Curriculum Vitae

Nama : DR. Rudi Supriyadi, dr., Mkes, SpPD-KGH,Finasim

Usia : 46 tahun
Jabatan :
Ketua PAPDI JABAR
Sekretaris papdi jabar 2009-2016
Senior lecture fk unpad, Tim irr, tim trainer intervensional ginjal-hipertensi

Akademik : dalam negeri dan luar negeri

Publikasi : nasional,internasional
Konsultan area : Karawang, Purwakarta, Cikarang, Cikampek, Subang, Indramayu, Bekasi,
Bandung dsk
Teknik Insersi Kateter Tenkhoff
dan komplikasinya
Rudi Supriyadi
Divisi ginjal hipertensi - Departemen Ilmu Penyakit Dalam
Fakultas Kedokteran UNPAD /RS. Hasan Sadikin Bandung
29 Juli 2017
Epidemiologi PD
USRDS 2009
Renal Unit yang mengirimkan data CAPD :
1. RS. Tabanan - Bali
2. RS. Saiful Anwar -Jatim
3. RSUP. Hasan Sadikin - Bandung
4. RSKG. Ny RA Habibie - Bandung
5. RSUP. Sanglah - Bali
6. KKG. Ny Ra Habibie - Batam
7. RSUD. Margno Sukarjo - Jateng
8. RS. Panti Wilasa Citarum – Semarang
9. RSUP. Dr Kariadi – Semarang
10.RSUPN Cipto Mangunkusumoh - Jakarta
11.RS SjaifulAnwar - Malang

IRR 2012

Di Bandung/jabar sudah sekitar 250 pasien

Pre-Operative Care
Pre catheter insertion clinic review and nursing assessment
Key assessment:
• Determine factors that may impair initial wound healing and
exit site management.
- Clinical status (chronic cough, steroid use, edema)
- Nutritional status (malnutrition impairs healing)
- Use of adult diapers
• Evaluate for:
- Abdominal wall hernias that require repair (PD should not
start during the first 4 weeks, due to increased risk of
leakage)
- Stop anti-coagulants for 1 week, e.g., Aspirin, Ticlid, and
Plavix.

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Preparing the Patient for Success

 Any previous abdominal surgery?

 Any hernias on physical examination?
 Is the patient on anti-coagulant?
 Any coagulopathy or bleeding risk?
 Is the patient on anti-platelet agent?
 Is the patient fluid overloaded?
- Can the patient lie flat the procedure

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Preparing the Patient for Success
Dress for Success…Roxette

• Marking of the exit site

• Done with the patient in sitting position
• Note the belt /pants line
- Exit site should be above or
below the line, not at the line
• Avoid placing within skin fold, scar,
eczema/ rash
• Location of APD machine: Right or left

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Anatomy
Saya tomy….

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Preparing the Patient for Success
Antibiotic prophylaxis
- Just prior to placement
- Shown to decrease the incidence of wound infection and
peritonitis
- IV Cefazolin 1g stat pre operatively
- IV Vancomycin if patient is allergic to cefazolin

Gadalia MF et al, Am K Kidney Dis 2000: 26: 1014

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Pre-Operative Care I
o Determine exit site location:
o Mark in sitting position (by
Surgeon)
o Avoid scars, belt line, skin folds
and pressure points from
clothing
o Locate to maximize self-care
skills (dexterity, vision,
handedness, strength, and
motor skills)

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 Pre-Operative Care II

o NBM after midnight

o Bowel preparation
o Empty bladder
o Shower with disinfectant soap (4% Chlorhexidine)
o Set IV Line
o Prepare patient:
Administer prophylactic antibiotic on call to OT
IV Cefazolin 1gr (if no Penicillin or Cephalosporin allergy)
Or...
IV Vancomycin 1gr (known MRSA for the pass 6 months)

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Peritoneal Catheter Placement Procedures

Chronic Catheter:
Performed by Surgeon or Nephrologist
Implantation methods
– Surgical dissection
- Peritoneoscope

