**6. The peritoneal dialysis catheter placement in patients with chronic heart failure: anesthesiology and surgical perspective**

Adequately positioned peritoneal dialysis (PD) catheter is necessary for successful long-term PUF [44]. PD catheter insertion can be performed using different surgical methods, such as open approach, laparoscopy, and peritoneoscopy, or percutaneously [45, 46]. For all of these procedures, some anesthesia is required. The anesthesia techniques used for PD catheter placement are general (most utilized), spinal, regional, and local anesthesia [47].

#### **6.1 Anesthetic considerations, including transversus abdominis plane block**

PD catheter placement using an open approach usually requires general, neuraxial, and rarely local anesthesia. Local anesthesia is preferable for patients with significant comorbidities. However, the local infiltration of an anesthetic can produce edema and bleed at the incision site, which disturbs the surgical field. In most patients, especially obese ones, local anesthetic infiltration must be repeated, which can be connected with the patient's fear and anxiety. General anesthesia is usually required for laparoscopic PD catheter placement [46].

The CHF patients represent a group with an increased risk for anesthetic procedures, especially general anesthesia. For this reason, less invasive methods and

#### **Figure 8.**

*Ultrasound image (linear ultrasound probe)visualised all three muscles of the abdominal wall:external oblique (A), Internal oblique (B). and trasversus abdonimis muscle(C). The space between the ineer oblique and transversus advominis muscles (transeversus abdominis plane) is a tareget area for applying a local anaesthetic. (Author's archive).*

#### **Figure 9.**

*Ultrasound image (linear ultrasound probe) showing a plane needle and needle tip positioned in the transversus abdominis plane just before injecting the loal anaesthetic. All three muscles of the abdominal wall are visualised: external oblique (A), interanl oblique (B) and transversus abdomimis muscle (C). (Author's archive).*

techniques are being used. One of these is the transversus abdominis plane (TAP) block. It is a newer regional anesthesia technique, more precisely, a type of peripheral nerve block. The target area is a fascial layer between the transversus abdominis and internal oblique muscles. In this plane are situated thoracolumbar nerves (T7-L1), which supply the anterolateral abdominal wall (**Figures 8** and **9**). Using a TAP block, analgesia from the skin to the parietal peritoneum is achieved, and recently, a TAP block was used for PD catheter surgery [48, 49].

We recommended a combined ultrasound-guided subcostal and posterior approach using a linear, high-frequency probe (6–15 MHz) as we described previously [48, 49]. Briefly, when the TAP is identified, the needle is advanced in the targeted area, and local anesthetic is injected. In most patients, 30 mL of 0.25% levobupivacaine hydrochloride or 30 mL of 0.75% ropivacaine is used. Standard equipment used for patient monitoring includes an oxygen saturation probe, a non-invasive blood pressure monitor, and an electrocardiogram. Cold and pain sensation tests (pinprick) are used before the operation. About 30 minutes after the TAP block, a skin incision is possible. Just before the skin incision, all patients received additional drugs, such as sufentanil (10 mcg) and/or propofol (0.1–0.2 mg/kg), for a better analgesic/sedation effect [48, 49].

### **6.2 Preoperative management**

As for any surgical procedure, patients must sign informed consent before the operation. Preoperatively, thromboprophylaxis (low molecular weight heparin) and antibiotics (cefazolin) were administered in all patients. The patient's position depends on the surgical approach, but a supine position is mainly used. The skin is disinfected with an antiseptic solution.

*Advanced Treatment of Refractory Congestive Heart Failure by Peritoneal Ultrafiltration… DOI: http://dx.doi.org/10.5772/intechopen.114022*

#### **6.3 Open approach**

The patient is in the supine position. In our institution, in concordance with the patient's will, we put the PD catheter on the side of the patient's dominant hand (most often the right side). We use a vertical paramedian, infraumbilical skin incision 3–4 cm long for all patients. The incision includes skin, subcutaneous tissue, anterior and posterior rectus sheath, preperitoneal tissue, and parietal peritoneum. The PD catheter (Tenckhoff type, two cuffs) is inserted in the peritoneal cavity. Both cuffs must be outside the peritoneum. The deep cuff is usually tied with the suture, which closes the peritoneum. After completing all the layers, the PD catheter is tunneled (inverse U shape), with an exit site different from the incision site. The proximal cuff is situated in the subcutaneous tissue, and the distal cuff is preperitoneally. The skin suture for the PD catheter's fixation is unnecessary because the catheter is fixed with sutures, including a deep cuff and peritoneum [48].

