Tunneled hemodialysis catheter placement- EXISTING ADVERSE EVENT CLASSIFICATION |
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Tunneled hemodialysis catheter placement
A 58 year old hemodialysis-dependent patient with end-stage renal disease is referred for tunneled hemodialysis catheter placement. He is classified as an ASA III due to a history of prior stroke, known coronary artery disease and a cardiac ejection fraction of 15%. A tunneled hemodialysis catheter is inserted from a right internal jugular approach, with the catheter tip terminating at the lower SVC. After placing the catheter, the operator did not aspirate and flush the catheter to assess the flow rate and attempt to determine its adequacy for performance of hemodialysis. During the patients dialysis session the next day, the catheter flow rates are poor. The dialysis staff is told to reverse the lumens for performance of hemodialysis and the dialysis session is continued but abbreviated. The patient returns the next day for catheter exchange with a serum potassium of 5.5 mg/dl and pulmonary edema. During the catheter exchange, the patient experiences a fatal arrhythmia. No code is called and no resuscitation is attempted as patient is DNR/DNI.
A 58 year old hemodialysis-dependent patient with end-stage renal disease is referred for tunneled hemodialysis catheter placement. He is classified as an ASA III due to a history of prior stroke, known coronary artery disease and a cardiac ejection fraction of 15%. A tunneled hemodialysis catheter is inserted from a right internal jugular approach, with the catheter tip terminating at the lower SVC. After placing the catheter, the operator did not aspirate and flush the catheter to assess the flow rate and attempt to determine its adequacy for performance of hemodialysis. During the patients dialysis session the next day, the catheter flow rates are poor. The dialysis staff is told to reverse the lumens for performance of hemodialysis and the dialysis session is continued but abbreviated. The patient returns the next day for catheter exchange with a serum potassium of 5.5 mg/dl and pulmonary edema. During the catheter exchange, the patient experiences a fatal arrhythmia. No code is called and no resuscitation is attempted as patient is DNR/DNI.