AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
A Painful Dilemma
Commentary by Sara N. Davison, MD, MHSc
The Case
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A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She has had multiple admissions associated with electrolyte abnormalities due to nonadherence with her outpatient dialysis schedule. Because her permanent arteriovenous (AV) graft normally used for dialysis was clotted and unusable, the patient had been receiving dialysis via a temporary catheter placed in her left femoral vein.
Given that her new presentation included fever, blood cultures were drawn, ultimately growing yeast. An echocardiogram revealed a large tricuspid valve vegetation. The patient's temporary dialysis catheter in her left femoral vein was removed and a new one placed in the right femoral vein. The unused clotted AV graft in the left arm remained in place, and the patient was transferred to a tertiary hospital for consideration of surgery for fungal endocarditis.
The case management department reviewed this case. Their assessment was that the patient's nonadherence to dialysis led to clotting of her permanent AV graft, which necessitated use of temporary femoral vein access. Femoral intravenous catheters are associated with significantly increased risk of infection, including fungal infection, when compared with the use of permanent AV grafts. Moreover, the case management department felt that her nonadherence to dialysis was encouraged by the primary physician's prescription of opiates.
Although this patient was believed to be addicted to narcotics, she was never formally diagnosed with an addiction. Her providers suspected that she often intentionally skipped dialysis sessions, became uremic or volume overloaded, then presented to the emergency department for treatment and admission to the hospital. After admission, her primary physician would usually order intravenous (IV) hydromorphone (Dilaudid) to be given for "body pain." The patient would ask the nurses to "push the hydromorphone fast" and flush after the medication (saying that the previous nurse would push it fast) and ask for dose escalation. When a substance abuse evaluation was recommended to the patient, she repeatedly declined it.
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