Spontaneous dislodgment of a peritoneal dialysis catheter inserted using the Seldinger technique: A case report

Abstract

BACKGROUND

Peritoneal dialysis (PD) is an important renal replacement therapy in patients with end-stage renal disease. PD catheters remain the lifeline for patients undergoing PD. The catheter technique survival rate is considered a core PD outcome domain.

CASE SUMMARY

The PD catheter spontaneously dislodged in a patient undergoing PD during regular fluid exchange without pain. Abdominal computed tomography showed a tunnel infection. A double-cuff straight Tenckhoff catheter had been inserted using the Seldinger technique. Before this incident, the patient had a history of tunnel infections. We speculate that recurrent tunnel infections and catheter insertion using the Seldinger technique may have led to catheter dislodgement.

CONCLUSION

The present case suggests that clinicians should more rigorously assess the persistence of catheter-related infections concerning the potential complications arising from catheter dislodgement associated with the Seldinger technique.

Key Words: Catheter; Dislodgment; Seldinger technique; Infection; Peritoneal dialysis, Case report

Core Tip: This study reports a unique case of spontaneous dislodgement of a peritoneal dialysis catheter, probably attributed to recurrent tunnel infections and the Seldinger insertion technique. This highlights the necessity for rigorous assessment of catheter-related infections to prevent the severe complication of catheter dislodgement. This case suggests that complications may arise from catheter placement using the Seldinger technique.

INTRODUCTION

Peritoneal dialysis (PD) is an important renal replacement therapy that offers patients with end-stage renal disease an alternative to hemodialysis and provides greater flexibility and autonomy. PD catheters remain the lifeline for patients undergoing PD. The catheter technique survival rate is considered a core domain in reports of PD outcomes, as important as the patient survival rate and cardiovascular disease[1]. Catheter displacement and obstruction are common mechanical complications. Few reports have described PD catheter extrusion with a superficial cuff due to weight loss or infection[2,3] rather than the entire catheter. We report a rare case of spontaneous dislodgement of a PD catheter during therapy.

CASE PRESENTATION

Chief complaints

A 54-year-old woman with end-stage renal disease undergoing continuous ambulatory PD for five years reported spontaneous dislodgement of the PD catheter without pain during fluid exchange (Figure 1).

Figure 1 The dislodged catheter was held by the patient.

History of present illness

A double-cuff straight Tenckhoff catheter had been placed using the Seldinger technique.

History of past illness

The patient reported a tunnel infection with a negative smear culture four months after catheter insertion. The patient was treated with amoxicillin-clavulanic acid for two weeks. However, she did not undergo scheduled follow-up tunnel ultrasonography. Thereafter, she had a grayish-white discharge, oozing intermittently from the exit site, but no other symptoms. The patient did not receive additional antibiotics. Three months prior, she experienced peritonitis caused by Actinotignum schaalii. The peritonitis resolved after two weeks of benzathine, penicillin, and amikacin treatment without tunnel infection symptoms.

Personal and family history

The patient has no significant personal or family history.

Physical examination

No skin dilatation or bleeding was observed at the exit site. No tenderness was observed in the tunnel or the abdominal area.

Laboratory examinations

Laboratory test results revealed a white blood cell count and hemoglobin level of 7.12 × 10⁹/L and 100.0 g/L, respectively. The levels of serum creatine, albumin, calcium, phosphate and intact parathyroid hormone were 1132.2 μmol/L, 32.0 g/L, 2.18 mmol/L, 2.16 mmol/L, and 311 pg/mL, respectively. Hypersensitive C-reactive protein levels were normal. The PD prescription contained a total volume of 8 L of 1.5% fluid. A peritoneal equilibration test revealed a high-average status.

Imaging examinations

Abdominal computed tomography (CT) after the catheter dislodgment revealed a tunnel infection involving the anterior sheath of the right rectus abdominis muscle (Figure 2). We retraced the patient's abdominal CT scan from one year previously and conducted a three-dimensional reconstruction. The catheter's measured length within the cavity was only 11.5 cm (the normal distance from the inner cuff to the catheter tip is 15.0 cm), indicating that the catheter had partially detached from the abdominal cavity (Figure 3).

Figure 2 Computed tomography image of the patient after the catheter falling out showed a severe tunnel infection (arrows).

Figure 3 Computed tomography image of intracavitary catheter segment length.

FINAL DIAGNOSIS

PD catheter dislodgment.

TREATMENT

Antimicrobial treatment with piperacillin sodium and tazobactam sodium was administered for two weeks.

OUTCOME AND FOLLOW-UP

PD was resumed with a new catheter on the left side of the abdomen.

DISCUSSION

To the best of our knowledge, only a few instances of complete PD catheter dislodgement have been reported. We suggest several possible reasons for the catheter spontaneously dislodging without an external force or pulling in this patient.

First, a recurrent tunnel infection was the main reason for catheter failure. As a result, the catheter lost its external cuff after the Dacron was encapsulated in the necrotic tissue and expelled from the body. Inflammation caused edema in the fibrous sheath tissue surrounding the catheter tunnel. When the tunnel infection extended to the rectus muscle, the pathway became dilated within the rectus sheath, providing space for the free movement of the catheter. Actinotignum schaalii is a rare pathogen that causes peritonitis, with only nine cases reported in the literature to date[4]. As the symptoms caused by this bacterium are mild and nonspecific, they usually present as an abscess or mass lesion fixed to the underlying tissue, often mimicking malignancies. The duration of the antibiotic therapy ranged from 4 week to 12 week. Hence, selecting appropriate antibiotics and ensuring an adequate duration of therapy are crucial for treating such chronic bacterial infections. Despite the successful resolution of peritonitis, the follow-up of the patient's tunnel infection was overlooked. Tunnel ultrasonography may be an adjunctive diagnostic tool for tunnel infection, assessing treatment response and providing suggestions for stopping therapy. Furthermore, this case may indicate the necessity of a salvage procedure before transmural progression of the infection with peritonitis. Surgical interventions for catheter-related infections should be strategically chosen based on infection severity and treatment response. The ISPD catheter-related infection recommendations indicate the removal of the PD catheter in cases where exit-site or tunnel infections progress to or occur concurrently with peritonitis caused by the same organism. If the infections do not resolve with standard antibiotic therapy, the catheter should be reinserted at a new site with antibiotic coverage. However, simultaneous removal and reinsertion should be avoided when there is significant deep cuff involvement with concurrent peritonitis. Additionally, cuff removal, shaving, and relocation of the exit site should be considered for persistent exit-site infections resistant to antibiotics for effective infection management[5].

Second, the placement of the PD catheter using the Seldinger technique may be a possible reason for catheter dislodgment. Because of the small incision, the anterior sheath of the rectus abdominis does not require sutures, and fixing the inner cuff to the peritoneum is not feasible. The intact inner cuff of this catheter demonstrates that it did not adhere to the surrounding tissues. During catheter tunnel construction and the early stages of tissue recovery, the inner cuff may completely or partially dislodge from the anterior sheath of the rectus abdominis. Interrupted sutures are required to close the anterior sheath around the catheter and ensure the position of the inner cuff in the rectus abdominis[6].

CONCLUSION

In conclusion, the spontaneous dislodgment of the PD catheter highlights the importance of thorough treatment of catheter-related infections and presents potential complications associated with catheter placement using the Seldinger technique.

ACKNOWLEDGEMENTS

The authors acknowledge the effort of the PD team in Sichuan Provincial People’s Hospital.