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GranuFlo/NaturaLyte – Case Review

Case Report

Parameter / Findings / Ref
Patient Name
DOB
Product Name
Product details / Dialyzer: FRES, OPTIFLUX 180NR
Dialysate: Bicarbonate
Formula/Serial No: 3231 (Na: 137.0, Ca: 2.25, K: 3.0)
Machine: FRES 2008 K
Dialyzing Facility
Length of dialysis treatment
Injuries / Death: Yes/No
If yes:
Date of death:
Cause of death:
Did Doctor link dialysis to injury? / Yes or no–
Current condition (If death, N/A) / N/A
Significant labs / Bicarbonate: (normal range: 22-29mEq/L)
Smoking History
Past history / Past medical:
Past surgical:
Family history:
Allergy:

Detailed Chronology

DATE / PROVIDER / OCCURRENCE/TREATMENT / PDF REF
06/18/2010 / AMM XXX
Dr. Craig YYY / Hemodialysis report:
Time on: 11:06
Time off: 16:05
Actual Hours: 04:59
Estimated Dry Weight (EDW): 74.00.
DFR (Dialysate Flow Rate): A2.0
BFR (Blood Flow Rate): 350
pH: 7.3
@15:15: Normal Saline (NS) flush lines dark.
Total Fluids: 400.
Post dialysis:
Comments: Trace edema lower extremity.
Patient post weight: Below Estimated Dry Weight.
Notes: Catheter care done with 3 x 3 Betadine without signs/symptoms of infection. / 11-13
06/20/2010 / AMM XXX
Dr. Craig YYY / Hemodialysis report:
Comments:
@13:29: Catheter care done. Cleaned with Betadine and triple antibiotic ointment applied. Covered with sterile 3 x 3 gauze and plastic tape applied. No redness, odor, swelling or drainage noted.
@ 13:24: Arterial pressure greater than negative 240, Blood Flow Rate (BFR) decreased to 250. Lines reversed. BFR at 300 with arterial pressure negative190. Arterial line sucking. Lines reversed back.
Multidisciplinary notes: @15:25: Patient seems drowsy today, called Val, she states patient didn’t sleep much last night and was spitting up yesterday. Saw Dr. White and received a suppository yesterday.
@17:13: Arterial pressure high.
Total fluids: 1050.
Post dialysis: Patient post weight: Above estimated dry weight. / 14-16
06/21/2010 / Stephen ZZZ, M.D. / Physician note:
Patient was seen for surgery for a new left arm graft. Her right arm AV fistula has some stenosis requiring frequent intervention but is not clotted. I would suggest continuing to use her catheter given the fact that they canceled her surgery; they did not feel she was medically fit. She came over here to have a tunneled catheter exchange as this was not functioning well. I spoke with the daughter who realizes she is at the end of her life and we tentatively discussed DNR which she seemed in favor of. Furthermore, I told her we would try to make this her last procedure. To this end, I would use her catheter and/or her fistula as necessary to keep her on dialysis for now. Discussions should center on what her daughter wants to do with regard to her quality of life and her contributing dialysis. / 6
06/21/2010 / Nephrology Associates / Post procedure Doctor’s orders:
Procedure performed and findings: Right IJ PC exchange with PTA centrally for fibrin sheath. Catheter placement confirmed by fluoroscopy, OK to use. / 7
06/21/2010 / AMM XXX / Problem list:
Venous Mapping:
08/03/2009 - Tunneled catheter placed by Dr. XXX in Montgomery prior to coming to our service.
12/27/2009 - Creation of right brachial artery and transposed elevated basilic vein fistula per Dr. ZZZ.
01/12/2010 - Right IJ tunneled catheter exchange with fibrin sheath disruption.
02/2010 - 7 mm angioplasty of long outflow stenosis, can begin using in approximately eight week point.
03/27/2010: Right upper arm cephalic fistulogram showed four areas of problem. Arterial end near sheath site 50-60%, mid fistula where scar crosses from inter to outer arm over biceps 60-70%, proximal cephalic near margin of deltoid 80% recurrent, probably some central stenosis around the catheter in the brachiocephalic vein 50% or greater. Angioplastied at site near the deltoid 7 mm. 100% with mild extravasation therefore other sites could not be addressed. Will rest fistula and have her return as soon as possible.
