State of Home Dialysis, Part I: Peritoneal Dialysis (PD) Catheter Placement in the COVID-19 Era

The COVID-19 pandemic has affected dialysis patients regardless of their treatment modality, including those dialyzing in center or at home. This post is a first in a series that looks at the state of home dialysis catheter placement and shares some industry best practices for providing clinical care to our home patients during this unprecedented time. Important Note: The information contained in this blog post does not constitute medical advice and each practitioner is obligated to use his/her own medical judgment in caring for his/her patients.

This post specifically covers best practices to help mitigate COVID-19 transmission during peritoneal dialysis (PD) catheter placements. These practices include considerations, recognizing that access placement is not an elective procedure, for choosing between laparoscopic and percutaneous catheter insertions, use of embedded catheters to proactively plan for potential surgical facility constraints or availability issues due to a surge in viral infections, use of telehealth for preoperative visits and catheter prioritization pathway developed collaboratively by nephrologists, surgeons and hospital administrators.

Before detailing these best practices, below are some general guardrails for any abdominal surgery performed during the COVID-19 crisis:

• Conduct universal pre-procedure COVID-19 testing
• Limit staff presence in room to only anesthesia personnel during intubation and extubation
• Use negative-pressure operating rooms or procedure rooms if available
• Evacuate room intraoperatively of smoke and insufflated gases, if appropriate filtration devices are available
• Prohibit exchange of room staff during procedure
• Require universal use of N95 masks and goggles or face shields
• Ensure proper post-procedure disposal and cleaning

Selection of a surgical approach for PD catheter insertions

Guidelines suggest that a PD catheter implantation approach be based upon the patient factors below.

Patient Factor	Previous Major Surgery or Peritonitis (Order of Suggested Technique)	No Previous Major Surgery or Peritonitis (Order of Suggested Technique)
Suitable for general anesthesia	1. Advanced laparoscopic 2. Open surgical dissection	1. Advanced laparoscopic 2. Image guided percutaneous 3. Open surgical dissection or Peritoneoscopic 4. Percutaneous without image guidance
Suitable for local anesthesia/sedation only	Open surgical dissection	1. Image guided percutaneous 2. Open surgical dissection or Peritoneoscopic 3. Percutaneous without image guidance

Several considerations exist for choosing a surgical approach for dialysis access in the COVID-19 positive patient. Laparoscopy has generally been considered inadvisable if smoke and insufflated gas filtration systems are not available. General anesthesia for laparoscopic procedures is contraindicated in symptomatic patients with both pulmonary insufficiency and advanced end stage kidney disease (ESKD) or acute kidney injury. Percutaneous PD catheter placement may be considered if a provider is available who has acceptable experience with this technique. Patients requiring prone ventilation have a relative contraindication for PD due to the risk of pericatheter leak. Insertion of a central venous catheter (CVC) for hemodialysis (HD) is indicated when safe and/or reliable PD access cannot be achieved. If the patient has a functional vascular access, conversion to PD should be postponed until the patient has recovered from COVID-19.

Catheter embedding procedure                                                                        

With catheter embedding, the external limb of the catheter is buried under the skin at the time of implantation. Then, the external limb is exteriorized weeks to months later when dialysis is needed. Externalization of embedded catheters is a clinic or bedside procedure. Thus, PD can be started immediately at full volume without the necessity of a break-in period. As hospitals and surgical centers have begun to relax restrictions and conduct a broader range of surgeries, consider embedding catheters to proactively plan for a surge in viral infections that may cause future surgical facility closures.

Barriers for embedding catheters include:

• Previous abdominopelvic surgery in which the need for adhesiolysis is likely
• A record of poor outcomes for ordinary catheter placements by the intended provider
• Anticipated need to start dialysis is < 4weeks

Telehealth for general appointments

Another way to mitigate COVID-19 transmission with PD catheter placements is to use telehealth for general visits, including:

• Consults
• Preoperative visits
• Postoperative visits
• Inpatient rounding

Although video appointments have their limitations especially in terms of conducting physical examinations, patients who have the technological knowledge and equipment to download the appropriate application may appreciate the convenience of staying in their homes. Once the patient is prepared for the visit by your staff or reading your team’s web page, video appointments are more likely to be successful if you treat them like in-person visits with the following components:

• Icebreaker of 1-3 minutes
• Medical history taking
• Visual examination
• Discussion of plan for surgery, follow up, recovery, etc.
• Delivery of follow up information and responses to patient questions
• Detailing of next steps (e.g., expected communication with PD nurses, call from scheduler for surgery date)
• Scheduling an in-person visit if the patient requires a more in-depth assessment in the office, especially if the patient appears to require a particular catheter device that may need to be ordered by the facility in advance of the PD access procedure or the presence of abdominal wall hernias.

Pathway development from collaboration

Nephrologists, surgeons and hospital administrators need to work collaboratively in order to develop pathways to mitigate COVID-19 transmission while assuring performance of dialysis access. In discussions with hospital administrators, it would be helpful for nephrologists and surgeons to:

• Advise on the position of the Centers for Medicare & Medicaid Services regarding the critical nature of dialysis access procedures as non-elective
• Discuss the potential clinical value of home dialysis to reduce exposure or spread of COVID-19 among high-risk, in-center HD patients that may potentially increase utilization of hospital resources if an outbreak of infection occurs in this susceptible population
• Counsel that CVCs for HD have their own risks for complications that can increase hospitalizations in addition to in-center HD exposure issues and may require more repeat interventions
• During the time of restricted operating room (OR) access, create dedicated time blocks for PD access procedures (eliminate backlog, support urgent/semi-urgent access, embedded catheters)
• Assure the OR is sufficiently prepared to mitigate exposure to COVID 19 during surgical and radiological procedures by having adequate virus testing, staffing, OR smoke/gas filtration systems, and personal protective equipment

Although COVID-19 aerosolization during open and laparoscopic procedures is speculative at this point, all available measures should be employed to mitigate risk of viral transmission during PD catheter insertion. While many considerations exist for selecting between a laparoscopic and a percutaneous catheter insertion approach, the most important consideration may be the experience of the surgeon. It may be appropriate to employ catheter embedding procedures in order to plan for surges in COVID-19 infections that may cause future surgical facility closures. In addition, use of telehealth for preoperative or general visits is a helpful method for mitigating COVID-19 transmission. Finally, collaboration amongst nephrologists, surgeons, and hospital administrators is essential in developing best practices to mitigate viral transmission while assuring performance of dialysis access procedures.

Upcoming post: State of Home Dialysis, Part II: Strategies to Utilize Telehealth for CKD Clinics and Education