What are the management and treatment options for a patient with a dialysis catheter in the right side of the chest who is experiencing chest pain?

Management of Chest Pain in a Patient with a Right-Sided Dialysis Catheter

Immediately obtain a 12-lead ECG to evaluate for myocardial ischemia, as this is the most frequent serious cause of chest pain during dialysis, and if the pain is acute and unremitting, transfer the patient by EMS to an acute care setting. 1

Immediate Assessment and Stabilization

First Priority: Rule Out Life-Threatening Cardiac Causes

• Perform a 12-lead ECG immediately to assess for ischemic changes, as myocardial ischemia is often induced by hypotension or tachyarrhythmias during dialysis in patients with underlying coronary artery disease 1
• Assess vital signs including oxygen saturation, blood pressure, and heart rate to identify hemodynamic instability 2
• Transfer by EMS to an acute care facility if chest pain is unremitting, as recommended for acute cardiac events in dialysis patients 1, 3

Critical Caveat About Dialysis Patients

• Be aware that acute myocardial infarction in dialysis patients is less frequently associated with typical chest pain compared to non-dialysis patients, so maintain high suspicion even with atypical presentations like diaphoresis or dyspnea alone 1
• Dialysis patients have exceptionally high cardiovascular disease prevalence, making them particularly vulnerable to cardiac events during dialysis sessions 1

Catheter-Related Complications to Consider

Mechanical Complications Specific to Right-Sided Catheters

• Vessel perforation by the catheter can cause chest pain and should be suspected if pain is new or associated with catheter manipulation 1, 4
• Obtain a chest radiograph promptly to verify catheter position, as recommended after placement of internal jugular catheters, and repeat if malposition is suspected 5
• Catheter malposition into the chest cavity can occur, particularly after repeated punctures that cause vessel stenosis and fragility, leading to perforation of great veins 4
• Right internal jugular vein is the preferred first-choice site for dialysis catheters, but complications including vessel perforation remain possible 5

Other Catheter-Related Causes

• Catheter fracture with embolization to the pulmonary artery can present with pleuritic chest pain and should be considered if chest X-ray shows catheter abnormalities 6
• Subclavian steal syndrome can cause chest pain during dialysis when catheters are placed in subclavian veins (though subclavian is the last-choice site) 1

Additional Differential Diagnoses

Non-Cardiac Causes During Dialysis

• Gastroesophageal reflux is a common cause of chest pain during dialysis and should be considered after cardiac causes are excluded 1
• Pulmonary embolism from inadequate anticoagulation during dialysis can present with sudden chest pain and dyspnea 2
• Pericarditis is a potential complication in dialysis patients that can cause chest pain 2

Dialysis-Related Hemodynamic Causes

• Intradialytic hypotension from rapid ultrafiltration can precipitate myocardial ischemia in patients with coronary artery disease 1, 2
• Electrolyte shifts during dialysis can trigger arrhythmias that manifest as chest pain 2

Management Algorithm

If ECG Shows Ischemic Changes or Patient is Unstable

1. Immediately transfer by EMS to acute care facility 1
2. Slow or stop ultrafiltration to improve hemodynamic stability 1
3. Administer oxygen and initiate cardiac monitoring 5
4. Follow standard acute coronary syndrome protocols per ACC/AHA guidelines 5

If ECG is Non-Ischemic and Patient is Stable

1. Obtain chest X-ray to assess catheter position and rule out pneumothorax, catheter fracture, or malposition 5, 4
2. If catheter malposition or perforation is identified, remove the catheter immediately and place a new catheter at a different site after stabilization 4, 7
3. Consider CT imaging if chest X-ray is inconclusive but clinical suspicion for vessel perforation remains high 4, 8
4. Evaluate for non-cardiac causes including gastroesophageal reflux and pulmonary embolism 1, 2

Prevention Strategies for Future Sessions

• Perform regular assessment of dry weight to prevent intradialytic hypotension that can precipitate cardiac ischemia 1
• Use slower ultrafiltration rates in patients with cardiovascular instability to prevent hypotension-induced chest pain 1
• Reduce dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction and maintain cardiac output 1
• Ensure appropriate anticoagulation during dialysis to prevent pulmonary embolism 2
• Verify catheter position with imaging before first use and if malfunction occurs 5, 4

Common Pitfalls to Avoid

• Do not dismiss atypical presentations in dialysis patients, as they may not present with classic chest pain during myocardial infarction 1
• Do not delay imaging if catheter malposition is suspected, as vessel perforation can lead to fatal outcomes 4, 8
• Avoid subclavian vein catheter placement when possible, as it causes stenosis, thrombosis, and vessel perforation 7
• Do not use NSAIDs for pain control in dialysis patients, as they can accelerate loss of residual kidney function 3