Hemolysis due to inadvertent hemodialysis against distilled water: Perils of bedside dialysate preparation

Critical Care Medicine

Volumn 34, Issue 10, 2006, Pages 2666-2673

  Pendergrast, Jacob M ^a   Hladunewich, Michelle A ^b   Richardson, Robert M A ^a  

^a UNIVERSITY HEALTH NETWORK   (Canada)

^b UNIVERSITY OF TORONTO   (Canada)

Author keywords

Dialysis; Dialysis solutions; Hemolysis; Hyponatremia; Intensive care; Medical errors

Indexed keywords

HEMOGLOBIN; WATER;

ACCIDENT; ADULT; AGED; ARTICLE; BLOOD ANALYSIS; BLOOD PRESSURE MEASUREMENT; CASE REPORT; CAUSE OF DEATH; CHEMICAL ANALYSIS; DIALYSATE; DISEASE COURSE; ERYTHROCYTE; FEMALE; HEMODIALYSIS; HUMAN; IN VITRO STUDY; INTENSIVE CARE; MALE; POINT OF CARE TESTING; PRIORITY JOURNAL; RETICULOENDOTHELIAL SYSTEM; SODIUM BLOOD LEVEL; STROKE; TEACHING HOSPITAL;

ADULT; AGED; BICARBONATES; DIALYSIS SOLUTIONS; DRUG COMPOUNDING; FEMALE; HEMOLYSIS; HUMANS; HYPONATREMIA; MAGNESIUM; MALE; MEDICAL ERRORS; RENAL DIALYSIS; SODIUM CHLORIDE;

EID: 33748774128     PISSN: 00903493     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.CCM.0000240230.10343.3E     Document Type: Article

References (29)

1. Uchino S, Kellum JA, Bellomo R, et al: Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 294:813-818
2. Tobe SW, Aujla P, Walele AA, et al: A novel regional citrate anticoagulation protocol for CRRT using only commercially available solutions. J Crit Care 2003; 18:121-129
3. Bunchman E, Maxvold NJ, Brophy PD: Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation. Am J Kidney Dis 2003; 42:1248-1252
4. Mujais SK, Ing T, Kjellstrand C: Acute complications of hemodialysis and their prevention and treatment. In: Replacement of Renal Function by Dialysis. 4th ed. Jacobs C, Kjellstrand CM, Koch KM, et al. (Eds). Dordrecht: Kluwer, 1996; 688-725
5. Said R, Quintanilla A, Levin N, et al: Acute hemolysis due to profound hypo-osmolality. A complication of hemodialysis. J Dial 1977; 1:447
6. Olivero J, Dichoso C: Severe hyponatremia in a home-dialysis patient. JAMA 1978; 239:108-109
7. Kageyama K, Onoyama Y, Kogawa H, et al: The maximum and minimum water content and cell volume of human erythrocytes in vitro. Biophys Chem 1989; 34:79-82
8. Kjeldsberg CR: Practical Diagnosis of Hematologic Disorders. 3rd ed. Chicago, ASCP Press, 2000
9. Mollison PL, Engelfriet CP, Contreras M: Blood Transfusion in Clinical Medicine. 10th ed. Oxford, UK, Blackwell Science, 1997
10. Jones JH, Kilpatrick GS, Franks EH: Red cell aggregation in dextrose solutions. J Clin Pathol 1962; 15:161-162
11. Creevy CD, Reiser MP: The importance of hemolysis in transurethral prostatic resection: Severe and fatal reactions associated with the use of distilled water. J Urol 1963; 89:900-905
12. Bell MD: Sudden death due to intravascular hemolysis after bladder irrigation with distilled water. J Forensic Sci 1992; 37:1401-1406
13. D'Agosto J, Ali NM, Maier D: Absorption of irrigating solution during hysteroscopic metroplasty. Anesthesiology 1990; 72:379-380
14. Istre O, Jellu E, Skajaa K, et al: Changes in amino acids, ammonium, and coagulation factors after transcervical resection of the endometrium with a glycine solution used for uterine irrigation. Am J Obstet Gynecol 1995; 172:939-945
15. Goldberg SD, Gray RR, St Louis EL, et al: Nonoperative management of complications of percutaneous renal nephrostomy. Can J Surg 1989; 32:192-195
16. Danielson C, Parker C, Watson M, et al: Immediate gross hemolysis due to hypotonic fluid administration during plasma exchange: A case report. J Clin Apher 1991; 6:161-162
17. Waters JH, Sprung J: Errors during intraoperative cell salvage because of inappropriate wash solutions. Anesth Analg 2001; 93:1483-1485
18. Centers for Disease Control and Prevention: Hemolysis associated with 25% human albumin diluted with sterile water - United States, 1994-1998. JAMA 1999; 281:1076-1077
19. Orlowski JP, Szpilman, D: Drowning: Rescue, resuscitation, and reanimation. Pediatr Clin North Am 2001; 48:627-646
20. Nickey WA, Chinitz VL, Kim KE, et al: Hypernatremia from water softener malfunction during home dialysis. JAMA 1970; 214:915-916
21. Borrego Dominguez RR, Imaz-Roncero A, Lonez-Herce Cid J, et al: Severe hypernatremia: Survival without neurologic sequelae. An Pediatr (Barc) 2003; 58:376-380
22. Lindner A, Moskovtchenko JF, Traeger J: Accidental mass hypernatremia during hemodialysis. Simultaneous observation in six cases. Nephron 1972; 9:99-105
23. Williams DJ, Jugurnauth J, Harding K, et al: Acute hypernatraemia during bicarbonate-buffered haemodialysis. Nephrol Dial Transplant 1994; 9:1170-1173
24. Reason JT, Carthey J, de Leval MR: Diagnosing "vulnerable system syndrome": An essential prerequisite to effective risk management. Qual Health Care 2001; 10(Suppl 2):ii21-ii25
25. Marshall MR, Ma T, Galler D, et al: Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: Towards an adequate therapy. Nephrol Dial Transplant 2004; 19:877-884
26. Bajer CJ, Norton PJ, Flintoft V, et al: The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Can Med Ass J 2004; 170:1678-1686
27. Osmon S, Harris CB, Dunaga WC, et al: Reporting of medical errors: An intensive care unit experience. Crit Care Med 2004; 32:727-733
28. Wu AW, Pronovost P, Morlock L: ICU incident reporting systems. J Crit Care 2002; 17:86-94
29. Association for the Advancement of Medical Instrumentation: AAMI Standards and Recommended Practices: Dialysis, 2005 Edition. Arlington, VA, AAMI, 2004