What is the dose of sodium bicarbonate and lidocaine is added to the dialysis solution to manage infusion pain?

Questions About PD

Mary Rose B., Doctor/MD from Philippines asked
What is the dose of sodium bicarbonate and lidocaine is added to the dialysis solution to manage infusion pain?

1 answer

Nurse Canada with members of the ISPD Nurse Committee March 9, 2022

We thank you for your question. We have listed information for you from the “UHN (University Health Network, Toronto, Canada) Division of Nephrology House Staff/NP Guidebook” for a local practice (1):
Sodium Bicarbonate (page 123)
For abdominal pain or cramps felt to be related to pH of dialysate
*Note: Bicarb should be added immediately before infused
CAPD Dose: NaHCO3 8.4% (1 mEq/mL) add 5 mL per L of dialysate
Xylocaine without Epinephrine (page 124)
Indicated for abdominal cramps or pain only after investigations support that the pain is related to dialysate solution (i.e. avoid risk of masking pain related to other causes). Not indicated if source of pain is unknown.
CAPD Dose: add 1.25 – 5.0 mL/L of 1% or 2% Xylocaine.
We would like to add that we answered a similar question posted to the ISPD website May, 2020. At that time, an informal survey of members of the ISPD Nurse Committee from different countries found that none of us had used IP sodium bicarbonate for infusion pain for many years, if at all. Subsequently, our experience has not changed.  Since there is an increased risk of contamination and infection with addition of sodium bicarbonate and/or lidocaine IP to each PD bag, we are not certain we would recommend this as a first step. As mentioned above in the UHN Guidebook, we would suggest that you review with your home PD nurses to be certain that the patient with “infusion pain” does not have peritonitis, or other causes for abdominal pain such as appendicitis or cholecystitis. Then, usually, to problem solve, it is necessary to check with the patient whether the pain is actually “fill” pain or “drain” pain.
If the patient describes pain on inflow, or infusion pain, then check that the patient is draining well with each drain, otherwise the pain may be due to increased volume. Also, check that the patient is having regular bowel movements, that is the patient 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 (2).
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 (3). 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.Gozdzik, A. editor. UHN Division of Nephrology House Staff/NP Guidebook. January 2022. Toronto, ON. Available at: https://ukidney.com/nephrology-publications/nephrology-manuals/university-health-network-nephrology-manual
2.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
3.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


Please login to submit an answer