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Last updated: Lesson of the Month - October 2017…
on 17 Oct 2017

June 2012

Mansoor Ali

Case Presentation

History

An 80 year old man, who was being seen in the Low Clearance Clinic (LCC) at frequent intervals, had been complaining of shortness of breath for the preceding few months. Concerned about his decreasing exercise tolerance, and in the knowledge that his kidney function had been steadily declining for the last few years, he rang the clinic and asked for his appointment to be brought forward. He was seen the next day in the LCC. His symptoms were thought to be secondary to fluid overload and a decision was made to commence dialysis. There were no slots for dialysis on the day he attended his clinic appointment, so an appointment was made for early the following week. Due to unavailability of slots on the dialysis unit, the patient was advised to call the unit, or attend the Emergency Department if his symptoms deteriorated

The patient continued to experience some shortness of breath, and over the weekend it slowly deteriorated. Alarmingly he also started to experience brief episodes of loss of consciousness with some chest discomfort. His wife and family were concerned by these new symptoms and insisted that he attend the Emergency Department as instructed - the patient felt he could wait until the next week, but his family took him to hospital anyway

On arrival in ED, the patient was first reviewed by an ED SHO, who noted the past medical history of CKD stage 5, and the recent developments and plans for dialysis in the near future. The patient explained that the renal team had explained at his last appointment that they felt his kidneys could no longer make enough urine and fluid was building up on his lungs, which was why he was short of breath. The ED SHO thought this was a more than plausible explanation for the patients symptoms, and completed a brief clerking. On examination he could not hear gross pulmonary oedma, and heard normal heart sounds. He could not make out the JVP. He sent off the following investigations:

  1. Blood tests including :FBC, U&E, LFT, CRP
  2. CXR
  3. ECG

Initial observations were

BP:  134/73
Pulse :  48
Sats: 92% on room air
Temp:  35.4˚C
Resp rate: 16
 

The SHO reviewed the CXR and was surprised to find the lung fields reasonably clear. He also had a look at the ECG, but could not see anything obvious straight away. He decided to wait for the results of the blood tests before ringing the oncall renal registrar. 2 hours later blood results became available - the ED SHO was particularly interested in the U&E's:

Na - 137,  K - 5.4,  Urea - 17.9,  Creatinine - 389,  (Haemoglobin - 9.8)

His renal function was largely unchanged from the clinic appointment the week before, and this really confused the ED SHO, who started to wonder what was going on. However, the patient was approaching 4 hours in the department and the ED coordinator was bcoming irritated with the SHO for not having referred the patient on already. The co-ordinator asked an ED registrar to move the process on a bit quicker and avoid a 4h breach

The ED registrar briefly reviewed the case and rang the renal registrar oncall informing him of the patient's presence. He relayed the history that he read from th SHO's clerking, with the working diagnosis of fluid overload secondary to worsening renal failure. He added that “the CXR is actually pretty clear, but ECG looks funny. Anyway, I am sure that this is his renal disease. He is fluid overloaded and needs dialysis”. The renal registrar was a little sceptical about the diagnosis, but arrived promptly in ED to review the patient. By the time he arrived in the department, the patient had been transferred to the resuscitation area. He was clammy and sweaty, and was bradycardiac at 40 beats/min with evidence of a few bibasal crackles. BP 90/60. The renal registrar reviewed the case again and all the investigations

The ECG is shown below

  

The renal registrar immediately spotted that there was no association between the p-waves and the QRS complexes, and that the patient was - in fact - in complete heart block

Management

The diagnosis was complete heart block and advanced CKD. The patient was stabilised in the department, and after discussion with cardiologists at a nearby regional centre, he was transferred for definitive management. He had a permanent pacemaker device inserted. It was also felt appropriate to commence dialysis whilst an inpatient under cardiology. The patient was discharged after a week with much improvement in his symptoms. He is now being followed up in the dialysis clinic

Discussion

Shortness of breath and dizzy spells are nonspecific symptoms and can be caused by numerous disease processes in patients with CKD/ESRF. Common causes may include:

  1. Fluid overload/Pulmonary oedema/Pleural effusion
  2. Metabolic acidosis
  3. Pneumonia
  4. Line related sepsis
  5. Ischaemic Heart Disease/Acute Coronary Syndrome
  6. Valvular problems
  7. Arrhythmias
  8. Pulmonary embolism
  9. Asthma/COPD exacerbation
  10. Pericardial effusion with intradialytic tamponade

Lessons

In this case, the SHO failed to take a full history, and did not carry out a careful enough examination to make the diagnosis. He had made his decision as to the cause of the patients problems, before he had gathered the information to support the diagnosis

It is important to repeat the history and examination of a previous colleague, no matter how senior, and the ED registrar failed to do this - he seemed pre-occupied by the pressure of a possible 4h breach. He therefore did not give the patient he was treating, the due care and attention he required. Remember, your duty of care is not to the hospital managers, or coordinators, but to the patient you are treating. And an acutely unwell patient should not be moved until they are stable to move - do not compromise patient care, just to meet 4 hour breach targets

It is also important to remember that not every patient with CKD/ESRF and shortness of breath has fluid overload (though many do). Basic investigations including an ECG are vital, and if someone had taken a proper look at this patients ECG the diagnosis could have been easily made, and the patient would have received appropriate treatment sooner

References

Acute Medical Algorithms; East Kent Hospitals. Treatment of shortness of breath in a dialysis patient, web edition 2005

Chhabra SC, Sandha GS, Wander GS. Incidence of cardiac arrhythmias in chronic renal failure, especially during hemodialysis. Nephron 1991; 57: 500-501

Soman SS Sandberg KR, SBorzak S, Hudson MP, Yee J, McCullough PA. The Independent Association of Renal Dysfunction and Arrhythmias in Critically Ill Patients. Chest 2002; 122 (2): 669-677

 


 



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