What are the guidelines for adding sodium bicarbonate to PD solution for patients experiencing dwell pain. What are other alternatives measures for addressing dwell pain?

Questions About PD

Kim M, Nurse from Illinois asked
What are the guidelines for adding sodium bicarbonate to PD solution for patients experiencing dwell pain. What are other alternatives measures for addressing dwell pain?

1 answer

Nurse Canada with members of the ISPD Nursing Liaison Committee May 12, 2020

We thank you for your question. You have given us limited information, but we will try to answer as well as possible. As a priority, you should be certain that the patient with “dwell pain” does not have peritonitis, or other causes for abdominal pain such as appendicitis or cholecystitis. Then, usually, to problem solve this dwell pain, it is helpful to check with the patient if it is “fill” pain or “drain” pain. Since there is an increased risk of contamination and infection with addition of sodium bicarbonate IP to each PD bag, we are not certain we would recommend this as a first step. An informal survey of members of the ISPD Nursing Liaison Committee found that none of us had used IP sodium bicarbonate for many years.

If the patient describes pain on inflow, or infusion pain, then check that the patient is draining well with each drain, otherwise the pain main may be due to increased volume. Also, check that the patient is having regular bowel movements, that is not constipated. Aggressive use of laxatives may help reposition the tip of the catheter which may be positioned against the sensitive peritoneal membrane. Sometimes the presence of gas in the intestine can cause pain too. Changing the position of the patient during fill may help, also changing position when the patient has a full dwell might help to reposition the catheter. As well, check that the PD solution being used is warmed – to body temperature. Slowing the rate of PD solution inflow with CAPD by lowering the height of the PD bag may help. If you have access to the new neutral pH PD solutions, use of these may decrease inflow pain because they are less acidic than the standard PD solutions. Finally, if the above non-invasive strategies are unsuccessful, and the PD catheter is found to be malpositioned on an abdominal Xray, it may be necessary to try for catheter manipulation (1).

On the other hand, if the patient describes more pain on drain, then again, aggressive use of laxatives may reposition the tip of the PD catheter, so that pain is not felt as the abdomen becomes empty. Finally, the strategy often used for drain pain is to start the patient with tidal PD, so that the abdomen is not completely emptied with each drain (2). While tidal PD is a quite common practice, there is limited research data on this practice or any of the above strategies to alleviate either drain pain or infusion pain for our patients on PD.

1. Crabtree JH, Piraino B, Gellens M, Guest S, Firanek CA. Mancini A. Access Care and Complications Management Update 2017 – Care of the Adult Patient on Peritoneal Dialysis. Available at: https://qxmd.com/wp-content/uploads/2017/10/2017-Access-Guide-Care-and-Complications-Guide_Full-version_FINAL.pdf

2. Blake PG, Sloand JA, McMurray S, Jain AK, Matthews S. A multicenter survey of why and how tidal peritoneal dialysis (TPD) is being used. Peritoneal Dialysis International. 2014 Jun 1;34(4):458-60. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079494/pdf/pdi_34_4_021.pdf

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