Automated Versus Ambulatory Peritoneal Dialysis Essay

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Automated Versus Ambulatory Peritoneal Dialysis Essay

I dedicated this dissertation to my Mum, Mary Carmen, Dad, Joseph, Brother Carmel and my friends.

ACKNOWLEDGEMENTS

The present dissertation was possible because of the personal and practical support from other individuals. I would like to gratefully and sincerely thank my academic supervisor, Mr. Martin Camilleri, M.Sc.; Dip. N. Ed; Teach Cert; A&E Pract.Cert.; F.L.M. R.N, for his guidance, understanding, constructive criticism and friendship. I believe that his actions provided me a unique opportunity to gain a wider breadth of experience while still an undergraduate student. Automated Versus Ambulatory Peritoneal Dialysis Essay. This is also a great opportunity to express my appreciation towards all my colleagues of nurses-to-be – class intake 2010. Finally and most importantly, I would like to thank my parents, my brother and my friends for their support, encouragement, patience and unwavering love.

In this chapter a clear and succinct background on peritoneal dialysis is given. The rationale for its selection and relevance to nursing practice is explained. Evidence Based practice is explained in context with this issue. In the final part of this chapter the framing of the research question using the PICO question framework is explained

1.2 Background and Foreground Information on Peritoneal Dialysis

Peritoneal dialysis (PD) has been used as an alternative method to haemodialysis (HD) for the treatment of end-stage renal disease (ESRD) for almost than three decades (Kannaiyan S. Rabindranath, 2007). In 1976 the introduction of continuous ambulatory peritoneal dialysis by Popovich made peritoneal dialysis an important treatment for end stage renal failure (Fijter, et al., 1994). Nevertheless, infection is one of the major complications of this dialysis, and contributes significantly to hospitalization, technique failure and even mortality (Boeschoten & Divino, 2006).

Peritoneal Dialysis (PD) involves using the cavity of the peritoneum as a dialysis (solute) and ultra filtration (removal of fluid) membrane. PD is used as an alternative method to haemodialysis (HD) for the treatment of end-stage renal disease (ESRD). ESRD is a chronic condition that occurs when the kidneys do not function well enough for one to live without needing to undergo treatment of dialysis or kidney transplant (American Kidney Fund, 2008). In ESRD the kidney function diminishes were the kidneys cannot remove toxic waste and excess water as well as control of blood pressure, red blood cells and maintain healthy bones. If kidney transplant is contraindicated for patients or if there are no kidneys transplant available, patients will have to undergo dialysis in order to survive (American Kidney Fund, 2008).

In Peritoneal dialysis, the dialysis fluid is introduced into the peritoneal cavity through a catheter that is placed in the lower abdomen. Automated Versus Ambulatory Peritoneal Dialysis Essay. The catheter is placed in the peritoneum which this lines the walls of the peritoneal cavity and covers all the organs.

In PD the peritoneum serves as a dialysis membrane. The peritoneal cavity can hold more than 3 litres of fluid, but in practice only 1.5-2.5 litres of fluid are used. The fluid that is introduced in the peritoneal cavity which in most cases glucose is used acts as osmotic pressure gradient (Redmond A, 2005). There are different concentrations of this osmotic agent and this is chosen according to the need to remove waste. The higher the concentration, the larger the osmotic pressure, which this then results in a larger fluid removal. Since the peritoneum is a thin, translucent and is made up of porous layer of tissue with numerous blood vessels solutes are transported across the membrane by diffusion. Waste products present in the blood perfusing the peritoneum will diffuse from the blood into the “cleaner” dialysis fluid which is the glucose. When the dialysis fluid is drained from the abdominal cavity, it contains the waste products and the excess fluids extracted from the blood. Solute and water exchanges occur in the peritoneal cavity by three different processes- osmosis, diffusion and convection which all of them are necessary for PD to work efficiently (Burke, et al., 2011).

