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J Thorac Cardiovasc Surg 1997;114:688-689
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

The safety of peritoneal drainage and dialysis after cardiopulmonary bypass in children

King Faisal Specialist Hospital
Department of Cardiovascular Diseases
MBC 16
P.O. Box 3354
Riyadh 11211, Saudi Arabia

To the Editor:

We read with interest the article by Werner and associates ¹ concerning the use of peritoneal dialysis in children after cardiopulmonary bypass, and the subsequent commentaries by Jonas and Mee. ¹ Although it is true that no controlled studies have been conducted in the use of elective peritoneal drainage after cardiac surgery, we do not agree with Jonas that this technique necessarily has a high risk of complications. The article by Werner's group focused on patients in whom renal failure developed after surgery. They studied the benefits and complications of peritoneal dialysis via a percutaneously placed peritoneal catheter. We offer our recent experiences on this subject.

At King Faisal Specialist Hospital and Research Centre, we routinely insert a Dacron-cuffed silicone rubber Tenckhoff peritoneal dialysis catheter (Pediatric Tenckhoff catheter, 37 cm, Quinton Instrument Company, Bothell, Wash.) via a subcutaneous tunnel in the following groups of pediatric patients undergoing cardiopulmonary bypass: any patient aged less than 4 weeks or older patients weighing less than 3.5 kg, patients at high risk for the development of right ventricular failure (e.g., conditions associated with severe pulmonary hypertension), after total cavopulmonary connection, and patients with poor myocardial function despite optimal surgical repair. Postoperatively, the catheter is attached to a closed system for peritoneal drainage or dialysis (PD-paed-System, Fresenius AG, Bad Homburg, Germany).

Our perfusion protocol involves a proportionate reduction in bypass flow rates (at a hematocrit value of 25% to 30%) as core temperature falls, adjusted to achieve a mean systemic arterial pressure of 30 to 40 mm Hg and normal venous oxygen saturation. Hemofiltration is routinely used, including modified ultrafiltration in every case. Despite this we continue to see evidence of capillary leak syndrome in high-risk patients.

The catheter is used to drain peritoneal fluid, which would otherwise accumulate as a result of capillary leak. If oliguria develops despite optimizing volume status and myocardial function, low-volume peritoneal dialysis (10 ml/kg cycled each hour) is commenced in an attempt to prevent or treat significant fluid accumulation. We have found this technique to be simple, safe, and effective.

Between September 14, 1996, and April 30, 1997, 329 neonatal and pediatric patients underwent cardiopulmonary bypass for correction or palliation of congenital heart disease, with 11 deaths (3.3%). Tunneled peritoneal dialysis catheters were inserted during the operation in 87 (26%) patients, aged 5 days to 12 years (mean age 15.5 months). The mortality in this group was 10 (11.4%). In two of 87 (2.2%) patients, positive cultures developed from the dialysate. Both of these were in children who had fatal multiple organ failure, sepsis in multiple sites, and who required peritoneal dialysis for more than 2 weeks. In no other case was the cause of sepsis, renal failure, or death attributable to the technique of peritoneal drainage or dialysis.

We believe that this approach to peritoneal drainage and ease of commencing dialysis has simplified fluid, respiratory, and cardiovascular therapy and is without significant risks. Our technique of using a subcutaneous tunnel with a cuffed peritoneal dialysis catheter provides a watertight seal in those patients who require dialysis. We believe that this is also the major factor for our low infection rate, ² along with the use of a closed irrigation/drainage system. ³ Finally, the risk of bowel perforation during and after insertion is significantly reduced by the use of a surgically placed Tenckhoff catheter compared with standard acute dialysis catheters, ² as described by Werner's group.

References

1. Werner HA, Wensley DF, Lirenman DS, LeBlanc JG. Peritoneal dialysis in children after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1997;113:64-70.[Abstract/Free Full Text]
   
2. Ash SR, Daugiras JT. Peritoneal access devices. In: Daugiras JT, Ing TS, editors. Handbook of dialysis. 2nd ed. Boston: Little Brown; 1994. p. 274-300.
   
3. Valeri A, Radhakrishnan J, Vernocchia L, Carmichael L, Stern L. The epidemiology of peritonitis in acute peritoneal dialysis: a comparison between open and closed drainage systems. Am J Kidney Dis 1993;21:300-9.[Medline]
   

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