Hopelessness Angue creative, Eulàlia Oriol Colominas
Loans.
Dialysis Unit.
Joan XXIII Tarona University Hospital.
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Background
A 56-year-old, active, mother with hypertension, father with a history of AMI.
Patient without drug allergies, chronic alcoholism, ex-smoker, severe hypertension of 8 years of evolution in pharmacological treatment, type II DM secondary to chronic pancreatitis, treated with insulin, hepatitis secondary to liver biopsy, hemobilia.
Puncture kidney biopsy: chronic tubulointerstitial nephritis with nephroangiopathy.
CKD on haemodialysis since 1998.
Severe secondary hyperparathyroidism, repeatedly declining parathyroidectomy.
In June 1998 the patient started dialysis.
In August of the same year a radial I AVF was performed, after 4 years ligation of this access was performed due to severe hemorrhage.
Here we begin extensive interventions to obtain a vascular access: an AVF in elbow D, an arteriovenous prosthesis PTFE in both femoral arteries, subclavian catheters in both jugular veins with difficult cannulation, catheters in both veins
Due to the impossibility of obtaining vascular access, in July 2005, peritoneal dialysis was initiated.
Exteriorization of PTFE prostheses
In March 2006, the patient came to our department from the emergency department with spontaneous exteriorization of the PTFE prosthesis in the left lower extremity, of a few hours of evolution, with signs of infection of the wound, inflammation and redness.
The prosthesis remains fixed to the wound, practically hanging on the thigh, the patient has not detected the opening of the wound or the exteriorization (see picture I and II).
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This PTFE arteriovenous prosthesis contained one anastomosis month later (subcutaneous tunneling was performed with venous thermo-lateral and arterial thermo-lateral), but it was never used because a thrombus was discovered.
The patient reported discouragement and indifference, showing little expression.
Establishment
TA 131/75 mmHg.
FC 54 px'.
Ta 36oC.
Conserved general status.
Eye disorders
Wounds in the left thigh with inflammatory signs and exteriorization of the vascular prosthesis.
Signs of hyperhydration with significant fovea edema in both limbs up to the knee
Eupneic at rest.
CA: rhythmic tone, no auscultation of murmurs.
AR: hypophonesis on the left lung base.
Abdomen blushing and depressible, not painful to constipation.
Nursing intervention
The affected area was irrigated with saline solution and then with povidone and femoral, removed with a sterile thermocouple culture from VascularFE - operating room where the patient was operated by the Surgery Department (II superficial arteries removed).
Empirical treatment with ceftriaxone was started.
The culture of the surgical wound is positive for S. Epidermis, sensitive to antibiotic treatment.
The surgical wound is healed every 24 hours with saline solution and povidone-iodine.
Peritoneal dialysis sessions are performed with increased concentration of glucose in the dialysis fluid, with consequent reduction of edema and hypervolemia.
Half of the staples are removed at 10 days and the rest at the next day.
The surgical wound closed without complications and signs of inflammation.
She's discharged.
Outcome
In September 2006 (six months after removal of the externalized prosthesis) she was admitted for peritonitis.
Family members bring the patient to the hospital in poor general condition and decreased consciousness.
The patient insinuates that she has days without performing peritoneal passages.
Fatigue and discouragement are indifferent.
From this situation derives the failure of peritoneal treatment, neglect of nutritional status and abandonment of any aspect related to the care itself.
A catheter is placed in the femoral vein for hemodialysis which, given the patient's hemodynamic instability, is performed at low flow for 6 hours.
You have ulcers in both gluli, cuxis and an ulcer in both lower extremities.
The ulcers are healed daily with debridement ointment, hydrocolloid dressings and povidone-iodine, according to the type of ulcers.
After eight days of admission, the patient was referred to a social and health center, apparently sad.
Six days later she was readmitted with severe cachexia due to a febrile syndrome attributed to an overinfection of cutaneous ulcers.
Ulcers are suggestive of calciphylaxis due to severe secondary hyperparathyroidism.
PTH higher than 1900 pg/ml than after treatment lowers to 300 pg/ml.
Skin biopsy was performed.
Ulcer cultures confirmed the infection and antibiotic treatment was established. In addition, three erythropoietin concentrates were also required.
Wounds were healed every 24 hours with debridement of sloughs and necrotic areas.
Due to the impossibility of obtaining access for hemodialysis, the hemodialysis program was suspended and prostituted with peritoneal dialysis with intraperitoneal administration of Nutracea and oral amino acid supplements.
In spite of all this, the ulcers extended to both lower extremities.
The patient developed progressive cachexia and died 4 days after her readmission.
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Our special thanks to Dr. Bailey.
M del Carme García Ruiz for his great help during the clinical case.
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Rev Colomb Anestesiol.
