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Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Open AccessPublished:November 24, 2020DOI:https://doi.org/10.1016/j.xkme.2020.09.009
      To the Editor:
      Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) has recently emerged as a global pandemic commonly presenting with fever, fatigue, cough, and myalgias that can turn severe.
      • Zhou F.
      • Yu T.
      • Du R.
      • et al.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
      Critically ill patients may develop a systemic inflammatory response with multiorgan involvement, most commonly manifesting as acute respiratory distress syndrome requiring mechanical ventilation.
      • Tang X.
      • Du R.
      • Wang R.
      • et al.
      Comparison of hospitalized patients with acute respiratory distress syndrome caused by COVID-19 and H1N1.
      Acute kidney injury necessitating kidney replacement therapy has been reported to occur in 10% of these patients.
      • Zhou F.
      • Yu T.
      • Du R.
      • et al.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
      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 through peritoneal dialysis (PD) can provide kidney replacement therapy in strained health care 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.
      • Tellier R.
      • Li Y.
      • Cowling B.J.
      • Tang J.W.
      Recognition of aerosol transmission of infectious agents: a commentary.
      A 5-mm bariatric optical trocar (VersaOne Optical Trocar LONG; Covidien) 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 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 the possibility of prone position, the second incision is made along the midaxillary plane for the exit site (Fig 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.
      Figure thumbnail gr1
      Figure 1Trocar insertion (green arrow) and catheter exit site (red arrow) of peritoneal dialysis catheter.
      During April 2020, a total of 21 video-assisted PD catheter placements were performed at our institution. Seven patients (33%) had a history of chronic kidney disease before admission. Patients who underwent video-assisted PD catheter placement were critically ill, with 20 (95%) requiring mechanical ventilation (Table 1). Only 2 patients (10%) experienced catheter leak. Follow-up as of May 25, 2020, resulted in 6 patients (29%) with complete recovery of kidney function. Two patients continued to need intermittent hemodialysis, and none remained on PD. Thirteen (62%) patients died during hospitalization.
      Table 1Descriptive Statistics for Surgically Placed PD Catheters
      CharacteristicValue
      No. of patients with PD catheters placed21
      Male sex12/21 (57%)
      Chronic kidney disease before admission7/21 (33%)
      Mechanical ventilation status
       Intubated20/21 (95%)
      Placed in prone position14/21 (67%)
      Catheter leak2/21 (10%)
       Follow-up as of May 25, 2020
       Kidney recovery (no longer on KRT)6/21 (29%)
       On iHD/CKRT (no longer on PD)2/21 (10%)
       Died during hospitalization13/21 (62%)
      Note: Subgroups are not mutually exclusive.
      Abbreviations: CKRT, continuous kidney replacement therapy; iHD, intermittent hemodialysis; KRT, kidney replacement therapy; PD, peritoneal dialysis.
      Although open PD catheter placement also obviates the need for pneumoperitoneum, video-assisted PD catheter insertion has several advantages. Given the often urgent need to start these patients on dialysis, this video-assisted technique minimizes the possibility of leaking by offering only minimal fascia disruption and giving the surgeon the ability to tunnel (skive) the catheter. Last, in the era of increased scrutiny regarding resource use, this technique solely requires a laparoscopic tower that can be moved to the patient’s bedside and instruments as detailed. To date, we have only used this technique on intubated patients because the ability to adequately locally anesthetize awake patients is difficult.

      Article Information

      Authors’ Full Names and Academic Degrees

      Jay A. Graham, MD, MBA, Julia Torabi, MD, Jaron Tepper, MD, Milan Kinkhabwala, MD, Ladan Golestaneh, MD, Maureen Brogan MD, and Juan P. Rocca, MD, MPH.

      Authors’ Contributions

      Study design/conception: JAG, MK, MB, JPR; data acquisition, analysis, and interpretation: JTorabi, JTepper, MB, LG. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.

      Support

      None.

      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Peer Review

      Received June 24, 2020. Evaluated by 1 external peer reviewer, with direct editorial input from the Editor-in-Chief. Accepted in revised form September 7, 2020.

      Supplementary Material

      References

        • Zhou F.
        • Yu T.
        • Du R.
        • et al.
        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
        Lancet. 2020; 395: 1054-1062
        • Tang X.
        • Du R.
        • Wang R.
        • et al.
        Comparison of hospitalized patients with acute respiratory distress syndrome caused by COVID-19 and H1N1.
        Chest. 2020; 158: 195-205
        • Tellier R.
        • Li Y.
        • Cowling B.J.
        • Tang J.W.
        Recognition of aerosol transmission of infectious agents: a commentary.
        BMC Infect Dis. 2019; 19: 101