Prophylactic Antibiotics And Anesthesia Studies Related To The Operation Of Peritoneal Dialysis Catheter Implantation

Part One Effects of prophylactic antibiotics before peritoneal dialysis catheter implantation on the clinical outcomes of peritoneal dialysis patientsObjective:To compare the clinical outcomes with or without prophylactic antibiotics before PD catheter insertion in PD patients with early start peritoneal dialysis post PD catheterization in order to get beneficial instruction for the development of peritoneal dialysis program.Methods:Two hundred and forty-seven patients with ESRD undergoing permanent peritoneal dialysis catheter(PDC)placement consecutively from February 2008 to June 2013 were enrolled in this retrospective study.The exclusion criteria were patients younger than 18 years.The demographic and bio-chemical laboratory data were collected from the patients’ medical record and nurses’ follow-up record.After catheter placement,intermittent low dose PD in the supine position was initiated within 24 hours without break-in periods which was administered a fill volume of 1000mL,a dwell time of 3 hours,and frequency of 4 times daily.The early and late complications including infection and mechanical complications after catheter implantation were recorded respectively.The patients were separated into antibiotic group and non-antibiotic group based on whether or not to use prophylactic antibiotics.The early complications and long-term outcomes post the PD catheter implantation were compared between the two groups.The Kaplan-Meier method and log-rank test were used to examine the technique survival,patient survival,and peritonitis-free survival by comparing antibiotic group with non-antibiotic groupResults:Of the 247 patients,120 were men(48.6%),127 were women(51.4%),with a mean age of 52.6±14.9 years.The most common primary diseases were chronic glomerulonephritis(CGN)and diabetic nephropathy.For the overall early complications,seven patients developed fat liquefaction of post-surgical incision,4(1.6%)patients presented exit site infection,11(4.5%)patients occurred peritonitis,and 2(0.8%)patients switched to permanent HD.There was no early pericatheter leakage occurred in the study.There were 154(62.3%)patients using prophylactic antibiotics before the PD catheter insertion and 93(37.7%)patients without prophylactic antibiotics.There was no significant difference in gender,age,weight,primary disease,comorbidities presented as diabetes mellitus,cardiovascular disease,cerebrovascular disease,and hypertension,as well as laboratory values between the two groups.No significant difference was found in the two groups in regard to early complications including fat liquefaction of incision,exit site infection,peritonitis and mechanical complications such as catheter tip migration,inflow and outflow dysfunction,catheter blockage and leakage.No significant difference was found in the two groups regarding late complications including exit site/tunnel infection and the number of peritonitis either.At the end of the study period,153 patients(61.9%)were still on PD,94 patients(38.5%)dropped out due to various causes,including 22 patients transferred to HD,9 patients received transplantation,58 patients died,and 5 patients lost their visit.Twenty-nine patients accounting for 30.9%of all drop-out patients have dropped out due to peritonitis directly or indirectly.Kaplan-Meier analysis of patient survival and technique survival at 1 year and 2 year post-catheter insertion showed no difference between the two groups.No significant difference was found between antibiotic group and non-antibiotic group regarding peritonitis-free survival evaluated by Kaplan-Meier method.Conclusion:In our PD patients with early start PD post PD catheterization,we can’t see any beneficial effect of antibiotic prophylaxis in reducing the postoperative peritonitis for patients undergoing surgical implantation of PD catheters.Part Two Clinical study of anesthesia for insertion of the peritoneal dialysis catheterObjective:To examine methods of anesthesia for laparoscopic insertion of PD catheters in order to investigate the feasibility of laparoscopic implantation of PDC under local anesthesia.Methods:This retrospective study includes 245 patients with laparoscopic PD catheter insertion from January 2008 to July 2013 at the University Health Network in Toronto.Collected data information for this study included demographic data,clinical details,and the most recent laboratory blood tests before the surgery.They were divided into local anesthesia(LA)and general anesthesia(GA)groups.The local anesthesia patients were given intravenous conscious sedation with midazolam,fentanyl and propofol.Nitrous oxide(N2O)and carbon dioxide(CO2)pneumoperitoneum were used for local anesthesia group and general anesthesia group,respectively.Hemodynamic fluctuations were managed with small doses of vasopressors or vasodilators during the procedure.A binary logistic regression model was used to identify the decisive factors of local anesthesia patient selection.Results:The age,the exit site position of the catheter,the history of abdominal surgery and co-morbidities such as diabetes and cardiovascular disease in the two groups were significantly different.All patients tolerated the procedure well.Of the 245 patients,105 were given local anesthesia,140 were given general anesthesia.Nearly 45%of the patients were given local anesthesia,there were more ASA grade IV patients in this group.Ten patients converted to general anesthesia from local anesthesia.There were no significant differences in systolic blood pressure(SBP)in the two groups at the beginning of the anesthesia,but during the surgery,the SBP of general anesthesia group was changed obviously.No significant differences of SPO2 were found between the two groups.The mean operating time and observation time in post anesthesia care unit(PACU)of the general anesthesia group was longer.After arrival the PACU,the PACU score in general anesthesia group was lower than local anesthesia group,but there was no difference between the two groups at discharge.Binary logistic regression analysis found that olde age,abdominal exit site,co-morbidity with DM,and those with higher ASA grade were the decisive factors for local anesthesia patient selection.Therefore,the choice of local anesthesia versus general anesthesia was not random,but informed by the risk factors carried by the patients.Conclusion:Both local and general anesthesia for laparoscopic catheter implantation is safe and feasible.Older patients,abdominal(as opposed to pre-sternal)exit sites,co-morbidity with diabetes mellitus,and those with higher ASA grade do well with local anesthesia.