Description of Event or Problem · 1
TWO INSTANCES OF MILD TO MODERATE HEMOLYSIS WHICH RPTR BELIEVES WERE POSSIBLY RELATED TO A PROBLEM WITH DIALYSIS BLOOD TUBING HAVE OCCURRED. ALTHIN MEDICAL INC RECENTLY RECALLED THEIR SERAFLOW HEMODIALYSIS BLOOD TUBING SETS BECAUSE OF PROBLEMS WITH BLOOD LEAKAGE. IN RPTR'S DIALYSIS UNIT, ALTHIN DIALYSIS MACHINES ARE USED AND THEY HAVE SUBSTITUTED MEDISYSTEM BLOOD TUBING SETS. RPTR HAS NOTED THAT THE SETS HAVE ESSENTIALLY NO SLACK IN THE LINE, WITH A TENDENCY TO KINK IN THE LINE CLIPS; HOWEVER, RPTR HAS BEEN ASSURED BY ALTHIN THAT THESE ARE THE PROPER LINES FOR THE MACHINES AND THAT THEY FIT CORRECTLY. UP UNTIL THE FIRST WEEK OF AUGUST UNIT IN FACT HAD NOT EXPERIENCED ANY DIFFICULTY WITH THEM. HOWEVER, TO CONTINUE TO TRY TO MEET DOCI GUIDELINES, UNIT'S BLOOD FLOWS HAVE GRADUALLY INCREASED OVER THE LAST FEW WEEKS. A PT RECEIVING CHRONIC HEMODIALYSIS PRESENTED WITH 3-4 DAYS OF ANKLE PAIN AND SWELLING (HAD ALSO HAD IN PAST). POST DIALYSIS SENT TO ER FOR X-RAY AND EVALUATION OF ANKLE. FOUND TO HAVE INCREASED WHITE BLOOD CELL COUNT, CONJUNCTIVITIS AND SWOLLEN ANKLE AND WAS ADMITTED; BLOOD STUDIES REVEALED HEMOLYSIS. NO SPECIFIC THERAPY NEEDED. STUDIES IMPROVED AND PT WAS DISCHARGED HOME. HEME POSITIVE STOOL, POSITIVE GASTRITIS ON ESOPHAGOGASTRODUODENOSCOPY. THE TWO PTS NOTED WERE ENTIRELY ASYMPTOMATIC, DIALYZED ON DIFFERENT DIALYSIS MACHINES, DIFFERENT PT SHIFTS, DIFFERENT DAYS, DIFFERENT SIZE DIALYZERS, AND RECEIVED DIFFERENT MEDICATIONS. THE NURSING STAFF WAS ALSO DIFFERENT. THE WATER SYSTEM PIPING TO THE DIALYSIS MACHINES INVOLVED WAS ON TWO DIFFERENT PIPING RUNS AND BOTH MACHINES WERE CHECKED OUT THOROUGHLY, INCLUDING TEMP, CONDUCTIVITY, ROLLER PUMP OCCLUSION, ETC BY TECH AND FOUND TO BE ENTIRELY WITHIN STANDARDS. ALL WATER CHLORINES AND CHLORAMINES AS WELL AS TESTS FOR RESIDUAL BLEACH IN THE BICARBONATE TANK WERE ALL NEGATIVE AND HAD BEEN BY PAST RECORD. THE ONLY POSSIBLE CAUSE THAT RPTR COULD ISOLATE WAS THE CRIMPING OF THE DIALYSIS LINES IN THE MACHINE AND RPTR HAS IMMEDIATELY CHANGED PROCEDURES TO PREVENT THIS BY NOT CLIPPING THE LINES IN PLACE UNTIL LONGER LINES ARE OBTAINED. IN ADDITION, RPTR DECREASED BLOOD FLOW RATE AND CHECKED PRE- AND POST-LDH LEVELS ON ALL 100 DIALYSIS PTS (FIVE SHIFTS) AS WELL AS CHECKED THEIR SERUM POTASSIUMS AND BILIRUBINS. ALL THESE STUDIES WERE ALSO WITHIN EXPECTED RANGES AND SHOWED NO CONSISTENT INCREASE IN LDH AT THE LOWER BLOOD FLOW. RPTR THUS FEELS THAT THE COMBINATION OF THE BLOOD LINE BEING OF INSUFFICIENT LENGTH TO PREVENT CRIMPING WHEN USED IN THE MACHINE AS SPECIFIED BY THE MFR (THE TUBING IS ALSO PURCHASED FROM THE MFR OF THE DIALYSIS MACHINES) AND THE HIGHER RATE OF BLOOD FLOW (400 CC TO 450 CC/MIN) CAUSED BOTH OF THESE EPISODES OF ASYMPTOMATIC HEMOLYSIS.