Catheter should be implanted 2-6

weeks before dialysis. This is to allow
tissue ingrowth into the external cuffs
and avoid leakage

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PD Catheter Implantation and Care

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 Catheter Peri-Operative Care

• Test catheter is patent, functioning well prior closure

- Irrigate with 1L of Normal Saline to observe inflow
- Verify outflow return
• Final catheter preparation
- Place catheter adapter
- Attach transfer set/ catheter extension and cap
- Apply sterile gauze or absorbent dressing

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Post-Operative Care
• Post-Op capping up and dressing should be done by a trained PD Nurse
- Irrigate 2L bag dialysate with heparin (1.000 IU/L) – 500ml/cycle
• Inspect dressing for absence of blood stains or contamination
• Post-Op: Maintain bed rest for at least 6 hours to prevent increase
intraperitoneal pressure.
• Start PD post implantation 10-14 days
• If uremic status requires initiation of dialysis, low volume (500 –
1000ml) to avoid leakage
• May start interim hemodialysis until wound healed

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 Post-Operative Care II
• Review post-operative instruction prior to patient discharge
• Provide written instruction regarding follow-up care
• Schedule return appointment for dressing (every 5 days) training date
• Exit site care:
- Minimize manipulation of catheter
- Inspect the exit site
- Palpate tunnel
- Clean with antiseptic solution
- Tape dressing securely and immobilize catheter to prevent trauma
to the exit site and minimize traction to the cuffs.

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Post-Operative Instruction to Patient
Patient education:
• Tub baths are not recommended. Shower must be avoided until the exit
site is well-healed. Sponge baths should be used during this period.
• Avoid heavy lifting, stair climbing, straining and constipation until catheter
healed (2-6 weeks)
• Practice good hygiene
• Notify PD unit if there is blood or other drainage on the dressing, pain or
tenderness, trauma to abdomen.
• Post-Op dressing on the 5th and 10th POD & PRN
• Start PD training post implantation – 14 days
• STO – 10th POD

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 Post-Operative Instruction

Instruction:
 Activity
 Diet
 Medication
 Wound care
 Special instruction
 When to consult doctor
or PD nurse
 Follow-up appointment

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Teknik Insersi Kateter PD
RUDI SUPRIYADI
CAPD (cuci darah perut)
PD catheter
THERE IS NO GOOD PD WITHOUT GOOD CATHETER
 The Ideal PD Catheter

• Excellent short inflow time

• Excellent drainage of abdomen
• No omental wrap
Selecting the catheter

• Ideal doesn’t exist.

• There are a bewildering array of catheters
present in the market right now.
• The catheter you finally select for your
patients should be something you’re
comfortable using and placing.
 Kateter PD
• Kateter PD terdapat dalam berbagai bentuk (straight, coiled, swan neck),

• Panjang kateter yang bervariasi

• Jumlah Dacron pengikat untuk perkembangan optimal dan fiksasi di exit site.

• Kateter terdiri dari sebuah tabung silikon fleksibel dengan ujung yang terbuka
di awal dan akhir dengan beberapa lubang samping untuk drainase dan
penyerapan dialisat yang optimal.
 Catheter Designs

• Subcutaneous tunnel-straight
or bend

• Methods of anchorage

• Number of cuffs

• Intraperitoneal portion:
Straight or curled/coiled
Year-Name

1968

1974

1976

1993

1983-1988
Ballon(Valli)

1985-Short(Vicenza)
TENCKHOFF

Merupakan kateter yang dimasukkan ke dalam

peritoneum dan terhubung dengan titanium adaptor.
Dipasang permanen, satu kali pada permulaan akan
menjalani dialysis peritoneal. Bisa dilepas apabila
terjadi infeksi yang berat.
Ada 2 macam, yang lurus dan koil.
Tenckhoff catheter- the ‘gold standard’

Dacron cuff
Kateter
TITANIUM ADAPTOR

Adaptor yang digunakan untuk menghubungkan kateter

tenckoff dengan transfer set. Sistem Luer lock sehingga
tidak memungkinkan terjadinya rembesan air dan
mengurangi risiko terjadinya infeksi.