04/19/2010 - 7 mm angioplasty of two fairly severe outflow stenoses. The plan would be to start using access.
06/05/2010 - Fistulogram, right brachiocephalic unfortunately shows recurrent stenosis both near arterial end 4-5 cm from anastomosis, 70-80% and near margin of deltoid 95%. No intervention today on these sites as she will either need surgical revision or just change to a graft. We will review with her surgeon.
06/21/2010: Right IJ tunneled catheter exchange. I would try to make this her last procedure given she is not going to live much longer. Her fistula feels okay. You could use one needle in venous drainage of catheter and draw from the fistula if necessary; otherwise you can use the catheter as needed. Her surgery was canceled today by anesthesia as they did not feel comfortable putting her to sleep for a new graft. / 8-10
06/22/2010 / AMM XXX / Physicians order sheet: Ok to use catheter. / 4
06/22/2010 / AMM XXX
Dr. Craig YYY / Hemodialysis report:
Total fluids: 600.
Post dialysis: Patient post weight: Below estimated dry weight. / 17-19
06/24/2010 / Memorial Hospital / Emergency physician record:
Since August-Kidney failure
Context: Breathing shallow then stopped breathing.
Review of system: Spitting up.
Physical examination: Wheezes on expiration.
@07:10: Too critical to transfer. / 27-28
06/24/2010 / Memorial Hospital / Emergency Department report:
Chief complaint: Family stated, she was talking and just stopped breathing. Brought in by Amstar Ambulance intubated and on ventilator-patient unresponsive.
Vital signs: Respiration: On ventilator.
SaO2: 100%.
Category: Immediate.
Time discharged: Transfer to Jackson Hospital at 22:45. / 29
06/24/2010 / Memorial Hospital / Cardio respiratory treatment and progress notes: (Illegible notes)
@1820: Arrived to see respiratory arrest patient in ER. Patient arrived prior at 17:50 per Ambulance intubated and mechanical ventilator in use. Patient awake agitated pulling at GT tube.
@18:25: Patient appears fatigued, suctioned ET tube, yellow secretions noted.
@19:04: Doctor informs me that patient is not a DNR.
@19:30: Patient is hypotensive, heart rate 88.
@21:30: Patient suctioned, no spontaneous respiration, ventilator on. / 40
06/24/2010 / Memorial Hospital / Nurse notes:
@1810: Breathing on her own but saturation down in 70’s.
@1840: Less responsive.
@1950: Trying to pull tube out, eyes wide open seems more awake/alert.
@2230: Transferred to Jackson Hospital. Remains intubated on ventilator. / 30
06/24/2010 / Memorial Hospital / Lab report: @18:35
Bicarbonate(HCO3): 24.5mmol/L / 31
06/24/2010 / Memorial Hospital / Lab report: @19:00
Bicarbonate(HCO3): 21.2mmol/L / 32-34
06/24/2010 / Memorial Hospital / EKG report:
@06:10: Sinus tachycardia, probable posterior infarct, acute. Artifact in leads I, II, aVR, aVL, aVF, V4 and baseline wander in leads III, aVF, V2-6. Abnormal ECG. Acute MI.
@07:16: Sinus rhythm, atrial premature complex, short PR interval, probable left atrial enlargement, right bundle branch block, baseline wander in leads V4, V6. Abnormal ECG. / 35-37
06/24/2010 / Memorial Hospital / X-ray chest:
Indication: Shortness of breath. Intubation.
Impression: Endotracheal tube has its tip 5.2 cm above the carina. There is likely a small right pleural effusion that is layering. Alveolar opacity in the right lung is not excluded, though. / 38-39
06/26/2010 / Lab report: (Result reported after death)
Bicarbonate level – 21meq/L (Low) / 2-3
07/17/2010 / Death Certificate:
Cause of death:
Immediate cause – Cardiopulmonary arrest
Underlying cause – Breast cancer, hypertensive, chronic kidney disease, end stage renal disease.
Manner of death: Natural cause. / 44

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