Selection of dialysis depends on various factors such as one’s co-morbidities, support system and the individual’s life style (Burke, et al., 2011) . There are two types of PD which these have been developed to maximise the efficiency of PD in terms of solute (clearance) and fluid (ultra filtration) transfer and for the social convenience of the patient (Redmond A, 2005). These are Continuous ambulatory peritoneal dialysis (CAPD) and Automated peritoneal dialysis (APD). There are variations of APD which include: Continuous cyclic peritoneal dialysis (CCPD), Nocturnal peritoneal dialysis (NPD), Optimised cycling peritoneal dialysis (OCPD), Intermittent peritoneal dialysis ( IPD) and Tidal peritoneal dialysis (TPD) (Redmond A, 2005).

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CAPD consist of three to five exchanges of fluid spread over 24 hours. This exchange take about 30 minutes and the fluid is instilled by gravity into the peritoneal cavity and then is drained after a dwelling period of several hours. On the other hand APD the exchanges of the dialysis solution are performed by a machine while the patient sleeps. Automated Versus Ambulatory Peritoneal Dialysis Essay. This usually takes place during the night and takes over and eight to ten hour period

Like in all invasive procedures there are number of complications and associated risks that arise. Peritoneal dialysis is prone to infections and these are: Peritonitis, exit site infection (ESI) and catheter infection which these cause technique failure, hospitalization and death among patients undergoing peritoneal dialysis (Haung, Hung, Yen, & Tsai, 2001) . Peritonitis is the inflammation of the peritoneum and this is the most frequent and limiting complication of peritoneal dialysis. Usually this then leads to considerable changes and the patient changes to haemodialysis therapy. Exits site infection and catheter tunnel infection can lead to an episode of peritonitis. Exit site infection can occur anytime from insertion of the catheter and can extend down the catheter to cause a tunnel infection (Boeschoten & Divino, 2006). Sometimes these infections are caused because when attaching the tubing of the dialysiate to the catheter aseptic technique is not considered and the area near the exit site is not clean. The most common organisms that cause these infections are Staphylococcus aureus and Staphylococcus epidermidis (Kannaiyan S. Rabindranath, 2007).

In January 2013 in Malta there were 97 patients who were on the treatment of peritoneal dialysis aged between 20 and 83 years. Out of these 97 patients 45% which is 44 patients were on the treatment of automated peritoneal dialysis and 55% which is 53 patients were on the treatment of continuous ambulatory peritoneal dialysis. The majority of patients on peritoneal dialysis (76%, n=74) perform their own treatment, while the remaining ( 24%, n=23 patients) are assisted by a relative or significant other. No research was traced locally on the incidence rate of peritonitis between the treatment of APD and CAPD.

The aim of doing this dissertation is about finding out which method of peritoneal dialysis produces less infections because some studies have detected lower incidence of infections in patients treated with APD , while others have found no significant difference of infection between the two methods. APD has been steadily increasing over the past decade. In the United States the overall percentage of PD patients on APD have increased from 9% in 1993 to 20 % in 2000 (Kannaiyan S. Rabindranath, 2007).Given this increasing trend towards the greater use of APD, it is important to know if there are clinical benefits of APD when compared to CAPD and whether it is associated with less infections. This is because some studies have reported that peritonitis rates are lower in CAPD compare with APD. Last year I have had a placement in the Renal Unit at Mater Dei Hospital witnessed a lot of patient doing the two types of peritoneal dialysis.Automated Versus Ambulatory Peritoneal Dialysis Essay. Since there was no local statistical date on the incidence of peritonitis between treatment of APD and CAPD encouraged me to do this study. These factors encouraged me to find studies and read about so I would then conduct this dissertation about which method of dialysis produces fewer infections.

1.3-Evidence Based Practice

Evidence based practice (EBP) is the evidence from scientific and empirical research. The knowledge is changing all the time and recent findings are the best results that one can find. EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care (Wood & Haber, 2010). The clinical expertise refers to the doctor’s cumulated experience over the years, education and skills. Finally the evidence can come out of the patient’s experience himself. (L.Sackett, 1996). EBP should be done by joining together our professional approach with the best evidence found through the systematic reviews (L.Sackett, 1996).

