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Peritonitis Associated with Massive Pneumoperitoneum from Failure to Flush

did not require admission. After each episode, the training nurses reviewed his technique ofperforming exchanges, which was found to be correct. Because of the frequent peritonitis episodes, the patient was strongly encouraged to transfer permanently to hemodialysis and finally agreed. Because of the poor condition of his skin, a decision was made to avoid temporary hemodialysis access and, ifpossible, a graft. After multiple attempts, a primary arteriovenous (A V) fistula was successfully placed. In the meantime, the patient continued on CAPD. While waiting for the AV fistula to mature, the patient was admitted with severe abdominal pain, vomiting, fever to 38.3°C, and cloudy effluent. He reported diarrhea 2 -3 days prior to presentation. He appeared acutely ill. His blood pressure was 160/90. His scaling and flaking skin had a number of areas of excoriations from scratching. His abdomen was soft with rebound tenderness. Bowel sounds were normal. He had two midline umbilical hernias. The peritoneal catheter site was normal. His left arm AV fistula was patent and well developed. The patient's white blood cell count was 15 400/&mu;L with 48% bands, his hemoglobin 8.8 g/dL, BUN 46 mg/dL, and creatinine 8.1 mg/dL with normal electrolytes. The cloudy effluent had 18000 white cells/&mu;L with 87% polymorphonuclear leukocytes and 5% bands. He was given intraperitoneal gentamicin and cefazolin. On the second admission day Staph. aureus was identified in the effluent culture. The nurse performing the exchange noted multiple air bubbles in the drained effluent (Figure 1). Because of this an abdominal film was obtained (Figure 2). Because of the massive pneumoperitoneum, a decision was made to proceed with laparotomy. However, the dialysis nurse questioned the patient regarding his technique and discovered that he had eliminated the flush completely several months before admission. Therefore, surgery was canceled. A gastrografin study showed no perforation in the stomach, duodenum, or proximal jejunum. The patient's peritoneal catheter was removed and he was transferred permanently to hemodialysis; recovery Peritonitis Associated with Massive Pneumoperitoneum from Failure to Flush