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Discussion

Code during dialysis

So bad day. Really busy patient hepaotrenal pt. Restraints, intubation, central line for HD, lotsa diarrhea, rectal tube (40 yo end stage liver disease on lactulose), bronchoscopy, then dialysis--- all this with a differrent post op day one cabg pt.

So during dialysis I let my guard down....I get ready to chart and eat and use the bathroom for first time in 8 hrs... my pt on a lasix drip, propofol, and levo---Hypotension--up the levo--lower bp---up the levo--brady---code. Arrrrgh!

Hindsight being 20/20 did this pt run dry...cardiogenic shock?

Or did dialysis do something i dont know?

Backstory is a self pay, no insurance, repeat offending 40 yo etoh abuser.

Or what? Fortunately my cabg pt did ok.

But so much work on this end stage pt. And I feel like there was something I missed.

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    • Featured Replies

    Sorry to be crude, but it sounds to me like it was his time to go. End stage liver disease can really cause a quick shutdown. I've seen it happen a couple of times sadly. Don't beat yourself up too much. You did the best you could.

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    • Expert

    I'm surprised they even received regular HD and weren't on CRRT.

    I'm not sure what his insurance status has to do with anything.

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    • Author

    It was SLED actually, and youre right S ---the insurance might not have even been mentioned. It just was mentioned late in the day and was on my mind.

    Thx for kindness P.

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    • Author

    Beginning to wonder if HD cathether was sucking the levophed right out of the RA.

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    Different arena of care but I had a LTC resident who was end stage cirrhosis and was up in his w/c smiling and waved "bye" to me after my night shift. When I came back in the next day he had died. Just like that. From what I was told, he went to take a nap and never woke up.

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    Why was the patient on a lasix drip while on dialysis? It definitely does sound like it was their time to go though.

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    Most likely could not tolerate the decrease in volume caused by dialysis. Any idea what the CVP was? Everyone is pushing for agressive fluid removal in these situations but the heart can not take such rapid removal in so short of time. Anything above 10ml/kg/hr actually stuns cardiac cells. CRRT might have been a better choice for this patient.

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    Why was the patient on a lasix drip while on dialysis? It definitely does sound like it was their time to go though.

    We have dialysis patients on Lasix and bumex all the time. Helps to pull the fluid out of the third spacing and then can be taken out by dialysis.

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    But so much work on this end stage pt. And I feel like there was something I missed.

    All your efforts were to buy time for a liver transplant. Unless he received a transplant he was not going to survive.

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    Like many others, I wonder why this patient was on IHD, and not CRRT? Sounds like that may have been the first mistake? Also, what WAS his K? Did they start the IHD emergently for severe hyperkalemia or something?

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