Seperti kateter tenckoff, hanya dipasang satu kali pada

permulaan akan menjalani dialisis peritoneal.
Gambar titanium adaptor dengan kateternya
 METHODS OF TENCKHOFF CATHETER INSERTION

Tenckhoff
Catheter

Surgical Physician
Techniques Techniques

Blind Trocar Fluoroscopy

Open Method Laparoscopic Peritoneoscope
(Seldinger (Seldinger
(Blind) Placement Method Technique)
Technique)

Guided wire + introducer

sheat
(Bandung methode)
Insersi PD dengan
Peritoneoskopi
Peritoneoscope approach
 operator dapat melihat langsung ke dalam struktur intraperitoneal
 dapat menghindari usus, omentum dan adhesi
 dapat menentukan lokasi yang paling tepat untuk kateter
 tidak insisi di fascia, rektus abdominis hingga peritoneum
 lapisan dinding abdomen anterior segera menutup kateter dan cuff segera setelah insersi
 CO2 insertion
 tredelenburg position
 anastesia diperlukan?
Peritoneuscope
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Peritoneuscopic
Insersi Kateter Peritoneal Dialisis
Metode Bandung
RUDI SUPRIYADI
D I V I S I G I N JA L - H I P E R T E N S I
D E PA R T E M E N I L M U P E N YA K I T DA L A M
FA K U LTA S K E D O K T E R A N U N PA D / R S . D R . H A S A N S A D I K I N
 SIMPLE TECHNIQUE OF PLACEMENT TENCKHOFF CATHETER
FOR CAPD WITH BANDUNG METHODE
Division of Nephrology, Internal Medicine Department, Faculty of Medicine,
Padjadjaran University / Hasan Sadikin General Hospital, Bandung, Indonesia

Pemasangan kateter Tenckkoff

oleh internist,nefrologis
Teknik Pemasangan Kateter CAPD
Metode Bandung
Modifikasi teknik perkutan dari Seldinger

Modifikasi yang dilakukan terhadap teknik perkutan adalah pengukuran kedalaman peritoneum
dari permukaan kulit sebagai panduan dalam memasukkan introducer needle dan pemberian
NaCl 0.9% pada saat introducer needle dan kateter Tenckhoff dimasukkan untuk memastikan
bahwa kedua alat tersebut sudah masuk ke dalam rongga peritoneum.
Simplified methode from Bandung
modification of blind Seldinger technique
 pendekatan sama entry dan exit site dengan teknik Seldinger
 anastesi lokal
 tidak perlu ruang ok
 insisi hanya di kulit selanjutnya pembukaan tumpul hingga peritoneum terlihat
 insersi jarum introducer setelah diukur kedalamannya test dengan saline
 masukkan guidewire setelah diukur hingga simpisis pubis
 masukkan dilator dan plastic sheat, cabut guide wire
 kateter Tenckhoff masuk dengan stylet / mandrain
 pastikan posisi tenckhoff dengan USG
Blind insertion (seldinger technique)
Advantages :
-Small incisions
-Local anesthesia
-Quick
-Inexpensive
-No need for operating room
-Could be one day care
Disadvantages :
-Not suitable for obese, multiple
prior surgeries, intraabdominal
adhesions
-Blind procedure
-Risk of organ/vessels
perforations
Risiko dan kelemahan yang masih ada
o Blind  perforasi  dikurangi dengan introducer dan guidewire, pembukaan tumpul dengan
dilator berbahan plastik dan persiapan pasien (kosongkan usus dan bladder
o Omentum dan adhesi tidak terlihat  screening dan pemilihan pasien serta persiapan
o Pasien pasca operasi daerah abdomen
o Riwayat ileus

o Pasien sangat gemuk  lebih baik open methode, exit site di thoraks?
o Pasien sangat kurus dengan dinding abdomen sangat tipis  risiko tinggi perforasi, sulit tunneling

