INTRADIALYTIC CARDIAC ARRHYTHMIAS: I

An 87‐year‐old white male with adult onset diabetes mellitus and progressive renal insufficiency was admitted because of dyspnea. Admission workup revealed a blood urea nitrogen (SUN) of 133 mg/dl, a creatinine of 5.6 mg/dl, a potassium of 5.0 mEq/l, and echocardiographic evidence of a pericardial effusion. The pericardial effusion was not hemodynamically significant, with no pulsus paradoxus and no evidence of right atrial or right ventricular collapse on echocardiogram. Of significance was a past medical history of third degree heart block managed by the placement of a sequential atrial‐ventricular (DDD) cardiac pacemaker. On admission his pacemaker was A‐V sequential pacing at a rate of 80 bpm . Hemodialysis was initiated without heparin, and transmembrane pressure was minimized so as not to precipitate cardiac tamponade. No net ultrafiltration occurred during the dialysis. Two hours after the initiation of hemodialysis, hypotension and an irregular tachycardia occurred. The hypotension was not volume responsive. Echocardiogram and rhythm strip showed atrial fibrillation with irregularly irregular ventricular pacing. Cardiology consultation was requested to further evaluate 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 .