What are the appropriate management and interventions for a patient on hemodialysis (HD) who develops fever and chills during treatment, with lab results indicating anemia, hyperkalemia, hypocalcemia, and hyperphosphatemia?

Management of Fever and Chills During Hemodialysis

Immediate Actions

This patient requires immediate blood cultures from both the catheter and a peripheral site (if obtainable), followed by prompt empirical antibiotic therapy covering both Gram-positive and Gram-negative organisms. 1

Blood Culture Protocol

• Obtain blood cultures immediately before initiating antibiotics, ideally from both the catheter and peripheral vessels not intended for future fistula creation 1
• If peripheral access is unavailable, draw blood samples during hemodialysis from bloodlines connected to the central venous catheter 1
• Blood cultures should be obtained as soon as possible after onset of fever or chills, as bacteria are rapidly cleared from blood and fever typically follows bacteremia by 30-90 minutes 1

Empirical Antibiotic Therapy

• Start vancomycin plus coverage for Gram-negative bacilli (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) immediately after cultures are obtained 1
• This combination is mandatory because hemodialysis patients presenting with chills have a 60% rate of infection and 33.5% rate of bacteremia 2
• If methicillin-susceptible S. aureus is identified, switch vancomycin to cefazolin 20 mg/kg (actual body weight), rounded to nearest 500-mg increment, administered after dialysis 1

Isolation and Cohorting Decision

This patient should be cohorted with other HBsAg-negative, anti-HCV-negative patients but does NOT require isolation. 1

• The patient's serologies show HBsAg negative and anti-HCV negative status, so standard infection control practices apply 1
• The minimal erythema at the right internal jugular catheter insertion site without discharge suggests early exit site infection rather than requiring isolation 1

Clinical Problems Based on Laboratory Results

Anemia (Hb 8.5 g/dL, Hct 25%)

• Consistent with chronic kidney disease-related anemia requiring erythropoietin therapy, which is already prescribed 3, 4
• Low serum iron (↓) and low TIBC (↓) with normal ferritin indicate functional iron deficiency 4
• Intravenous iron supplementation is more efficient than oral iron in dialysis patients with chronic iron deficiency 4

Hyperkalemia (K 5.8 mEq/L)

• Plasma potassium above 5.0 mEq/L defines hyperkalemia and increases mortality risk 4
• Requires immediate dialysis with appropriate potassium bath (2.0 mEq/L dialysate) and continuation of current HD prescription 5, 4

Hypocalcemia (Ca 7.8 mg/dL) and Hyperphosphatemia (P 6.5 mg/dL)

• Typical mineral-bone disorder in dialysis patients requiring phosphate binders and calcium supplementation 5, 3
• The dialysate calcium of 2.5 mEq/L is appropriate and should not be increased to 3.5 mEq/L, which may cause hypercalcemia 1

Metabolic Acidosis (Bicarbonate 16 mEq/L)

• Common in acute kidney injury and dialysis patients, efficiently treated by dialysis 5

Hypoalbuminemia (Albumin 2.8 g/dL)

• Indicates malnutrition and is an independent risk factor for bacteremia in infected patients 1

Probable Causes of Fever and Chills

Catheter-Related Bloodstream Infection (CRBSI) - Most Likely

• Vascular catheter as dialysis access increases bacteremia risk 6-fold (OR 6.2; 95% CI 3.2-12.0) 2
• Fever increases bacteremia risk 1.6-fold (OR 1.6; 95% CI 1.1-2.3) 2
• The combination of right IJ catheter, minimal erythema at insertion site, fever (38.5°C), chills, and hypotension (90/60 mmHg) strongly suggests CRBSI 1, 2

Exit Site or Tunnel Infection

• Minimal erythema without discharge suggests early exit site infection 1
• If drainage develops, culture it before continuing antibiotics 1

Other Potential Sources

• Minimal coarse right basal crackles could indicate pneumonia or volume overload 1
• However, the temporal relationship to dialysis initiation and catheter presence makes CRBSI most likely 2

Diagnostic Examinations Required

Mandatory Tests

• Blood cultures from catheter and peripheral site (if possible) before antibiotics 1
• Complete blood count with differential to assess leukocytosis (leukocytosis increases infection risk with OR 1.265) 2
• Chest X-ray to evaluate the coarse crackles and rule out pneumonia or pulmonary edema 1
• Exit site culture if drainage develops 1

Additional Monitoring

• Repeat blood cultures if symptoms persist beyond 72 hours after catheter removal or antibiotic initiation 1
• Surveillance blood cultures 1 week after antibiotic completion if catheter is retained 1

Probable Causes of Venous Pressure Alarm

Catheter Dysfunction

• Catheter malposition, kinking, or fibrin sheath formation causing increased resistance 1
• Thrombosis at catheter tip 1

Hemodynamic Changes

• Hypotension (BP 90/60 mmHg) can trigger venous pressure alarms due to decreased venous return 1
• Sepsis-induced vasodilation and decreased cardiac output 1

Catheter Management Strategy

For this patient with suspected CRBSI and right IJ catheter, the catheter should be removed immediately if S. aureus, Pseudomonas species, or Candida species are identified. 1

If S. aureus, Pseudomonas, or Candida:

• Remove catheter and insert temporary catheter at different anatomical site 1
• If absolutely no alternative sites available, exchange over guidewire 1
• Place long-term catheter only after blood cultures are negative 1
• Administer 4-6 weeks of antibiotics if bacteremia persists >72 hours after catheter removal 1

If Coagulase-Negative Staphylococci or Other Gram-Negatives (excluding Pseudomonas):

• Continue empirical antibiotics without immediate catheter removal 1
• If symptoms resolve within 2-3 days and no metastatic infection, exchange catheter over guidewire 1
• Alternatively, retain catheter and use antibiotic lock therapy (10-14 days after each dialysis) if symptoms resolve and bacteremia clears within 2-3 days 1

Management of Hypotension During Dialysis

Immediate Interventions

• Place patient in Trendelenburg position to increase systolic blood pressure to 100-110 mmHg 6
• Administer small boluses of normal saline (5-10 mL/kg), though use caution given minimal coarse crackles suggesting possible volume overload 6
• Temporarily reduce or stop ultrafiltration 1

Dialysis Prescription Modifications

• Consider cool dialysate (lower than patient's core temperature of 36.5°C) to improve vascular reactivity and cardiac contractility 1
• Maintain dialysate calcium at 2.5 mEq/L (current prescription appropriate) 1
• Avoid sodium modeling as it may lead to increased thirst and interdialytic weight gain 1

Pharmacological Support if Hypotension Persists

• Midodrine 10 mg three times daily at 4-hour intervals during daytime hours is the only FDA-approved medication for symptomatic orthostatic hypotension 1, 6
• Monitor for piloerection (goosebumps) as common side effect 6

Critical Pitfalls to Avoid

• Do not delay antibiotic therapy while awaiting culture results in a symptomatic hemodialysis patient with fever, chills, and catheter access 1, 2
• Do not remove catheter before obtaining blood cultures 1
• Do not use dialysate calcium >3.0 mEq/L, as this may cause hypercalcemia and decreased bone turnover 1
• Do not withhold renin-angiotensin blockers solely for hyperkalemia; instead optimize dialysis and consider potassium binders 4
• Avoid opioids for any associated headache or discomfort 7