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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.
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.
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.
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
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.
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.
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.
The authors declare that they have no relevant financial interests.
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.