Prophylactic Peritoneal Catheter Placement in Congenital Cardiac Surgery

Background

Fluid overload, a frequent problem for children after congenital heart surgery, results from pre-existing cardiac dysfunction, cardiopulmonary bypass (CPB)-related hemodilution, and intraoperative administration of fluid and blood products. Postoperative kidney dysfunction and capillary leak due to systemic inflammatory response to CPB may exacerbate this problem.

Several strategies exist to remove unwanted fluid. Traditional methods such as postoperative fluid restriction and medical diuretic therapy are, however, often insufficient to manage extravascular fluid overload, as they require maintaining enough intravascular volume for appropriate hemodynamic stability and end-organ perfusion. Another common method is placing chest tubes such as pleural or mediastinal drains to passively drain excessive fluid and thus avoid pleural and pericardial effusions. Additionally, employing a peritoneal catheter may be useful ¹ as it allows to either drain ascites passively out of the peritoneal cavity or utilizing cycles of peritoneal dialysis. Peritoneal catheters are suitable for children of all sizes. ² The aim of this article is to provide a step-by-step guide on how to implant a peritoneal catheter, avoiding pitfalls and considering contraindications.

Material and Methods

The decision to implant a peritoneal catheter is made by the surgeon based on the following considerations:

Preoperative patient condition

Surgical Technique in the Operation Room

After completion of cardiac surgery, and before chest closure, a peritoneal catheter is inserted. The peritoneum is opened at the inferior part of the sternotomy incision (Figure 1A), and a right-angled clamp is inserted into the intraperitoneal cavity to determine the appropriate site for a small stab-incision (Figure 1B). The catheter is grasped with the clamp and tunneled into the mediastinum (Figure 1C and D). Under direct visualization, the catheter is placed into the peritoneal cavity (Figure 1E). Finally, the peritoneal incision is closed with an absorbable running suture (Figure 1F). The peritoneal catheter is fixed to the skin with a stay-suture. The drain exit should be placed in the upper abdomen. This avoids pitfalls of the procedure, like bowel perforation, bowel herniation, and omental adhesions.

OPEN IN VIEWER

Figure 1.

Steps of placing a peritoneal catheter. (A) Peritoneum is opened at the inferior part of the sternotomy incision. (B) A small stab incision is made. (C) Peritoneal catheter is grasped with the right-angled clamp. (D) Peritoneal catheter is tunneled into the mediastinum. (E) Peritoneal catheter is placed into the peritoneal cavity under direct visualization. (F) Peritoneal incision is closed.

The peritoneal catheter can now drain freely into a drainage bag. No suction is applied, to prevent occlusion of the catheter with omental fibers.

Comment

Studies on the role of a peritoneal catheter for passive drainage of ascites after congenital heart surgery have focused on: removing inflammatory mediators caused by CPB, impact on fluid management, and complications due to peritoneal catheters.

Pro-inflammatory cytokines resulting from CPB may be associated with capillary leakage and therefore fluid overload. Bokesch and associates observed that serum concentrations of pro-inflammatory IL-6, IL-8, and anti-inflammatory IL-10 increased significantly after CPB, and the concentrations of IL-6 and IL-8 in the peritoneal fluid even exceeded those of the serum. ⁴ Consequently, peritoneal fluid may be a reservoir for harmful inflammatory cytokines, suggesting that removal via a peritoneal catheter may lower serum concentrations, reduce capillary leakage, and facilitate recovery. ⁴ Nevertheless, in a randomized study by Pourmoghadam and associates, there were no significant differences in serum cytokine levels between a peritoneal catheter group and a control group without peritoneal catheter. ⁵ Time to achieve a negative fluid balance was significantly shorter in patients receiving a peritoneal catheter, despite lower use of diuretics and higher administration of fluids.^5,6

A study of patients with atrioventricular septal defect (AVSD) or tetralogy of Fallot (TOF) showed that AVSD patients with peritoneal catheters achieved a negative fluid balance significantly faster than those without. ⁷ In contrast, no significant differences were observed in TOF patients. ⁷ These results suggest that the benefit of a peritoneal catheter may not be universal but dependent on patients’ underlying physiology. One patient in that study required surgical revision because of a small colonic perforation by the peritoneal catheter, which prolonged hospital stay. ⁷ In a separate study of Fontan patients, the peritoneal catheter group needed significantly less time to achieve negative fluid balance. ⁸ The Fontan patients with peritoneal catheter also required longer mechanical ventilation. ⁸ Authors suggested that Fontan patients may not tolerate rapid achievement of negative fluid balance in the immediate postoperative period. In contrast, a randomized-control trial in patients after the Norwood procedure suggested that the peritoneal catheter group did not achieve a negative fluid balance more rapidly nor did they benefit in any other postoperative variable. ⁹ Besides, more severe adverse events (postoperative CPR, and the need for extracorporeal life support) occurred in the peritoneal catheter group. However, as these severe adverse events were not directly linked to the peritoneal catheter, it is difficult to establish whether the peritoneal catheter was a risk factor. ⁹ Minor complications observed in the peritoneal catheter group were hyperglycemia, hypokalemia, catheter leakage, and retention of peritoneal fluid. ⁹

Barhight et al ¹ reported an in-depth review of the usage of a peritoneal catheter for fluid management with peritoneal dialysis after pediatric cardiac surgery. Most studies reviewed showed no severe complications related to peritoneal catheter placement; however, contraindications need to be considered, and bowel perforation, herniation or omental adhesion are potential pitfalls. By following some simple steps, like a drain exit in the upper abdomen or using ultrasound in secondary placement in the ICU, the risk of complications may be reduced.

In summary, the implantation of a peritoneal catheter is suitable for children of all sizes, even for neonates and low birth weight babies. Besides, the technique can easily be performed not only in high-income countries but also in low-resource settings, even with simplified catheters. The routine use of peritoneal catheters may improve postoperative fluid balance in selected patient populations recovering from surgery for congenital heart disease, but their use must be balanced against the rare but potentially serious complications.