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Infant Peritoneal Dialysis Setup Using the GESCO Dialy-Nate Set (Pediatric) (3.17-P)

Infant Peritoneal Dialysis Setup Using the GESCO Dialy-Nate Set (Pediatric) (3.17-P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Genitourinary

3.17-P

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
December 26, 2016


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 3.17P

Original
Revision

Page
1
of 6

Title: Infant Peritoneal Dialysis Setup Using
the GESCO® Dialy-Nate Set (Pediatric)

I. PURPOSE

To establish a procedure for the qualified registered nurse (RN) to initiate manual
peritoneal dialysis (PD) in the infant patient needing fill volumes of less than 100 mL
using the GESCO Dialy-Nate Set. This set may also be used for older children if there
is a medical need to use dialysate that is not warmed.

II. POLICY

A. Only qualified nurses or nurses under the supervision of an qualified nurse should
carry out the PD procedures. The Wisconsin Dialysis, Inc. Team can be reached
through hospital paging to assist with catheter placement and initiation of dialysis.
The PD nurse will always set up the Gesco Dialy-Nate Set initially and every 24
hours thereafter.
B. Subsequent assistance is available from the PD Program, Wisconsin Dialysis, Inc.
The PD program also has a nurse on-call 24 hours daily reachable through paging.
Ask for PD/Home Dialysis nurse on call. PD office hours are M-F, 8:00 a.m.-4:30
p.m. 270-5643

III. EQUIPMENT

A. GESCO Pediatric/Infant Disposable Peritoneal Dialysis Se [CS] Item Number
4005247 with coiled tubing, 4015945 with double burette, 4015171 straight
tubing(to be used with the Astoflo Plus Fluid Warmer)
B. Three-way stopcock (CS Item Number 2203015)
C. Baxter Peritoneal Dialysis Solution, 1.5%, 2.5%, 4.25% (as ordered)
D. Medications as ordered
E. Astoflo Plus Fluid Warmer
F. Masks
G. Sterile gloves
H. Baxter Transfer Set (CS Item Number 4012037)
I. Baxter Mini Cap (CS Item Number 2204129)
J. Alcavis Solution (provided by PD nurse)
K. Gauze 4x4s

Parts of GESCO Set:
A. Three (3) luer lock connectors for PD bags
B. Graduated (150 mL) Administration Burette with Injection Site and Air Vent
C. 0.2 micron filter

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D. Straight tubing or coiled tubing
E. 3-way Stopcock
F. Graduated Dialysate Meter with Overflow Bag (Drain Bag)

NOTE:
• PD solution does not have to be pre-warmed prior to administration when using
the Astoflo Plus Fluid Warmer.
• Baxter transfer set must be attached to PD catheter by the WDI Peritoneal
Dialysis Team prior to starting PD treatment.
• GESCO Dialy-Nate system will be changed every 24 hours by the PD nurse to
maintain infection control.
• If a new bag of dialysate needs to be added, this can only be done if there is a
sterile connector that has NOT been used.
• DO NOT reconnect a bag of dialysate to a used connector.

IV. PROCEDURE FOR PRIMING THE GESCO DIALY-NATE SET

A. Review procedure order.
B. Gather supplies.
C. Close door to room and identify patient.
D. Put on mask. All people in room must wear a mask during set up of system and
connection and disconnection.
E. Wash hands with antibacterial soap and water for one (1) minute.
F. Open kit.
G. Put on sterile gloves.
H. Place 3-way stopcock on patient end of Gesco system. Close all clamps on entire
system.
I. Connect luer lock end of the GESCO system to the prescribed Baxter peritoneal
dialysis solution bag. Frequently, more than one bag is used.
J. Dialysate should be hung on IV pole approximately 3-4 feet above the level of the
patient and drain bag should be below the patient since fluid flows by gravity. The
IV pole may be raised to increase flow of dialysate.
K. Break frangible on the neck of dialysate solution bag and release the clamp
directly under the selected dialysis solution bag to fill burette with approximately
80 mL of dialysate. Close the clamp to stop flow from the dialysis solution bag. If
physician orders more than one strength of dialysate, then system should be
primed with a combination of prescribed dialysate.
L. Open the roller clamp all the way to prime the tubing of the Gesco set. Make sure
to release clamps and check that stopcock is in proper position. Make sure entire
system is primed by redirecting the stopcock to prime patient line and drain line.
Ensure that entire system is free of air.
M. Close all clamps once the line is primed. Label the specific lines by the stopcock
with “patient”, “drain” and “fill”. Label each line coming from the Baxter solution
bags with strength of solution.
N. Once the tubing is completely primed, place the tubing into the long blue cord
wrap of the fluid warmer. The tubing slips easily into the wrap. Plug in the
Astoflo Plus warmer. The Stand-by light comes on. Press the Stand-by button to
start the warmer. The default temperature of the warmer is set at 41 degrees C.

