. An 8MHz probe produces accurate images for the slimmer patient; in obese individuals, the 4MHz probe may be needed for adequate penetration, but the image is with lower quality. The ultrasound interrogates the following issues: 1. Urinary Bladder 2. Proposed Peritoneal Entry Site 3. Inferior epigastric artery on the ipsi-lateral on the same side of PD insertion,
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SECTION 3: PD CATHETER REVERSE MAPPING
There are two components of reversed mapping: 1. The mapping a suitable Catheter Exit Site for the PD catheter that is convenient and accessible to the patient. This is usually done by the PD nurses pre-op, but when using PSPD acutely, the operator must be prepared to do this herself on the operating table. 2. The second component is reverse mapping the designated catheter tract onto the abdominal wall, initially designed by Dr John Crabtree. Reverse mapping is not unique to nor specific to PSPD, but by incorporating it into the technique. Catheter placement, catheter length and catheter tip positioning becomes very accurate and reliable.
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SECTION 4: ANAESTHESIA
MSPD described in this module can generally be performed with a high degree of patient comfort under local anaesthesia (LA) only. LA does not control anxiety, common in these sick patients, The addition of sedation in many patients is recommended and needed.
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SECTION 5: ACCESSING THE PERITONEAL CAVITY
The skin exit site is marked at the time of Reverse Mapping, 2-3 cm lateral to but never through the umbilicus. The area is infiltrated with dilute LA with Adrenaline, then, a small 1- 2 mm incision is made with a scalpel; this small incision is then stretched to 2-3 mm with a mosquito hemostat (a stretched incision is less likely to bleed than a cut incision). The retrograde subcutaneous tunneling and exit site creations are similar for all PD catheter placement options are also presented in module 6 for open and laparoscopic procedures.
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SECTION 6: TRACT DILATATION AND INSERTION OF THE PD CATHETER
Tract dilation is the painful part of the procedure, therefore a long 5F sheath is placed down the Bentson wire into the Pelvic Pouch. Then, with one operator injecting and one operator retreating the sheath over the wire, the Pelvic pouch, peritoneum, and abdominal tract are laced infiltrated with 30 ml of solution, consisting of 15mls of dilute LA and 15mls of contrast. The ultimate sheath size is 16F; we therefore dilate up the tract, over the Bentson wire, with 6F, 8F, 10F, 12F and 14F dilators. If the tract is tight (as in healthy young muscular patients), we add a 16F dilator. care is taken not to kink the Bentson wire. Once the dilator has passed through the track, it is advanced back and forth to facilitate the next dilator passage.
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SECTION 7: SUBCUTANEOUS RETROGRADE TUNNELING TO THE CATHETER SKIN EXIT SITE
The subcutaneous retrograde tunneling procedure is identical for the open, laparoscopic, and percutaneous PD placement techniques. There are different approaches favored by individual operators. Techniques must emphasize minimal trauma especially at the exit site. A detailed description of tunneling devices and techniques is also d=given in module 6 at www.kidneyacademy.com
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SECTION 8: FINAL CHECK
This involves 2 steps. a. Completion Peritoneogram b. PD flush
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SECTION 9: POST-OPERATIVE CARE
Patients are kept under observation for 4 hours post op, to monitor sedation recovery and for the rare problem of post-operative bleeding (exit site only in our series).
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SECTRION 10: SUMMARY AND TAKE AWAY POINTS FROM MODULE 16 ON MSPD
Eight summary and take away points om
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SECTION 11: GLOSSARY
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SECTION 12 POST_TEST
15 Questions  |  Unlimited attempts  |  11/15 points to pass  |  Graded as Pass/Fail
15 Questions  |  Unlimited attempts  |  11/15 points to pass  |  Graded as Pass/Fail pre-test of 15 questions
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SECTION 13: CME MANDATORY MODULE SURVEY
6 Questions
6 Questions
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SECTION 16: DOWNLOAD CERTIFICATE
Up to 3.00 medical credits available  |  Certificate available
Up to 3.00 medical credits available  |  Certificate available
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