Delayed bowel perforation after instilling over warmed peritoneal dialysate

Area of Science:

• Nephrology
• Gastroenterology
• Medical Safety

Background:

• Peritoneal dialysis (PD) is a common home-based treatment for end-stage renal disease (ESRD).
• While generally safe, complications can arise from improper procedure execution.
• Direct thermal organ damage during PD is considered rare.

Observation:

• A case of a peritoneal dialysis patient experiencing severe abdominal pain and feculent effluent is presented.
• Symptoms emerged three weeks after the patient instilled heated dialysis solution.
• The patient's condition rapidly deteriorated, leading to septic shock despite emergency surgical intervention.

Findings:

• Autopsy and biopsy revealed intestinal necrosis and perforation.
• The findings indicate delayed bowel perforation as a direct consequence of using excessively hot dialysis fluid.
• This rare complication underscores the potential for severe thermal injury.

Implications:

• This case highlights the critical importance of standardized protocols and meticulous technique in home peritoneal dialysis.
• Healthcare providers must emphasize the risks associated with improper fluid temperature management.
• Ensuring patient education and adherence to safety guidelines is paramount to prevent such devastating outcomes.