3 Mar - Febrile Illness in Dialysis Patient

Always respect febrile illnesses in dialysis patients and poorly controlled diabetics.  Signs of significant pathology are often muted in these populations and clinical suspicion is key (isn't it always...)

One study showed hemodialysis access and chills to be strong predictors of S aureus bacteremia, a finding that has been described by other clinicians. 

In this case the gallbladder was felt to be the likely source.  Diabetic patients are at risk for empysematous cholecystitis, a rapidly progressive and often fatal infection.  Clostridium perfringens accounts for a significant number of these infections.  Surgical or percutaneous drainage is essential.

Regarding the atriall fibrillation portion of the case - patients with Afib/RVR that are in shock or are experiencing ischemic chest pain should be promptly cardioverted (synchronized shock, 100J).  If still awake enough to feel it, see if anesthesia can get there quickly and give some sort of conscious sedation beforehand.  If the BP is marginal and they are not in shock, try digoxin for rate control.  0.5mg IV bolus often has prompt effects on the AV node and can slow the rate within minutes.  As you do not see digoxin used much these days, it would be useful to review this article covering the contemporary use of digoxin.