o Dengan screening, pemilihan pasien dan persiapan yang baik  Komplikasi menjadi rendah
Persiapan alat
1. Kateter Dialisis Peritoneal Tenckhoff 2 cuff (straight/coiled)
2. QuintonTM Pull Apart Introducer Set 16 FR
3. Betadine dan Alkohol,Kassa steril
4. Sarung Tangan Steril min 2 set (no 7 dan 7,5)
5. Kain Bedah Steril, Duk bolong
6. Baju Bedah Steril 2 set
7. Spuit disposable 10 cc,5cc,1cc
8. Lidocain inj 2% 10 amp
9. Set Bedah Minor 1 set
10. Benang Silk 2.0 steril dan chromic/cat gut 2.0
11. Larutan NaCl 0.9%/Ringer Lactate
Persiapan alat
Topi bedah
Transfusion set 1
Maindren (stainless steel) steril untuk tenkhoff 1
Kauter (electric cutter)
Heparin
Lampu operasi
USG dengan probe linier (optional)
 Alat-alat yang Dibutuhkan Untuk CAPD

 Paket awal (ASKES) :

1. Tenckoff kateter (T/K) : seumur hidup, kec infeksi

2. Titanium adaptor : idem
3. Transfer set : diganti 6 bulan sekali
4. Ultraclamp 2 buah : diganti bila rusak

 Paket cairan dan minicap :

1. Paket 90 : 90 kantong cairan + 90 minicap

2. Paket 120 : 120 kantong cairan +120 minicap

 Cairan yang tersedia :

1. Dianeal PD 4 1,5 % ; 2,5 % ; 4,25 %

2. Extraneal (Icodextrin) : 7,5%
 TITANIUM ADAPTOR TRANSFER SET
TENCKOFF KATETER

ULTRACLAMP MINICAP
MINICAPS

Merupakan kelengkapan dari produk CAPD, sebagai

pelindung pada locking connector di transfer set,
mengandung povidone iodine.

Diganti dengan yang baru setiap kali dilakukan

pertukaran cairan.
 Minicaps

 Mengandung povidone iodine (PVPI)dlm impregnated sponge

 Men-deaktifkan resiko kontaminasi dari transfer set.
Deactivation 10 CFU
TRANSFER SET

Merupakan kateter penghubung antara titanium adaptor dan

kateter Y dengan system connector on – off.

Diganti setiap 6 bulan sekali.

 Ultraclamp
Merupakan clamp/penjepit pada selang / kateter Y, digunakan sebagai pengatur
mengalir/tidaknya cairan.
Post Op Care

• Flush the catheter with small volume of Dialysate

• Add heparin 500 – 1000 IU/L in Dialysate
• Flush till clear
- Blood can cause thrombosis of catheter
• Cover the wound and exit site with gauze dressing
• Immobilize the catheter to minimize trauma and handling

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Post Op Care
• Pain relief
- Paracetamol is often adequate
- Tramadol may be given for breakthrough pain
• If for immediate use,
- Low volume APD to avoid “Stressing” the wound and
pericatheter leak
• To minimize leak, wait at least 10 – 14 days before
beginning on PD

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• Bleeding
• Outflow failure
• Catheter cuff extrunsion
• Exit site granuloma
• Exit site/ tunnel tract infection

Potential PD Access Catheter Problems

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Bleeding
• Post catheter insertion
• Incidence ~2%
• Usually secondary to trauma of small vessels in
abdominal wall
• Risk factors:
- Anti-coagulation
- Anti-platelets
- Thrombocytopenia
- Uremia

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Bleeding
 Primary Prevention
 Identify high risk patients
 Suspend anti-coagulantion or bridge with heparin if
necessary
 Correct coagulopathy or thrombocytopenia if indicated
 Consider DDAVP in uremic patient
 Consider hemodialysis for uremic clearance
 Prophylactic pressure bandage over the tunnel tract post
surgery

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Bleeding
• Treatment:
• Identify the site of bleeding
- Incision wound
- Exit site
• Direct compression over the bleeding site
• “Peanut” dressing + pressure bandage over the tunnel tract
• Bed rest
• DDAVP (0.3 mcg/kg)
• Adrenaline dressing
• Purse string suture over the exit site

