UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
MEDICAL CENTER

PROCEDURE

PURPOSE: To provide guidelines for the use of thrombolytics in the management of alterations in PD catheter patency and recurrent episodes of bacterial peritonitis.

SUPPORTIVE DATA: Catheter obstruction due to fibrin deposits on the catheter can lead to poor outflow of peritoneal fluid. Sequestration of bacteria within the fibrin clots can cause peritonitis to be resistant to therapy and contribute to recurrent peritonitis. Streptokinase and Urokinase have been shown to be useful in the treatment of catheter obstruction and recurrent peritonitis.

EQUIPMENT:

1. Either 250,000u Urokinase or Streptokinase
2. 20cc syringe
3. 20 guage, 1-inch needle
4. 10cc normal saline, or 50cc-100cc bag NS, depending on option used
5. IV tubing
6. Alcohol pads
7. lcc allergy syringe for Streptokinase test
8. Two masks
9. P.D. minicap
10. Supplies for CAPD exchange appropriate to patient’s system

1. General Guidelines

Attempts should be made to determine the etiology of catheter malfunction based on the protocol for alterations in catheter patency. If no etiology is found for catheter malfunction or peritonitis recurs despite adequate treatment, then thrombolytics can be used.

 

2. Administration of Thrombolytics:

1. Urokinase (Option 1)

1. 250,000 units of urokinase diluted in 6 ml normal saline is infused through the catheter adapted into the catheter.
2. The catheter is clamped and urokinase left in overnight, after which an exchange is attempted.
3. If flow remains poor or no flow post infusion, the catheter is clamped and the procedure repeated.
4. Once flow is achieved, the patient can resume routine dialysis.
5. If poor flow or no flow persists, notify physician.

2. Urokinase (Option 2)

1. 250,000 units of urokinase is diluted in 50 ml bag of normal saline and infused into peritoneal catheter by drip method over one hour.
2. The catheter is clamped for two hours after which flow is attempted.
3. If flow remains poor or no flow post infusion, procedure can be repeated once.
4. Once flow is achieved, the patient can resume routine dialysis.
5. If poor flow or no flow persists, notify physician.

3. Streptokinase

1. An allergy test is done by making a 100 IU/ml solution. The skin is scratched with a 25-gauge needle and a drop of solution is placed over the scratch. Observe for 15 minutes and if no wheal, then 0.l ml of solution is injected intradermally. If no wheal, anaphylaxis is unlikely.
2. 250,000 units of streptokinase is reconstituted with 100 ml normal saline and infused into the PD catheter over 30 minutes and the catheter is clamped for two hours.
3. If catheter flow remains poor, Step 2 is repeated except the catheter is clamped for 24 hours.
4. Mark front of chart date of streptokinase administration.
5. If poor flow or no flow persists, notify physician.

4. Treatment of Recurrent Peritonitis

1. Follow the procedure as outlined above for the administration of streptokinase and urokinase.
2. Continue the protocol for the management of peritonitis.

REFERENCES:
Norris et al. The Use of Intracatheter Instillation of Streptokinase in the Treatment of Recurrent Bacterial Peritonitis        in Continuous Ambulatory Peritoneal Dialysis. American Journal of Kidney Diseases 1987, 10:62-65.

Pickering, S.J. Urokinase for Recurrent CAPD Peritonitis. Lancet 1987, 1:1258-59.

Strippoli et al. A Hemostasis Study in CAPD Patients During Fibrinolytic Intraperitoneal Therapy with Urokinase.        Advances in Peritoneal Dialysis 1989, 5:97-99.

Wiegman et al. Effective Use of Streptokinase for Peritoneal Catheter Failure. American Journal of Kidney Diseases  

      1985, 6:119-123.

Scalamogna et al. Intraperitoneal Infusion of Streptokinase in the Treatment of a Total Peritoneal Catheter

      Obstruction. 1986, 6:41.

RESOURCE PERSON: Andrea Easom, RN, HNM