Question

1. What are you concerned about if the patient’s peritoneal dialysis outflow is brown/bright yellow
2. Signs of infection in your patient receiving peritoneal dialysis-infection at catheter site vs peritonitis.
3. Patient teaching regarding peritoneal dialysis

Answer 1

answer1:

The concerns if the patient’s peritoneal dialysis outflow is brown/bright yellow are as follows:

The normal color of the dialysate fluid is transparent colourless or bright yellow as per its composition The color of the effluent or the outflow is normally transparent lightest yellow or straw coloured.It is such that the labels can be read across the bag.Any change in the color of the effluent indicates underlying derangement or pathology and must be evaluated.

1.brown-fecal contamination,bowel perforation

If the color of the effluent is brown, it indicates contamination with the feces and bowel perforation must be ruled out.

2.bright yellow-indicates dialysate fluid obstruction and return without action.

a)A block in the dialysis system flow due to peritoneal adhesions or peritoneal sclerosis or inflow catheter kink or partial block ,disalignment must be suspected if the outflow is bright yellow(same as the inflow if bright yellow color dialysate used) and one must reassess the catheter systems inserted for delivery .It indicates ineffective dialysis.

The bright yellow outflow(if same as inflow dialysate) indicates ineffective dialysis and is a cause for concern.However history of medications and presence of jaundice must be ruled out.

b)Presence of severe jaundice can cause yellowish to greenish discoloration of the outflow dialysate fluid due to the bilirubin pigment and this must be ruled out by history ,clinical examination and liver function tests

c)bright yellow fluorescein color of outflow-suggests medications and dyes injections.

In case of patients who receive IV fluorescein dye, there may be a temporary discoloration of the outflow dialysate to fluorescent bright yellow color and hence history of intake of any medications, intravenous or oral vitamin supplements must be confirmed with the patients. The intake of multivitamin tablets especially the vitamin B group  also tends to color the peritoneal fluids yellow in some cases.

The other colours of outflow fluid causing concern and their interpretation is listed below:

cloudy-as in peritonitis or infection

milky-lymphatic obstruction

bloody-indicates trauma and peritoneal haemorrhage, blood-tinged outflow is normal for the first 3-4 dialysis episodes

green-bile indicating duodenal or gall bladder perforation.

answer 2:

The Signs of infection in the patient receiving peritoneal dialysis-infection at catheter site vs peritonitis are listed in the table below:

	Signs of infection in peritoneal dialysis-infection at catheter site	Signs of infection in peritoneal dialysis-infection of peritonitis.
	local signs predominate redness,pain,swelling ,tenderness at the local site of the catheter insertion exit or over the subcutaneus tunnel.	systemic signs predominate. fever,tacypnea,tachycardia,abdominal pain,hypotension in stage of sepsis. Abdominal tenderness,rebound tenderness.abdominal distension,abdominal guarding and rigidity ,decreased bowel sounds.
	pus for culture positivity confirms diagnosis	peritoneal fluid culture confirms diagnosis.
	purulent discharge from the dressing site,wet dressing,foul smelling-pus in dressing at catheter exit or on applying pressure to subcutaneous tunnel(confirmatory indicative signs)	cloudy dialysate,brown or green dialysate.-pus or altered peritoneal tap(confirmatory indicative signs).

Sterile peritonitis which occurs due to reaction to the dialysate contents maybe considered if the signs resemble peritonitis and the peritoneal  culture is negative

answer 3: The Patient teaching regarding peritoneal dialysis include the following:

1.diet:

The patient on peritoneal dialysis loses proteins and also faces constipation .Hence the patient must take a high protein, high fibre diet as specified by the physician and also include multivitamins and minerals in the diet.Constipation increases risk of bowel perforation and peritonitis and hence patient must take lots of vegetables and fruits in the diet.

2.fluid intake.The fluid restriction as advised by the physician must be followed. The fluid balance has to be closely observed in the patient of dialysis .The intake of fluid must be as per his/her dietary recommendations.The patient must be explained about the fluid excess risk ,its,signs and symptoms and careful fluid intake monitoring

3.cleanliness:

The patient must be educated regarding the need to keep the catheter site and the dressing clean and dry and keep general cleanliness precautions with daily Bath and clothes change in order to maintain personal hygiene and prevent infections like the local catheter infection and peritoneal infections

4.bath:The patient should be educated about a daily bath and warned against the use of a bathtub. Also the catheter should not be immersed in the water and should be carefully anchored while the patient is dressing to prevent dislodgement.

5.cathetar care:

The patient should be careful about the catheter and take general precautions while daily movements, playing, resting, sleeping to avoid the catheter from getting kinked, blocked or dislodged. The risk of infection at the catheter site and the peritoneal cavity must be explained to the patient in case of poor hygiene and skin contamination

6.Education about the procedure and the complications:

The newly diagnosed patients are in a state of knowledge deficit.

The patients must be educated about the procedure of peritoneal dialysis and explained the steps involved the should be also involved in the monitoring of the rate of the dialysis and the volume and color of the returning fluid. The possible complications of the procedure must be explained to them and they must watch out for the symptoms of these complications and report to the physician at the earliest.

The patient must be educated to monitor the amount of dialysis fluid returning and its color and report the same to the physician in the case of home dialysis or Ambulatory dialysis..Also in cases of home dialysis, patient must observe the returning amount of dialysate. if there is a decrease in the returning amount by 500 ml in a single setting for 1 litre over three consecutive settings, it must be immediately brought to the attention of the physician.

6.risk for infection

The patient should be explained about the increase to risk of infection and its prevention by having nutritive diet and taking general precautions of cleanliness and hygiene. The symptoms of infection at the catheter site and that of a peritonitis must be explained to the patient,Diabetic patients must follow regular medications and strict blood glucose monitoring to decrease this risk.