DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. INTRADIALYTIC CARDIAC-ARRHYTHMIAS

An 87-year-old white male with adult onset diabetes mellitus and progr essive renal insufficiency was admitted because of dyspnea. Admission workup revealed a blood urea nitrogen (BUN) of 133 mg/dl, a creatinine of 5.6 mg/dl, a potassium of 5.0 mEq/l, and echocardiographic evidenc e of a pericardial effusion. The pericardial effusion was not hemodyna mically significant, with no pulsus paradoxus and no evidence of right atrial or right ventricular collapse on echocardiogram. Of significan ce was a past medical history of third degree heart block managed by t he placement of a sequential atrial-ventricular (DDD) cardiac pacemake r. On admission his pacemaker was A-V sequential pacing at a rare of 8 0 bpm. Hemodialysis was initiated without heparin, and transmembrane p ressure was minimized so as not to precipitate cardiac tamponade. No n et ultrafiltration occurred during the dialysis. Two hours after the i nitiation of hemodialysis, hypotension and an irregular tachycardia oc curred. The hypotension was not volume responsive. Echocardiogram and rhythm strip showed atrial fibrillation with irregularly irregular ven tricular pacing. Cardiology consultation was requested to further eval uate the pacemaker status. The pacemaker was emergently converted to a VVI mode of 90 bpm. The patient subsequently became normotensive and hemodynamically stable. He was also given a loading dose of 1000 mg of procainamide and a continuous infusion of procainamide was initiated at 1 mg/min. Organized atrial activity was restored within 15 min. No further atrial arrhythmias were noted during subsequent hemodialyses.