A Tale of Two Lines: Line Positioning Affecting Ability to Tolerate CRRT
- Hemodialysis: Case Reports, Series, QI Projects
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 801 Dialysis: Hemodialysis and Frequent Dialysis
- Patel, Devang Bharat, Ochsner Medical Center, New Orleans, Louisiana, United States
- Velez, Juan Carlos Q., Ochsner Medical Center, New Orleans, Louisiana, United States
- Kovvuru, Karthik, Ochsner Medical Center, New Orleans, Louisiana, United States
Continuous renal replacement therapy (CRRT) is the modality of choice for delivering dialysis to patients with hemodynamic instability. However few patients have a precipitous drop in blood pressure with initiation of CRRT warranting discontinuation, followed by prompt improvement in blood pressure. Some of this drop in blood pressure could be secondary to removal of vasopressors by CRRT. The degree of blood pressure drop is likely related to the proximity of vasopressor delivery to the arterial end hole of the hemodialysis catheter and the prescribed clearance. We report a patient who tolerated CRRT when the vasopressors were infused through a distal port of a Trialysis (Power-Trialysis, short-term triple lumen dialysis) catheter instead of PICC (peripherally inserted central catheter) line which was delivering the pressors close to arterial end hole of the Trialysis catheter.
A 64-year-old female who was being treated with antibiotics through a right arm PICC for leg stump infection was transferred to ICU due to acute kidney injury and septic shock. Norepinephrine and vasopressin were infused as vasopressors through the PICC. A right internal jugular Trialysis catheter was inserted to initiate dialysis. CRRT was attempted twice with precipitous drop in blood pressure within 3-5 mins needing significant increase in vasopressor dose, warranting discontinuation of CRRT. A prompt rise in blood pressure and decrease in vasopressor dose to that pre CRRT was noted following discontinuation of CRRT. The possibility of vasopressors being removed by CRRT was suspected due to the proximity of the tip of the PICC to the Trialysis catheter arterial end hole. CRRT was reattempted after switching vasopressors infusion from the PICC to the distal port of the Trialysis catheter. Patients’ hemodynamics stayed stable affirming the suspicion of vasopressor removal by CRRT.
Inadvertent removal of vasopressors should be considered as a potential cause of hemodynamic instability during CRRT initiation. Risk can be mitigated by infusing the vasopressors away from the arterial end hole of dialysis catheter either distally or proximally, which can be achieved by repositioning the tip of catheter.