#### **6.4 Laparoscopic approach**

The patient is supine, with the surgeon on the right side (if the right-sided implantation is planned) and the assistant on the left side. The scrub nurse is on the side of the surgeon. The monitor is usually opposite the surgeon or near the legs. A periumbilical incision is used to create a pneumoperitoneum. In most cases, three trocars are used. One is in the camera's periumbilical position (10 mm), and two are in both lower abdominal quadrants. Through the left lower abdominal quadrant, a 5-mm trocar is placed usually for grasper, and on the right lower quadrant, the specially designed trocar (the so-called "Čala's trocar" according to his inventor). Čala's trocar is a metal trocar, with the possibility to be dismantled and through its internity, the PD catheter could be inserted (**Figure 10**) [45]. After trocar placement, the patient is placed in the Trendelenburg position, and the whole abdomen is explored. Via the Čala's trocar, a PD catheter is inserted in the peritoneal cavity using grasper for directed catheter deep in the pelvis. During catheter insertion, the deep cuff must be placed in a preperitoneal position, not in the peritoneal cavity. The Čala's trocar is dismantled and removed, and the catheter must be clamped to prevent exufflation of the peritoneal cavity. A subcutaneous tunnel is made with the finger, and a skin exit site is created. PD catheter is fixed to the skin in its exit site. After PD catheter fixation, the exufflation of CO2 is performed, the trocars are removed, and their exit sites are closed.

Another trocar is placed when the deep cuff goes inside outside the peritoneal cavity. A suture is put laparoscopically to decrease the hole in the peritoneum and prevent migration of the deep cuff, which stays in an extraperitoneal position. If the patient has intrabdominal adhesions, adhesiolysis must first be performed using ultrasound or bipolar scissors.

#### **6.5 Peritoneoscopic approach**

This approach is partly similar to laparoscopic and is made under local anesthesia and in the supine position. First, the pneumoperitoneum is created. The guide is then inserted through the small skin incision through the abdominal wall in the peritoneal cavity with the optical control using a small diameter endoscope (peritoneoscope). After verification of proper position, the channel is dilated, and the catheter is inserted into the abdominal cavity.

#### **Figure 10.**

*Cala's trocar is a metal trocar (A), with the possibility to be dismanted (B) and through its internity, the PD catheter could be inserted (C). (Author's archive).*

#### **6.6 Selecting the best method for PD catheter insertion**

CHF patients have substantially more comorbid conditions than the general population, leading to higher mortality in this group of patients. General anesthesia impacts the pulmonary and cardiovascular systems contrary to peripheral nerve block and local anesthesia, whose influence is negligible. For this reason, peripheral nerve block and local anesthesia can be recommended for placing PD catheters in patients with CHF, especially those with significant comorbidities. The guideline for choosing a PD catheter insertion approach is shown in **Table 1** [50].

Compared to general anesthesia, a TAP block has increased anesthetic induction time and requires additional equipment (ultrasound), performance time, and technical skill. A TAP block provides a longer duration and better quality of analgesia *Advanced Treatment of Refractory Congestive Heart Failure by Peritoneal Ultrafiltration… DOI: http://dx.doi.org/10.5772/intechopen.114022*


#### **Table 1.**

*Guideline for selecting a PD catheter insertion approach.*

compared to local anesthesia [51]. In our institution, the TAP block is used as a primary anesthetic technique for PD catheter surgery for all patients, but especially for elderly patients and patients with significant comorbidities. Complications from a TAP block are rare and include nerve injury, injection site bruising, infection, allergic reaction, and liver laceration [52]. Contraindications for TAP block include infection at the injection site, patient refusal or inability to cooperate, allergy to local anesthetics, and coagulopathy [53]. An elevated BMI index was not a barrier to a successful TAP block [48, 49].

#### **6.7 Outcomes of different PD catheter placement approaches**

The two most common methods for PD catheter placement are open and laparoscopic approach [54]. Catheter malfunction is lower in the laparoscopic approach (13%) than in open surgery (35%). The one-year catheter survival rate was higher in the laparoscopic group compared to the open surgery group, but in the other study, this difference was not found [51, 55]. Dialysate leakage, exit-site infection, and peritonitis incidence between the laparoscopic and open surgery groups were similar [56].

The successful implantation of a PD catheter using a TAP block as a primary anesthetic method is from 82.2 to 94.2% in ESRD patients [48, 49, 57–60].

Such data is not available yet for CHF patients. Still, the use of TAP block as the primary anesthetic technique for PD catheter insertion should be considered in this patient group (authors' opinion).
