“Let’s Talk About Peritoneal Dialysis” Post 3: Drain Pain…Ouch

“Hey doc, it hurts every time I do this.”  “Well, stop doing that.”

Ah, if it were so simple.  What is one to do when “this” is draining peritoneal dialysis (PD) dialysate?  A simple question with a not so simple answer.

First, when dealing with pain in a PD patient, it is important to take a detailed and thorough history.  Drain pain is different from infusion pain, though pain at anytime during infusion or drainage may be the harbinger of peritonitis.  A wise man once said that all pain is peritonitis until proven otherwise. If one does prove otherwise pain is often due to excessive vacuum pressure or catheter tip position. We will discuss the management below.

Our initial approach when confronted with drain pain is aggressive laxative administration.  This strategy can help by forcing peristalsis and forcing movement of the tip of the catheter. If the catheter tip is against a highly innervated organ such as the bladder the suction applied during drainage can be extremely painful, furthermore irritation of the peritoneal membrane during drainage by the catheter tip can be extremely painful..  

If laxatives don’t do the trick, one can attempt to decrease the force of suction by adjusting the height of the cycler.  Placing the cycler at the same height as the patient will result in less suction applied to the abdominal viscera as gravity is overcome.  Some patients find that squeezing the drain tubing to provide more resistance to the negative pressure helps alleviate the pain.

Finally, tidal PD is often efficacious.  In tidal PD, the full dwell volume is not drained with each exchange.  The presence of fluid in the peritoneal cavity at the end of drain can be enough to keep the catheter tip from irritating the abdominal viscera. While drain pain is not the only reason to try tidal PD, it remains the most common indication. 

Notably little data on the efficacy of any of these interventions exists.  If pain persists, as a last resort, catheter removal and replacement in a new position can be attempted.

Post by: Ankur Shah, MD (@NephroShah)
Nephrologist, Brown University

6 comments

  1. I am confused with “adjusting the height of the cycler”

    Dr. Wong (Cleveland Clinic and Baxter supported) says in his presentation: ‘by raising the cycler it will reduce the suction on catheter and therefor reduce or minimise the drain pain. This is opposite to what is written in this post: “Placing the cycler at the same height as the patient will result in less suction applied to the abdominal viscera as gravity is overcome”.

    What do I misunderstand? Pls help to clarify?

  2. I’m experiencing drain pain with machine on initial and final drain (and manual drain from Baxter machine). I am finding some less pain when standing with my feet a little more than shoulder width (or more). I will be trying the squeeze tube method. My machine is currently a little higher than my bed.

  3. With peritoneal dialysis what part of the Claria machine should be the same height as the bed. We are trying to reduce drain pain

  4. Anna, according to the article, cyclers use negative pressure which causes suction which can cause pain.

  5. Robert: both manual exchanges and cyclers are drained by gravity.

  6. Is gravity better than the machine.

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