Page 3 of 6

Check with physician for specific temperature setting to be used for PD
exchanges.
O. Refer to product insert for detailed description of the GESCO Set.

V. SPECIAL INSTRUCTIONS

A. Any medications that are ordered to be added to the PD solution bags will be
performed by Pharmacy.
B. Dialysis solution comes in three strengths and is determined by the physician
based on volume status of the patient:
1. 1.5% Dextrose
2. 2.5% Dextrose
3. 4.25% Dextrose
C. Check each bag prior to use for:
1. Expiration date
2. Clarity-stronger solution may be slightly yellow
3. Correct solution, strength
4. Pinholes: squeeze bag to check for leaks. If bag is leaking, DO NOT USE.

VI. PERITONEAL DIALYSIS EXCHANGE TO INITIATE PD

A. Before initiating PD-disinfect end of transfer set with Alcavis solution:
1. Put on mask and wash hands with antibacterial soap and water for one (1)
minute. Refer to Hospital Administrative Policy 13.08.
2. Saturate 4x4 gauze pads with ample amounts of Alcavis solution (8 – 12
mL).
3. Put on clean gloves.
4. Wrap 4x4 gauze pads around the transfer set cap to be disinfected. You
must leave transfer set cap on for this soaking. Leave gauze pads in the
4x4 paper wrapper to avoid bleaching clothing.
5. Scrub the end of the transfer set with the cap ON with Alcavis for one (1)
minute and then allow the end of the transfer set to soak in the Alcavis
soaked gauze for one (1) minute. Total soaking time should be two (2)
minutes.
6. Leave transfer set on opened gauze pads so that the transfer set is ready for
connection. Perform hand hygiene, according to Hospital Administrative
policy 13.08, Hand Hygiene and put on sterile gloves. Continue
connecting to Gesco set.
7. The correct steps for a PD exchange are:
a. Drain or outflow
b. Fill or inflow
c. Dwell (dialysis process)
8. When initially starting PD, always drain the patient first so there is no
chance of overfill.
B. After ensuring that the catheter has stopped draining, start the flow of dialysis
solution by opening the clamp under the bag and fill the burette with the correct
fill volume of dialysate. If using more than one concentration of dialysate the
burette should be filled with equal parts of dialysate. Close the solution clamp and

Page 4 of 6

then open the roller clamp to begin filling the patient. Make sure clamp to the
drainage bag is closed and the stopcock is in the correct position for filling.
C. Clamp the tubing to the bag after patient fill.
1. The nurse MUST remain with the patient during the fill so that the burette
does NOT run dry instilling air into the system.
2. Usual order of the exchange is:
a. Three to ten (3-10) minutes for solution to drain (drain time is
volume dependent)
b. Three to ten (3-10) minutes for solution to run in (fill time is
volume dependent)
c. Thirty (30) minutes to four (4) hours to dwell (according to MD
order)
3. If solution does not run in well, check that proper clamps and stopcock are
open and that there are no kinks in the tubing.
4. Raising the solution bag and/or lowering the patient's bed will increase the
rate of inflow of the solution.
D. Take blood pressure, pulse and temperature every 15 minutes during the first
exchange or more frequently as indicated by patient response.
E. Notify physician of any changes, e.g., irregular pulse and/or a drop in blood
pressure, which may indicate excessive fluid loss or pressure on vena cava.
F. Allow for physician ordered length of dwell time.
G. Open stopcock to the drainage bag to drain dialysis fluid.
1. Drainage may be facilitated by turning patient to his/her side. Avoid
retrograde flow.
2. Do not leave patient in a drain for longer than 30 minutes; this can cause
catheter malfunction and cause abdominal discomfort.
H. Observe the rate of flow and color of fluid and presence of fibrin (white, stringy
or egg white looking piece); clamp drainage tubing at the end of the drain period.
1. The first drain after PD catheter insertion may be blood tinged from the
trauma of inserting the catheter, but usually it begins to clear after the first
few exchanges. If outflow is extremely bloody or does not clear, consider
the possibility of an intra-abdominal bleed and notify MD.
2. A closed drainage system is maintained at all times to avoid infection.
3. Cultures of drained dialysis solution are performed when ordered and if
cloudy fluid is observed. Call physician and PD nurse. PD nurse will
obtain and send a cell count with differential, gram stain, aerobic and
anaerobic culture and sensitivity. (The first sign of peritonitis is generally
cloudy fluid.)
4. If drainage is significantly less (i.e., 50%) than the amount put in, notify
physician and/or PD nurse to assist with troubleshooting before the next
exchange.
I. Drain solution from drainage bag into a graduate for accurate measurement.
Record amount on CAPD flowsheet in doc flowsheets in the clinical record.
J. Start the next fill, dialysis is generally continuous.
K. Use appropriate standard precautions in handling drain fluid. Site care and
dressing change will be performed by PD staff.




