Infusion Pain

Infusion pain is a frequent problem in peritoneal dialysis (PD), and can markedly vary in intensity and risk.  Among the many etiologies are peritonitis and other inflammatory processes of the peritoneum, accidental infusion of air, and acidic pH of the dialysate, and expired dialysate with high concentrations of glucose degradation products or GDPs, extreme temperatures of dialysis solution, hypertonicity of the solution, rapid infusion rates and high pCO2 levels in the peritoneal dialysis fluid.  Infusion pain also results from stretching of the intraperitoneal structures as in the case of compartmentalization due to adhesions.

Diagnosis and Management

The diagnosis usually relies on physical findings and a history consistent with the above etiologies. Peritonitis should also be excluded or treated. Adhesions and compartmentalization are best confirmed through air contrast cannulography or a CT scan of the abdomen. In general, treatment of infusion pain is dictated by the specific cause. If pain is caused jetting of dialysate against the peritoneum, reducing the infusion rate may alleviate the pain. Constipation is another possible cause that can lead to infusion pain. In such cases, treatment of constipation using laxatives or other appropriate treatment should be the first line treatment option. Acidic pH of the solution can also lead to infusion pain, and adding bicarbonate to the dialysate before the infusion may be possible treatment option(1,2). In a report by Bunchman et al., the authors reported relief of infusion pain in two continuous ambulatory peritoneal dialysis (CAPD) patients when sodium bicarbonate was added to their dialysate bags(2). However, such practice may increase the risk of contamination and peritonitis(1). Among the two reported patients, one patient developed peritonitis 6 weeks after receiving bicarbonate therapy(2). Studies also have suggested that using bicarbonate or bicarbonate/lactate peritoneal dialysis solutions may relieve infusion pain(3–5). In a prospective, cross-over, randomized controlled trial by Mactier et al., patients experienced significant reduction in infusion pain when they received either bicarbonate (38 mM) or bicarbonate/lactate (25mM/15mM) dialysate compared to conventional lactate solution (40 mM)(3). Additionally, compared to bicarbonate solution, bicarbonate/lactate showed a greater reduction in adjusted infusion pain score (p= 0.048)(3). Similar results were reported in a long-term study by Tranaeues(4). In this randomized prospective study, controlled, open-label study, the author states that 41% of patients who were treated with bicarbonate/lactated dialysate solution (25 mmol/15 mmol) reported reduction in pain and infusion discomfort while patients treated with conventional lactate solution (40 mmol) did not any reduction in such discomfort. Finally, Fusshoeller et al., also reported significant reduction of infusion pain p<0.05) in patients treated with bicarbonate/lactate solution compared to conventional lactate solution(5).

References

  1. Guest S. Catheter Dysfunction. In: 2Handbook of Peritoneal Dialysis. Lexington, KY; 2010:76.
  2. Bunchman TE, Ballal SH. Treatment of inflow pain by pH adjustment of dialysate in peritoneal dialysis. Perit Dial Int. 1991;11(2):179-180. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1649645.
  3. Mactier RA, Sprosen TS, Gokal R, Williams PF, Lindbergh M, Naik RB, Wrege U, Gröntoft KC, Larsson R, Berglund J, et al. Bicarbonate and bicarbonate/lactate peritoneal dialysis solutions for the treatment of infusion pain. Kidney Int. 1998;53(4):1061-1067. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551418.
  4. Tranaeus A. A long-term study of a bicarbonate/lactate-based peritoneal dialysis solution–clinical benefits. The Bicarbonate/Lactate Study Group. Perit Dial Int. 2000;20(5):516-523. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11117242.
  5. Fusshoeller A, Plail M, Grabensee B, Plum J. Biocompatibility pattern of a bicarbonate/lactate-buffered peritoneal dialysis fluid in APD: a prospective, randomized study. Nephrol Dial Transplant. 2004;19(8):2101-2106. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15213322.

P/N 102499-01 Rev. A 06/2016