SPECIALIZATION INDUCED TUNNEL VISION – A CAUSE OF LIFE THREATENING DIAGNOSTIC DELAY

Learning objectives:  Pericardial effusions are seen in 20% of patients with end stage renal disease (ESRD) on dialysis. Pericardiostomy should be reserved for hemodynamic destabilization. Morbidities associated with inherent complications of invasive procedures are significantly increased by delay in their detection. Such delays may be patient, disease or physician related, of which physician related delays are generally longest.

Case information: A seventy year old gentleman with hypertension, seizure disorder and ESRD on peritoneal dialysis was admitted and treated for pneumonia. After symptomatic recovery with antibiotic therapy, an echocardiogram showed moderate sized pericardial effusion with possible right atrial inversion. Pericardiostomy drained 600cc of bloody fluid which was negative for infection or malignancy. Over the next 5 days in the intensive care unit, pericardial drainage became clear but increased to two liters per day. Laboratory studies revealed worsening renal parameters and electrolyte abnormalities. The patient became progressively more confused, lethargic and uremic until his nurse observed that his daily pericardial drainage (output) equaled the amount of dialysate fluid instilled into his peritoneum (input). Pericardial drainage glucose was 900mg/dl which was consistent with dialysate fluid. CT scan confirmed the intraperitoneal course of the pericardial drain. He was started on hemodialysis and the pericardial drain was removed. Within a day, he reverted back to his baseline.

Discussion: In our case, despite daily evaluations by an internist, cardiologist, surgeon and nephrologist, collective “tunnel vision” delayed diagnosis of a dangerous iatrogenic problem. Sub-specialists must evaluate the whole patient rather than the organ of physician interest. Better patient care and safety can be achieved in challenging cases by improved communication between members of health care team combined with frequent clinical reassessment.