Page 5 of 6

VII. POSSIBLE COMPLICATIONS DURING DIALYSIS AND POST-DIALYSIS

A. Notify physician:
1. If persistent bloody drain fluid or recurrence of bloody drain fluid.
2. Peritonitis: May be indicated by cloudy drain fluid, pain, fever.
3. Perforation of the bladder or intestine: May be indicated by patient
developing diarrhea and signs of peritonitis and/or excessive urinary
output.
4. Electrolyte imbalance: Indicated by changes in cardiac rhythms,
confusion, disorientation, general change in state of patient's cerebral
function, irritability, muscle twitching or deepening lethargy.
Hypokalemia is the most serious complication. Serum potassium may
need to be monitored closely.
5. Abdominal pain: Usually as a result of the surgical procedure. Some
patients may experience cramping or pressure in peritoneum during
outflow or when abdomen is full.
6. Respiratory difficulty: Resulting from large fluid volume in abdomen
pushing against the diaphragm. Have patient sit up if any respiratory
difficulty occurs. If status does not improve, drain part or all of solution
out.
7. Nausea, vomiting and abdominal distention: If symptoms are mild and
patient is able to eat, frequent small feedings are preferable. If abdominal
distention is severe, notify physician (may be paralytic ileus).
8. Hypovolemia: May be due to rapid removal of fluid or to excessive fluid
removal from patient.
9. Decreased dialysis outflow: Facilitate drainage by checking tubing for
kinking, elevating head of bed, rolling patient from side to side; if these
measures do not help, notify PD nurse.
10. Constipation: May cause abdominal pain and difficulty in drainage during
dialysis. Patient should be on a bowel regimen per physician order.
11. Catheter exit site leakage or subcutaneous leak: Stop PD exchange.

VIII. DOCUMENTATION

A. Document the following in the patient’s clinical record during the course of the
treatment:
1. Date and time procedure was started, and physician who initiated it.
2. Patient's weight. Weigh at the same time daily and wearing same clothing.
Preferably patient will be drained before weighing. Consistency with
weight is key.
3. Temperature and blood pressure, pulse and heart rate.
4. Number of exchanges, type of dialysis solution, exact time and amount
infused and drained.
5. Time for each period of drain, fill and dwell.
6. Cumulative fluid balance, if requested. If drainage is less than amount
infused, the balance is recorded as a positive (+) number of mL; if
drainage is greater than infused amount, balance is recorded as a negative
(-) sign for number of mL.
7. Medication added to dialysis solution.

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8. Color and characteristics of the drainage fluid (cloudy, bloody, or clear).
9. Patient's reaction to the procedure and his/her condition, including
complications and actions taken.

IX. UWHC CROSS REFERENCE

Hospital Administrative Policy 13.08, Hand Hygiene

X. REFERENCES

A. National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI)
Clinical Practice Guidelines for Peritoneal Dialysis, 2006
B. Pediatric ISPD Guidelines/Recommendations: 2012 Update, Peritoneal Dialysis
International 2012, 32:S29-S86

XI. REVIEWED BY

Clinic Manager, Home Dialysis, Wisconsin Dialysis, Inc.
Nursing Patient Care Policy and Procedure Committee, December 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer