Altered mental status & dialysis

[Epi-do]

Just a couple questions that I am hoping to get some answers to.

1. If you have a dialysis patient that you suspect has had too much fluid taken off, would it be possible for that to cause a sudden change in mental status?

2. If it could cause a sudden change in mental status, how long after dialysis would you expect to see that change?

I ask because I transported a patient that when we initially got to her, was complaining of shortness of breath, nausea, and just generally feeling ill. She also told us that towards the end of her dialysis treatment, she began cramping in her legs. According to family, she had been home for a while, but they were rather vague about when she did get home for the day.

We loaded her up into the ambulance to transport to the ER. Her pressure remained around 150/85 through out the transport. Her HR was aprox 105 through out the transport, and her respiratory rate varied from 18-28. She was sinus tach on the monitor without ectopy. Initially she was answering questions, able to tell us what her complaint was, how dialysis had went today, etc.

About half-way to the ER she went off the deep end. She began alternating between babbling and speaking nonsense words/sounds and being delusional. She began trying to hand me things that weren't there, telling me "it's in my leg" (but couldn't tell me what was in her leg), and showing me her dialysis access and saying "it needs to come out". I did dex her and her blood sugar was 110.

Yes, I realize this change in mental status could be completely unrelated to the dialysis. I was just curious if anyone had seen something like this in relationship to it. I really think they took too much fluid off of her given the complaints she had when we first got to her. I have just never seen a sudden change in mental status like that as a result of complications from dialysis.

 

[kittaypie]

possible electrolyte imbalance?

 

[wvditchdoc]

Just like the other site...

It is 110% possible that it's related to the treatment. It is a very common after effect for dialysis patients. The effect will happen very suddenly in these patients. It is a system wide, massive fluid shift. Every single drop of blood is run through a filter, scrubbed, and sent back into the vasculature. A very minute mistake in the calculations can result in a very bad treatment session for the patient. It is better known as Dilutional Hyponatremia.

It appears, from your description, that this patient wasn't new to dialysis and the family should have been able to see the problem. Let alone the mentally challenged dialysis center workers.

 

[Aidey]

I ask because I transported a patient that when we initially got to her, was complaining of shortness of breath, nausea, and just generally feeling ill. She also told us that towards the end of her dialysis treatment, she began cramping in her legs. According to family, she had been home for a while, but they were rather vague about when she did get home for the day.

It is 110% possible that it's related to the treatment. It is a very common after effect for dialysis patients. The effect will happen very suddenly in these patients. It is a system wide, massive fluid shift. Every single drop of blood is run through a filter, scrubbed, and sent back into the vasculature. A very minute mistake in the calculations can result in a very bad treatment session for the patient. It is better known as Dilutional Hyponatremia.

It appears, from your description, that this patient wasn't new to dialysis and the family should have been able to see the problem. Let alone the mentally challenged dialysis center workers.

In case you missed it, the patient had been home for some time, and most likely was not symptomatic at the end of her treatment. Cramping is not uncommon, especially when a patient's dry weight or prescription has changed, or they are not adhering to their diet. When cramping occurs the patient's treatment will be altered to reduce the rate of fluid removal or the sodium profile will be adjusted if it is present. They may also be given a saline bolus (either 0.9% or a hypertonic solution in some cases).

Honestly, after thinking about it for a while, several someones would have to screw up big time to allow a patient to become that severely hyponatremic. The machine should also have a lowest allowed limit to set the goal sodium to in order to prevent removing too much. Dialysis staff generally know their patients pretty well, and they usually aren't in the business of sending unstable patients home. I'm not saying that it doesn't happen, but I don't want you to think that every other dialysis patient is going to have this either.

There is something called Dialysis Disequilibrium syndrome that could possibly also cause her symptoms. It can occur when the blood is "cleaned" too well basically, causing a shift in fluid and swelling in the brain.

I know that sounds like dilutional hyponatremia, but it isn't the same thing. DDS is related to the pts BUN level, and it is the relative drop in levels that causes the symptoms, without the BUN actually being clinically low. It is usually see in newer dialysis patients when their body is still adjusting to the treatment, but it can happen in anyone. Especially non-compliant patients who skip treatments (which allows their BUN to build up). Patients who have just switched from peritoneal dialysis to hemodialysis are also at risk.

I can think of multiple other causes too. Some medications can be dialyzed off, causing withdrawal symptoms (pain meds, psych meds, and a whole bunch more). The patient could be anemic. The patient could be septic (bacteria aren't dialyzed off, so a local infection can cause a patient to become septic in 1 treatment). She could be having a stroke caused by the heparin. She could be having a stroke or TIA caused by a clot form her dialysis access that has broken loose. And I know there are more.

Or, as you said, it may have had nothing to do with the dialysis at all. Let us know if you get a chance to follow up.

 

[wvditchdoc]

In case you missed it, the patient had been home for some time, and most likely was not symptomatic at the end of her treatment.

In case I missed it? Really?

It also said that the family was

rather vague about when she did get home for the day

Are you saying cramping does not constitute being "symptomatic" for a dialysis patient? Since when?

I've work in a hellish dialysis center as a tech and I've also worked in a few very good ones. It takes a very simple miscalculation to put someone into hyponatremia that is on hemodialysis. We aren't talking about a normal metabolic process here.

In all fairness, Aidey, you did bring up some good points as well in your reply. I didn't bash on Epi cause she didn't know anything about transporting a dialysis patient. But you want to jump right on my *** and try to make me look stupid? Like I can't or didn't read the OP? :censored: you!

I've been off this site for a few months and I thought maybe this site had changed, guess not.

 

[Epi-do]

Thanks for the info guys! I can tell you that as we were leaving the ER, the staff was drawing blood cultures on her. She was pretty hysterical about the whole thing, too.

We don't get down to that particular ER a whole lot, so chances are I won't be able to follow-up on her. If I do happen to learn something though, I will be sure to pass along what I find out.

I know that working for a 911 service, I don't do transports to/from dialysis of these patients. However, I do see them occasionally, most often at home. Typically, it is because they haven't went for the last several days for whatever reason and have too much fluid on board. Often times they present with pulmonary edema, something that I am confident in treating. When I get a patient that has been to dialysis regularly and they are too dry, I don't feel as confident about what to expect. Would it be reasonable to expect alot of the same signs/symptoms as a pt with symptomatic dehydration? I mean, in a sense, isn't that what is going on?

I know dialysis is supposed to filter the blood when the kidneys are no longer able to do so, but like any other medical procedure, it does have associated risks and side effects. I certainly don't feel like I have been educated at all in this area. Guess it's time to go do some research...

 

[Aidey]

I'm sorry you read it that way, but I was trying to point out that it was not immediately after her treatment, because I wasn't sure if you had read that or not, since you were blaming the dialysis unit staff on her condition.

If they treated her cramping and it went away, then yes, I would call that not symptomatic when she left treatment.

I've also worked dialysis, and maybe I just worked in a good place, and didn't see the problems you apparently have. However, I stand by what I said, several people would have to mess up big time to drop a patient's sodium that low.

 

[redcrossemt]

If the change is sudden, it's usually during or immediately after dialysis. This sounds like it could be something else.

I wonder if the patient was febrile, and possibly septic? Not sure why they would draw cultures unless they suspected infection due to a fever or something like that.

 

[Aidey]

Dialysis patients can become septic so easily cultures are a first line test. Nearly all of them have MRSA, and some have VRE so they need to know what they are dealing with.

 

[redcrossemt]

Dialysis patients can become septic so easily cultures are a first line test. Nearly all of them have MRSA, and some have VRE so they need to know what they are dealing with.

Really? ED's routinely culture dialysis patients for vague chief complaints?