Differential Diagnosis for CKD Patient with Chest Pain and Hypotension during HD Catheter Insertion

Single Most Likely Diagnosis

• Pneumothorax: This is a highly likely complication given the procedure (HD catheter insertion) and the symptoms presented (chest pain and sudden hypotension). The insertion of a catheter can accidentally puncture the lung, leading to air in the pleural space, which can cause chest pain and hypotension due to decreased cardiac output.

Other Likely Diagnoses

• Hemothorax: Similar to pneumothorax, but involves blood in the pleural space, which can also occur due to the catheter insertion procedure. Symptoms would include chest pain and hypotension.
• Cardiac Tamponade: Although less common, the procedure could potentially cause a cardiac tamponade, especially if the catheter inadvertently punctures the heart or a major vessel, leading to fluid accumulation in the pericardial space, which can cause hypotension and chest pain.
• Air Embolism: Introduction of air into the vascular system during the procedure can lead to an air embolism, which can cause sudden hypotension and chest pain.

Do Not Miss Diagnoses

• Pulmonary Embolism: Although less directly related to the procedure, a pulmonary embolism could present with sudden hypotension and chest pain. Given the potential for fatal outcomes, it's crucial not to miss this diagnosis.
• Cardiac Ischemia/Myocardial Infarction: Patients with CKD are at higher risk for cardiovascular disease. The stress of the procedure, along with potential underlying coronary artery disease, could precipitate a myocardial infarction, presenting with chest pain and potentially hypotension.
• Anaphylaxis: A severe allergic reaction to any of the materials or drugs used during the procedure could lead to anaphylaxis, characterized by hypotension and potentially chest pain or discomfort.

Rare Diagnoses

• Aortic Dissection: An extremely rare but potentially catastrophic complication, especially in patients with pre-existing hypertension or vascular disease. The force of the catheter insertion could theoretically cause a dissection, leading to severe chest pain and hypotension.
• Venous Catheter Malposition: Incorrect placement of the catheter could lead to various complications, including those that might cause chest pain and hypotension, though this would be less common and more related to the technical aspects of the procedure.