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Bleeding

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Causes of Outflow Failure
• Constipation
• Intraluminal catheter occlusion
- Thrombus
- Fibrin
• “Early”
- Catheter malposition
- Catheter kinking
• “Late”
- Catheter migration
- Extra-luminal catheter occlusion
* Omentum

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Approach to Outflow Failure
History
• Constipation?
• Position related?
• Onset
- Immediately after placement?
- Functioning well previously
• Fibrin in outflow bag
AXR
• Kinks
• Position of catheter tip
- Pelvis
- Last documented position? May be
malpositioned but good flow
previously
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Management of Outflow Failure
Constipation
• Laxatives
Fibrin Clot
• Heparin 200-500 IU per liter
- Prophylactic: Hemoperitoneal, fibrin strand
• Trial of Urokinase
- Instill 5000 units/ml in PD catheter x1 hour
- Aspirate and test flow

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Management of Outflow Failure
Malposition/Migrated catheter
• Remove and reinsert
• Laparoscopic revision
- Redirect the catheter
- Omentectomy or adhesiolysis
• Fluoroscopic adjustment
- Long term outcome poor

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Extrusion of Catheter Cuff

• Ideal position of cuff

- 2 cm away from exit site
• Cuff extrusion
- Too superficial placement of cuff
- Consequence of exit site infection

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Management
• Severity of extrusion
• Presence of infection?
• Treatment
- LA to exit site
- Small incision to skin
- Blunt dissection to free the cuff
- Shave off the cuff
- Allow granulation and healing of exit site

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Exit Site Granuloma
• Can form as a result of exit site infection or trauma
• Fleshy tissue overgrowth
• May be painful
• Treatment
- Silver nitrate sticks + antibiotics
- Surgical resection

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Exit Site Infection

Infection should be assumed with exit site score of 4 or more

purulent
discharge - infection

Perit Dial Int 2005; 25: 107

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Exit Site Infection
Primary prevention
• Post peritoneal catheter placement
- Dressing changes are not needed till 7-10 days post
operatively
- Keep dry
- If change is needed (wet/ bleeding), should be by PD Nurse
with sterile technique
• Chronic care
- Daily with povidone iodine or chlorhexidine
- Allow drying after cleaning
- Antimicrobial prophylaxis: Bactroban, Gentamicin,
Chlorhexidine
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Management of Exit Site Infection
• Mild infection
- Minimal erythema
- No pus
- Treatment: povidone iodine + topical antimicrobial
• Moderate infection
- Pus present: gram stain & culture
- Empirical antibiotics till cultures are out
- Antibiotics till exit site is healthy
 Minimal 2 weeks
 3 weeks for pseudomonas infection

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Management of Exit Site Infection
• Moderate infection
- Assess response
- Exclude tunnel tract infection if not responding
- Position of cuff
- Surgical revision or removal if:
o Not responding
o Abscess formation, or
o Development of peritonitis
o Definite fungal infection of exit site

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Conclusions

• Placement technique and skill of operator most important determinant of

catheter outcomes
• Advanced laparoscopy has advantages for direct observing
• Bandung methode has advantages in low cost, fast first use, and minimal risk
• Careful planning of exit site placement very important
• Early break-in possible, if needed
• Doctor’s decision in selecting the patient to technique of insertion, catheter
choice, exit site placement is the most important for patients safety and
comfort
Summary
Patient selection is the most important for patient to be placed on CAPD
It will determine modality of dialysis, modality of catheter placement and survival of catheter
Skill and experience of the physician is more important than the technique
Blind seldinger with Bandung methode and Peritoneuscopic tecnique performed by intervention
nephrologist have success equal or better than surgical placement
Peritoneuscopic or laparoscopic technique are most helpful in patients with multiple prior
surgeries, to determine extent of adhesions.
Surgical placement or laparoscopic require general anesthesia, this adds risk and morbidity to
the placement procedure
Laparascopic is better methode to rescue catheter failure