I have a patient who is transitioning from hemo to CAPD, initially I drained her and she drained over 1000 mls of dark amber colored effluent. I infused her with 1.5% dextrose solution 1000 mls she dwelled for an hour and then drained 1500 mls of dark amber colored hazy effluent. I relayed this info to my supervisor who asked if she had hx of liver failure, liver enzymes were good, I obtained cultures and cell count, called the doctor. Doc said she has ascites from heart failure, hx of chf, that is why he suggested her to go on pd, for fluid removal, he reports she has a good residual. I asked him for guidance as to how much fluid to work with as I am afraid to put her in hypovolemic shock. He suggested low volumes, her bsa <1.7, I am going to start with 1000mls and see how she responds. I have all kinds of concerns , this is not my typical Pd pt and I have been practicing for a little over a year, any suggestions ?
Hello,
When you initially started PD - with no dwell, did she initially have significant drainage (i.e. ascites)? How bad is her LV dysfunction? I would also ensure her ascites is a transudate and not an exudate that might be indicative of something else.
PD in the setting of cardiac ascites will be problematic in that the PD will be diluted by extracellular fluid (ECF) - her ascites- that is isotonic to her. Meaning, the concentration gradients that PD relies on to remove solutes will be significantly reduced. And so in this case, clearance should be monitored and signs of uremia followed. As for overly reducing her ECF volume and causing shock; you could always reduce the strength of her PD, reduce other diuretic dosages etc. In the end, the ascites being drained will be one other source of ECF volume control in the setting of heart failure if indeed it is that severe.
Dr. Jordan Weinstein
When you initially started PD - with no dwell, did she initially have significant drainage (i.e. ascites)? How bad is her LV dysfunction? I would also ensure her ascites is a transudate and not an exudate that might be indicative of something else.
PD in the setting of cardiac ascites will be problematic in that the PD will be diluted by extracellular fluid (ECF) - her ascites- that is isotonic to her. Meaning, the concentration gradients that PD relies on to remove solutes will be significantly reduced. And so in this case, clearance should be monitored and signs of uremia followed. As for overly reducing her ECF volume and causing shock; you could always reduce the strength of her PD, reduce other diuretic dosages etc. In the end, the ascites being drained will be one other source of ECF volume control in the setting of heart failure if indeed it is that severe.
Dr. Jordan Weinstein
Hi,
Thank you for responding, initially this pt drained 1300 mls, I do not know off the top of my head how bad her LV dysfunction is , I have to get her chart from the hemo side and investigate which I will do this week. This was her first day of PD training. I did send out cultures and a cell count on friday, should get results mid week. Defintley will be using 1.5% and low volume to start. Will also look at her med list, do a 24 hour urine. Pt is also a insulin dependent diabetic.
Respectfully,
Sue
Thank you for responding, initially this pt drained 1300 mls, I do not know off the top of my head how bad her LV dysfunction is , I have to get her chart from the hemo side and investigate which I will do this week. This was her first day of PD training. I did send out cultures and a cell count on friday, should get results mid week. Defintley will be using 1.5% and low volume to start. Will also look at her med list, do a 24 hour urine. Pt is also a insulin dependent diabetic.
Respectfully,
Sue
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