key: cord-0735193-9wrg86rh
authors: Graham, Jay A.; Torabi, Julia; Tepper, Jaron; Kinkhabwala, Milan; Golestaneh, Ladan; Brogan, Maureen; Rocca, Juan P.
title: Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients
date: 2020-11-25
journal: Kidney Med
DOI: 10.1016/j.xkme.2020.09.009
sha: 8fa11b0333613ffd531df4f4ab6591b519277d76
doc_id: 735193
cord_uid: 9wrg86rh

nan

To the Editor:

Novel coronavirus SARS-CoV-2 causing coronavirus disease 2019 has recently emerged as a global pandemic commonly presenting with fever, fatigue, cough and myalgias that can turn severe.(1) Critically ill patients may develop a systemic inflammatory response with multiorgan involvement, most commonly manifesting as acute respiratory distress syndrome requiring mechanical ventilation.(2) Acute kidney injury necessitating kidney replacement therapy has been reported to occur in 10% of these patients.(1) Though the actual incidence is unclear, a surge in the need for conventional hemodialysis has been met with the limited availability of dialysis machines and staff. Moreover, it is unsafe to permit staff to spend an extended amount of time at the bedside to monitor these machines. An alternative method via peritoneal dialysis (PD) can provide kidney replacement therapy in strained healthcare systems.

Video-assisted PD catheter placement has allayed some of the fears related to possible SARS-CoV-2 exposure. Borrowing from a laparoscopic technique to obtain transperitoneal access, PD catheters can be placed safely at the bedside with a single port and without establishment of pneumoperitoneum. Given that the concerns center on possible aerosolization of virus with laparoscopy, optical trocar peritoneal entry provides a necessary alternative. (3) A 5 mm bariatric optical trocar (VersaOne™ Optical Trocar LONG) is placed in the lower left quadrant. Though choice of brand is unessential, the bariatric length allows for tunneling of the catheter under direct visualization so that the catheter can be directed down into the pelvis. A 0.035" glide wire is then placed through the trocar. The trocar is J o u r n a l P r e -p r o o f then removed and the PD catheter is fed over the wire. The distal cuff is set by feel in the preperitoneal space or in-between the rectus sheath. Importantly, to accommodate to possibility of prone position, the second incision is made along the midaxillary plane for the exit site ( Figure 1) . A video of the procedure and a written transcript are provided in Movie S1 and Item S1. This retrospective study was approved by the Albert Einstein-Montefiore Medical Center Internal Review Board (2020-11371), and informed consent was obtained for all patients from patient proxies.

During April 2020, 21 video-assisted PD catheter placements were performed at our institution. Seven patients (33%) had history of chronic kidney disease prior to admission. Patients who underwent video-assisted PD catheter placement were critically ill with 20 (95%) requiring mechanical ventilation (Table 1) While open PD catheter placement also obviates the need for pneumoperitoneum, video-assisted PD catheter insertion has several advantageous. Given the often urgent need to start these patients on dialysis, this video-assisted technique minimizes the A 5 mm incision is made in left lower quadrant and an optical trocar is inserted perpendicularly into the abdomen in the left para-umbilical area. A bariatric trocar is needed to tunnel the trocar into the pelvis.

Once the trocar traverses the anterior and poster rectus sheath, the surgeon should change the plane to skive through the preperitoneal space towards the pelvis for about ~ 3 cm to create the tunnel.

The peritoneal cavity is then entered in a more upright position. Correct placement of trocar through all layers of the abdomen is confirmed under direct vision.

An 0.035 glide-wire is passed through the port and the port removed. A 62 cm, double cuffed curled tip Tenckhoff peritoneal dialysis catheter is inserted over the wire using Seldinger Technique into the pelvis. The catheter is then tunneled subcutaneously to the right paramedian/axillary area. The catheter is tested for patency with 1 liter of dialysate fluid and capped. The skin is reapproximated with 3-0 nylon and dressed appropriately.

Of note, prior to setting up for the procedure, the room is only entered once, and the door is closed quickly. Only 1 person is scrubbed to minimize utilization of PPE and possible infectious exposure. Lastly, this procedure allows for dialysis to start immediately by the introduction of the 1L of dialysate.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet

Comparison of Hospitalized Patients with Acute Respiratory Distress Syndrome Caused by COVID-19 and H1N1

Recognition of aerosol transmission of infectious agents: a commentary