The process of EBP leads to practice. First one needs to identify a problem and then form a question about it. The person should search all known evidence and analyze it to identify the strongest and most relevant research studies. After a research is done one should think of how this evidence will be modified for practice and how this change will occur. Literature reviews are done to help the author identify and to understand the existing research of a specific are or topic. This allows eventually studies to be appropriately informed and critically influenced. Automated Versus Ambulatory Peritoneal Dialysis Essay. To carry and EBP one should plan the PICO question in order to identify the appropriate literature/ research studies.

1.4-The PICO Question

The PICO is a useful model to help structure an answerable question. It is used to formulate clinical question breaking it into four key elements. The four main components are population, intervention, comparison intervention and outcome.. The use of the PICO will eventually help me to phrase the key elements of the question for an effective and manageable search strategy.

The research question that was formulated was done by using the PICO method:

Population: All patients with end stage renal disease that are undergoing peritoneal dialysis

Intervention: Automated Peritoneal Dialysis. All forms of Automated Peritoneal Dialysis ( Continuous Cyclic Peritoneal Dialysis, Intermittent Peritoneal Dialysis, Nightly Intermittent Peritoneal Dialysis and Tidal Peritoneal Dialysis) were considered as eligible.

Comparison: Continuous Ambulatory Peritoneal dialysis.

Outcome: Less incidence rate of peritonitis

Research Question:

Is automated peritoneal dialysis more effective, in terms of peritonitis than continuous ambulatory peritoneal dialysis in treating end stage renal disease patients?

1.5- Conclusion

The next chapter will discuss in detail the strategy that is adopted to retrieve research together with the appraisal tools used to criticise the studies that are selected.

CHAPTER 2: THE METHOD

2.1-Introduction

This chapter will describe how the literature review for this dissertation was developed, through the research question established in the previous chapter. Hence, the next step in forming an EBP is to seek relevant evidence that will help you answer the question that was based. This can be achieved by finding information from books, journal, electronic databases and much more (Akobeng, 2005). So in this chapter, the whole method done in reviewing and identifying the studies on the subject and the search strategy will be described. Also the inclusion and exclusion criteria that was applied, the key words that were used and all the electronic databases that were used for the search. Automated Versus Ambulatory Peritoneal Dialysis Essay. The databases that were used are explained clearly in a Table 1, the key words used are shown in table 2 and the results obtained from the different databases were tabulated in Table 3. Table 4 provides information about the research studies that will be used in this dissertation. The results of the search activity and the critical appraisal methods used to assess the selected studies will also be highlighted in the this chapter.

2.2- Search Strategies, Databases, Keyword and Other Sources Used For Literature Search

A widespread search was conducted on literatures such as systematic reviews using a combination of electronic databases, search engines, reference list of some articles, medical journals in order to identify evidence which shows the least occurrence peritonitis in patient who are using Continuous ambulatory peritoneal dialysis (CAPD) and Automated peritoneal dialysis (APD) for their treatment in dialysis.

The following electronic databases were used to the find the articles and studies on the research question that has been formed, EBSCOhost, Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, HighWire Press, ELSEVIER/EMBASE, Google Scholar and the Malta Medical Journal Database. The EBSCOhost, Medline, PubMed and HighWire Press were accssessed through the website of the University Of Malta through the e-library system. A clear explanation of the electronic databases that were used can be found in the following Table 1. Automated Versus Ambulatory Peritoneal Dialysis Essay.

Table 1: Databases Applied

Type of Database

Description of databases

EBSCOhost:

Academic Search Complete/Academic Premier; Ageline; CINAHL Plus with Full Text; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; Inspec

A valuable and comprehensive scholarly, multidisciplinary full-text database.

MEDLINE