Long-term pneumoperitoneum in continuous ambulatory peritoneal dialysis (CAPD) caused by handling fault of Stay.Safe(R) system associated to bicaVera solution

Abstract

We found chronic pneumoperitoneum in two continuous ambulatory peritoneal dialysis patients from two different hospitals. Both patients used the Stay.Safe® system and bicaVera solution, whose extension tubing is not primed with fluid but air-filled, unlike that of the conventional solution bags. This fact, together with a handling fault common to both patients, resulted in the inflow of the air in the tubing of bicaVera bags into the peritoneal cavity during every exchange. We warn of this complication, which must be specifically pointed out during training, and we recommend providing the system with a mechanic device to prevent this handling fault.

Assisted peritoneal dialysis in Europe: a strategy to increase and maintain home dialysis

“…For example, with the use of the StaySafe™ connection device, pneumoperitoneum was observed in two patients. In both cases, the cause was not a malfunction of the device itself, but rather improper use by the patient [ 25 ]. This illustrates that these devices are only a support tool, and that proper training and adequate cognitive functioning of the patient or assistant remain extremely important.…”