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Nephrologist's Nightmare

Posted Sep 16 2010 12:00am

Have you encountered any patient who just can't keep any line/cannula in his/her body? I've met a difficult one, and I must say that I'm really amazed.

This is a patient with advanced chronic kidney disease, came to us with acute on chronic renal failure needing hemodialysis. Her caretaker revealed that, she used to be followed-up in another hospital, was planned for CAPD as long term RRT (renal replacement therapy), however she pulled out (ya you saw it right, she pulled out) the tenckhoff catheter and subsequently defaulted follow-up. My nephrologist found this part of history unreal, as he doesn't think anyone can sustain the pain pulling out the catheter!

She then agreed to a femoral catheter insertion for dialysis. A few sessions of hemodialysis were done and she then improved. Then the mystery happened. During a ward round few days later, when a HO was checking her femoral catheter, it was missing. It was no longer at her thigh site and she gave a very innocent look that she's unawared of what happened. The catheter, was then found in the drawer next to her bed. How did she remove it? And there's no even bleeding? (She did self-compression?)

Then the nephrologist starts to believe that the previous history could be true. This has to be a difficult patient. In view of difficult vascular access and she needs long term RRT, she was then referred for a permanent catheter insertion. It went uneventful, and subsequently she was discharged and continue her dialysis in one of the district hospitals.

Just few days later, I received a call from the district hospital MO.
MO: "Hi, I think I have to refer this patient back to you. Her perm cath has dislogded!"

Me: "What? How did it happen?"

MO: "No one saw it. But the whole thing is out now."

Me: "It can't be you know? The catheter is tunnelled subcutaneously and securely sutured, removal without analgesics is near impossible. Are you really sure it's out?"

MO: "Ok, the whole thing is in a plastic bag now. Do you think it's out?"

She just did it again. But how? ? And everytime when you ask, you'll just see a very innocent face with a smile.

It will remain a mystery I think. And, a nightmare to the nephrologist!

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