Welcome to post 4 of the “Let’s Talk About Peritoneal Dialysis (PD)” Series! In post 3 we discussed drain pain, and today we discuss infusion pain (pain during dialysate infusion into the abdomen) which can be just as distressing to the peritoneal dialysis (PD) patient. Data on the prevalence of this entity is lacking, but experience notes that infusion pain is a common problem.
As with drain pain, any pain related to the dialysis procedure could be peritonitis, and thus the first step in infusion pain is to look for peritonitis as a cause. Then, the differential for infusion pain includes: hypersensitivity to acidic dialysate, physical irritation of viscera, physical or chemical irritation of the peritoneum (Table 1).
Care should be taken (particularly with patients on the AMIA cycler) to assess amount drained with each dwell, as infusion pain could be pressure mediated from incomplete drainage of a prior dwell or from pocketing of the abdomen from adhesions resulting in a small compartment for dialysate and increased pressure.
As with drain pain, the first step in infusion pain management is aggressive laxative administration to promote peristalsis of bowel which can result in a reposition of the PD catheter tip. If the tip is abutting the membrane or viscera with sensory innervation, this may help reposition the catheter. Should this intervention fail, the pain is presumed to mediated by the acidic pH of lactate dialysate. This problem can be resolved in a few different ways:
If available, switching to a neutral pH dialysate is efficacious in resolution of infusion pain. If not available, the addition of 2-5 meq/L of sodium bicarbonate to dialysate is typically enough to alleviate any infusion pain. With bicarbonate addition, there is an increased risk of contamination and infection. Novel bicarbonate/lactate solutions have been studied to alleviate the infection risk. Tidal PD, also discussed in post 3, can be effective in the alleviation of infusion pain as the retained dwell dilutes the acidic dialysate.
Other therapeutic strategies include the addition of lidocaine or other local anesthetics to the dialysate. If all options fail, removal of the PD catheter with replacement in a different site can be attempted. Of note, in many cases infusion pain is a self limiting condition that resolves after 2-3 months of dialysis.
Post by: Ankur Shah, MD (@NephroShah)
Nephrology, Brown University