“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