Chief Complaint
Norma is a 54 year-old, former ICU nurse, referred from the Clinic for admission due to symptoms of increasing dyspnea, peripheral edema and hypotension. 

History of Present Illness

She is well known to the cardiologists from previous evaluations. Norma has a history of hospitalizations that average an admission every 5 months, the latest being at the beginning of June 2003.  This hospitalization lasted approximately 5 days with very little fluid removed using IV Lasix®, Natrecor®, and a Primacor® drip. 

Previous Medical History
On August 6, 2003, she presented at the Clinic in a similar manner to her admission in June.  Prior to this admission, Norma has been taking Lasix® 80 mg b.i.d., Aldactone® 25 mg q.d., K-Dur® 10 mEq b.i.d., Digitek® 0.125 mg q.d., Darvocet®, Zaroxolyn®, Restoril® 30 mg q hs, Altace® 5 mg q.d., Coreg® 6.2 mg b.i.d., in addition to attending the Infusion Clinic twice a week for Primacor® and the recently added, Natrecor® infusions.

Norma has a history of hypertension, diabetes mellitus, coronary artery disease, status-post coronary artery bypass grafting in April 1994 with repeat bypass grafting due to graft occlusion in March 2002.  She has a history of ventricular arrhythmia and is status-post automatic implantable cardioverter defibrillator (AICD) implant.  She was upgraded to a biventricular pacer with AICD in June 2003.

Case Details
Her worsening condition required her admission to Hospital and her treatment plan was unknown at the time of her admission.  She was showing signs of becoming refractory to most medications.  In April of 2003, the hospital began evaluating the use of  our system for fluid removal.  When Norma was admitted, it was clear that she would be a strong candidate for use of the device.  A venous catheter was placed for blood withdrawal and an existing peripheral IV catheter was used for infusion. 

 After spending 2 nights in the hospital and going through two (2) treatments, Norma was discharged from the hospital.  With no clinically significant effects to her hemodynamics or blood chemistry, a total of 9.75 liters of fluid was removed.  Although this amount only represented a portion of her excess fluid, Norma’s cardiologist believed that by removing this initial bulk of fluid through this system, the kidneys would become more responsive to the medications and diurese the remaining fluid.  This theory was confirmed when Norma called the hospital 3 days after the final treatment to report that she did in fact void the remainder of the fluid.  Norma is scheduled to resume her visits to the Clinic where she will be evaluated for continued maintenance therapy or for additional system treatments with our unit.

After her our unit treatments, Norma has been responding well to her oral diuretics.  In fact, her doses have been cut in half to what they were prior to treatment.  She is currently prescribed Lasix® 40 mg b.i.d., Aldactone® 12.5 mg q.d., K-Dur® 10 mEq b.i.d., Digitek® 0.125 mg q.d., Darvocet®, Zaroxolyn®, Restoril® 30 mg q hs, Altace® 5 mg q.d., Coreg® 6.2 mg b.i.d.

Discussion
The nurses reported that our system is quite simple to use.  After seeing how effectively the device operates, they are eager to use it to help more patients.  More than this, they are impressed by how stable the patient remains on the device, the levels of monitoring it really requires, and the immediate improvements to the patient’s fluid overloaded condition with a reduction of symptoms.  Norma would have to agree.  As the treatments began, she soon stated that her breathing had improved and she could now lean over, bend her legs, and put her socks and slippers on.  Upon admission, she was unable to lift or bend her legs to get into the car without assistance.  Norma summed up her feelings in the following quote:

“As a former ICU nurse, I have taken care of patients in the same condition that I am now.  I never dreamed I would be the patient.  After one treatment, my abdomen went way down, I was able to bend my legs to sit in a chair, and my breathing became so much better.  The difference in how I feel, in such a short period of time, is remarkable.”

- Norma, August 8, 2003

Marion, OH