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Probe after dialysis patients suffer an unexpected illness
Thursday, 11 December 2008
An investigation has been launched after 10 seriously ill patients in Northern Ireland receiving dialysis treatment suffered unexpected complications.
Dialysis units — which help patients filter blood and can be used during kidney failure — across the province have been affected.
The cause of the problem, which involves the breakdown of red blood cells, has not been established. Units at Daisy Hill, Belfast City, Tyrone County and Antrim Area were included.
A spokesman for the four health trusts said: “Dialysis units across Northern Ireland are participating in a full and thorough investigation of all of these cases and in the interim staff are vigilant to the possibility of further cases and to the need for early identification and treatment.”
The patients affected have recovered and all receiving dialysis have been contacted and advised of symptoms to look out for.
The illness is called haemolysis and can cause abdominal or chest pain, vomiting, shivering or flushing and rising blood pressure.
It involves the release of haemoglobin into the surrounding fluid of the blood, plasma.
The health trusts spokesman added: “Haemolysis is an uncommon but recognised complication of dialysis.
“It can occur in clusters and while there are possible causes, an underlying cause isn’t identified in around 50% of incidents.”
Reasons vary and take detailed investigation. Haemolysis may relate to how blood is collected.
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It sounds more like a chlorine breakthrough in the water treatment plant - ? exhaustion of carbon tank media.
This has happened previously in various part of the world.
Posted by Robyn | 05.01.09, 22:10 GMT
Has the dialysate been sent for detailed chemical analysis(like water for hemodialysis is sent?)
Could the dialysate have been hypotonic?( maufaturer's error or local in-hospital error in mixing bicarb?)
has the water been sent for detailed organic analysis?
Kindly keep me informed when the findings are out.
many thanks
Posted by Mukesh Gajaria | 12.12.08, 19:14 GMT
This was posted in our renal Clin Gov meeting last month: a Patient Safety warning about haemolysis in dialysis patients.
University Hospitals of Leicester NHS Trust – Water disinfection using silver-stabilised hydrogen peroxide and its impact on renal water treatment systems. Used to prevent Legionella. In consequence, some renal HD patients experienced haemolysis. RCA being undertaken but all renal HD units advised to suspend and review disinfection procedures involving Hydrogen peroxide.
Posted by jennie king | 12.12.08, 14:19 GMT