Sweet SJ, McCarthy S, Steingart R, Callahan T
Hemolytic reactions mechanically induced by kinked hemodialysis
Am J Kidney Dis
(Feb) 27:262-266 1996
Ten severe hemolytic reactions, manifested by severe abdominal or back pain
2.5 hour into dialysis occurred, resulting in 8 hospitalizations and one
death. The cause, initially obscure, was traced to kinking of the blood line
between the blood pump and dialyzer. The cause of the kink was redundant
tubing in this segment, and the problem was fixed by changing to a tubing set
with a shorter blood pump to header segment.
No post-pump pressure monitor was used in these cases. A post-pump pressure
monitor may have picked up the problem if the kink was distal to the monitor.
Many units now utilize prepump pressure monitors only, and these would not be
affected even by a severe kink in the post-pump segment.
Comment: This is a potentially very serious problem, for which no
obvious remedy exists other than awareness, choice of a properly sized blood
tubing, and routine examination of this blood tubing segment for kinking.
(John T. Daugirdas, M.D., University of Illinois)